Inspection on 08/11/05 for Granby Place

This inspection was carried out on 8th November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Granby Place 15/01/09

Granby Place 17/01/08

Granby Place 24/07/07

Granby Place 20/07/06

Granby Place 16/07/05

Granby Place 08/11/04

Similar services:

Insight - Eastchurch

Southfields

Thorndene

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Granby Place 1-3 High Street Northfleet Gravesend Kent DA11 9EY Lead Inspector Helen Martin Unannounced Inspection 8th November 2005 2:15 Granby Place DS0000059719.V261451.R01.S.doc Version 5.0 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 Granby Place DS0000059719.V261451.R01.S.doc Version 5.0 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. Granby Place DS0000059719.V261451.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Granby Place Address 1-3 High Street Northfleet Gravesend Kent DA11 9EY 01474 326233 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) DGSM Limited Mrs Rae Sayers Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Granby Place DS0000059719.V261451.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two of the 10 service users also have mental health difficulties Ages will be from 45 years of age and above 20th July 2005 .Date of last inspection Brief Description of the Service: Granby Place provides accommodation and support for up to 10 people with learning disabilities who are forty-five years of age or above. Currently there is a condition of registration for two residents who also have mental health difficulties. The home is one of four services, within the area, provided by DGSM Limited. The building is owned by a housing association. Granby Place is located in Northfleet High Street and is within easy reach of public transport and all the usual town amenities. Residents have single bedrooms which are located on the ground and first floor. There are two lounge areas, a dining room and a visitors’ room. There is a garden to the rear of the property with car parking facilities. The home employs support workers, operating a roster that gives 24-hour cover. There is one member of staff who ‘sleeps-in’ at night with on-call cover. The home does not employ specific staff for catering or domestic duties. Granby Place DS0000059719.V261451.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 8th November 2005 between 14.15 and 19.00. The visit included talking with senior support workers, support workers and residents. The manager was not at the home on this occasion. Some judgements about the quality of life within the home were taken from observation and conversations. Some records were looked at. In addition, a tour of the home and garden was undertaken. Residents were happy to talk to the inspector about their life in the home. Granby Place currently has nine residents; there is one vacancy. Since the last announced inspection on 16th July 2005, the home has had an additional inspection visit on 20th July 2005 specifically to discuss care plans. Issues from both of these inspections have been included within this report where appropriate. What the service does well: What has improved since the last inspection? Staff have worked hard with one individual regarding their choices and preferences. Since the last inspection, this resident has chosen their own routines, which staff are supporting, with positive results. The bathroom and a resident’s room have recently been redecorated and two new fire doors fitted. A spare bedroom is in the process of being re-furbished. Since the last inspection, an additional bedroom has been provided on the ground floor and the visitors’ room is now upstairs. This has recently been refurbished and redecorated. Granby Place DS0000059719.V261451.R01.S.doc Version 5.0 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. Granby Place DS0000059719.V261451.R01.S.doc Version 5.0 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 Granby Place DS0000059719.V261451.R01.S.doc Version 5.0 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): 1, 2, 3, 4, 5 Prospective residents and their representatives would benefit from additional information and assessment before they decide to move in. EVIDENCE: Previous inspections identified that, although the pre-admission information available for prospective residents and their representatives contained some useful information, it did not comprise full and unequivocal details about the home’s services and facilities. The organisation is currently liaising with the Commission regarding this issue. The home’s statement of purpose and service users’ guide were not available for inspection on this occasion. Residents benefit from an assessment prior to their admission to the home, to ensure that their needs can be met. This process would be enhanced by a review of the home’s assessment format to ensure that all items listed within Standard 2 are included. The senior support worker said staff have worked hard with one individual, who has mental health difficulties, regarding their choices and preferences. Since the last inspection, this resident has chosen their own routines, which staff are supporting. As a result, they do not feel so frustrated, they have become less anxious and their behaviour has become more stable. This has happened in conjunction with a review of their medication. The staff team have been supported by health and social care professions, such as a care manager Granby Place DS0000059719.V261451.R01.S.doc Version 5.0 Page 9 and psychiatric nurse. Staff demonstrated a good understanding of the needs of another resident with mental health difficulties and how these have been addressed. Previous inspections identified that the manager undertook to review the current personal contract and to have a revised contract available for any new residents. It was unknown at the time of this inspection whether this had been undertaken; documentation was not available. Granby Place DS0000059719.V261451.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Residents are supported to make their own choices. Their changing needs would be better reflected by improvements to the systems for care planning and risk assessment. EVIDENCE: Care plans and risk assessments do not fully reflect residents’ changing needs and goals. The home continues to be in the process of transferring information to a new care plan format. The format is clear and easy to follow, although little or no information is detailed within it. The home’s current care files contain a great deal of information, some of which is up to date and some of which is not. They are difficult to follow and not all presented in good order. One resident’s file contains no specific care plans. Positive changes and staff guidelines for one resident are not recorded. Some documents seen were hand written, difficult to read and undated, two were dated 2000 and 2001. Evidence of reviews with care managers is present, although not all reviews are recorded. Daily notes are recorded in individual books. It was agreed at the time of inspection that the review and update of care plans would be completed by 28th February 2006. Granby Place DS0000059719.V261451.R01.S.doc Version 5.0 Page 11 Residents are supported to take risks as part of maximising their independence, although not all are recorded. Some risk assessments are up to date, whilst some are not. One related to an activity no longer undertaken, some contained insufficient information. Residents are encouraged to make choices. Residents receive continuity of care by having individual key workers. Residents are encouraged to participate as much as possible in all aspects of life within the home. Residents’ meetings are held monthly where there is the opportunity to talk about any problems, activities, events and choice of food. Staff demonstrated an understanding of confidentiality issues. Residents’ finances were not inspected on this occasion. Granby Place DS0000059719.V261451.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 Residents enjoy individual lifestyles, which include opportunities for social, educational and recreational experiences. EVIDENCE: Residents are supported towards independent living skills, dependant on their capacity, and also have the opportunity for personal, emotional and social development. Residents are treated as individuals who have different interests and aspirations. Activities and development opportunities are provided accordingly. The senior support worker said staff have worked hard with one resident regarding their choices and preferences. Since the last inspection, the resident has chosen their own routines, which staff are supporting with positive results. Additional choices will continue to be encouraged. Residents are part of the local community. During weekdays some residents enjoy attending day centres, participating in social events, activities that personally interest them or to further develop their life skills. Transport is provided by the day centres. Residents have enjoyed a disco, a Christmas party, a barbeque, a barn dance and a trip to the theatre. One resident Granby Place DS0000059719.V261451.R01.S.doc Version 5.0 Page 13 described how they enjoyed a game of bowls today. One resident has been in paid full time employment for some years and is able to travel to and from the home independently using public transport. Residents spend time at the home in the evening, weekends and on the days when they do not attend day centres or work. They are able to relax watching television and videos or doing puzzles and quizzes. Residents’ individual interests are encouraged. One resident likes to arrange flowers and some of their artwork was displayed within the home. Another likes steam trains and collects magazines. All the residents’ individual interests are in evidence. The home has a budgie as a pet. Residents are encouraged with shopping, cooking, cleaning and laundry tasks wherever possible. They also visit local venues. The senior support worker explained that additional staff are provided for activities and trips out organised by the home. A trip to a pantomime is being organised for this Christmas. One resident enjoys attending their church and associated events regularly. Residents have access to the home’s garden. Residents are able to see their family, friends and befrienders as often as they wish. Individuals can visit the home at any reasonable time and can be received in private, either in residents’ rooms or the designated visitor’s room. Some residents visit their families on occasions. Residents have been able to maintain friendships outside of the home. Some residents are able to go on holiday; two have been to Wales and two to Yorkshire. The organisation pays for staff costs but does not pay for the resident to go on the holiday; they fund the holiday themselves. Residents enjoy privacy in their rooms and staff respect this. Staff talk to residents in a friendly and polite way. Residents are able to receive phone calls and visitors in private. Residents are asked on a fortnightly basis what they would like to eat and a written menu is developed from this. Residents enjoyed an evening meal at the time of inspection of barbeque chicken with rice. The meals looked appetising, well presented and in good sized portions. It was mentioned that yesterday’s main meal was sausages in gravy with sweetcorn, cabbage and potatoes, whilst tomorrows will be macaroni cheese. The senior support worker demonstrated a good understanding of individuals’ likes and dislikes. It was mentioned that residents can have snacks at any time and that fresh fruit and fruit juice are available. Residents’ nutrition and weight is monitored. Granby Place DS0000059719.V261451.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 Residents benefit from support that meets their individual needs. They would be better protected by improvement to the system for the administration of medication. EVIDENCE: Residents are given the personal support they need to maximise their independence, while respecting their dignity and privacy. Residents are able to exercise choice. They have individual clothing and hairstyles. Staff have an understanding of the preferred routines of each resident. Residents have access to health care professionals, such as GP, psychiatrist and psychiatric nurse. They are supported with hospital appointments and admissions. Residents’ nutrition and weight is monitored and recorded. The senior support worker said that residents are offered a weekly keep fit class. No residents currently keep their own medication. Residents are protected by the arrangements in place for the storage of medication. Staff sign administration records devised by the home and not those provided by the supplying pharmacy. Two staff sign the record, one for administration and one for witnessing administration. One resident’s medication has recently been reviewed and this has had a positive effect on their behaviour. Granby Place DS0000059719.V261451.R01.S.doc Version 5.0 Page 15 The insight of members of staff into the challenges of aging faced by residents is considerable. Staff enabled a resident, who had been accommodated for some years, to stay at the home for as long as possible during developing problems and illness until their recent death. Staff are supporting residents to come to terms with their loss according to their individual capacity. One resident who had know the individual for many years is able to talk to staff about how they feel and is involved in the preparation for the funeral. At the time of the inspection, staff demonstrated thoughtful consideration and sensitivity. Granby Place DS0000059719.V261451.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Residents’ views and concerns are listened to, although they would benefit from written complaint information that they could easily understand. Residents are protected from potential abuse. EVIDENCE: Residents are at ease talking with staff who listen to their views and concerns. The senior support worker said that no complaints had been received by the home, although should this be the case, these would be taken seriously and acted upon. The home provided a written complaints procedure. It was mentioned that this continued to be in the process of review, in order to provide a format that residents can easily understand. Residents are protected from potential abuse by the procedures in place within the home. Written policies and procedures were available for staff. The senior support worker demonstrated an understanding of adult protection procedures. Granby Place DS0000059719.V261451.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 Residents benefit from living in a clean, comfortable and homely environment. This would be enhanced by some additional facilities. Their safety would be increased by improvements to the fire procedures and exits. EVIDENCE: The building fits in with the local community and has a style and atmosphere that meets individuals’ needs. Residents are able to go anywhere in the house and garden. The back garden is attractive, although a fence is in need of repair. The back garden is not enclosed and opens directly onto the car park and service road, leading to the main road. Two of the home’s four external doors are alarmed and locked at night; a chain secures one, whilst another is mortice locked. The locked doors are used as fire exits. It was mentioned that there is also a fire exit through a first floor resident’s room, via a locked window (with the key kept downstairs) onto a flat roof, with no access to the ground level. The senior support worker said that they would check these arrangements with the local fire authority. Residents benefit from living in a clean, comfortable and homely environment. The house is well maintained and decorated by Hyde Housing Association. The Granby Place DS0000059719.V261451.R01.S.doc Version 5.0 Page 18 bathroom, a resident’s room and the visitor’s room have recently been redecorated and two new fire doors fitted. A spare bedroom is in the process of being re-furbished. Since the last inspection, an additional bedroom has been provided on the ground floor and the visitors’ room is now upstairs. The visitors’ room has recently been refurbished and re-decorated. Adequate recreational, dining, toilet, bathing and individual accommodation are available to residents. The home provides two lounge areas, a conservatory and a visitors’ room. All residents have their own rooms, which are on the ground and first floor. Residents clearly like their rooms, which are all individual and highly personalised. They are able to choose the colour schemes and how their furniture should be arranged. The senior support worker described the system used for informing Hyde Housing of residents’ wishes. Bedrooms are reasonably well furnished. All residents’ bedrooms are provided with washbasins except two. The suitability of armchairs for individual residents could not be assessed on this occasion. A hoist is available for residents who need assistance with bathing. The home has a staff call system and external doors are locked or alarmed. The first floor is not served by a shaft or stair lift. Granby Place DS0000059719.V261451.R01.S.doc Version 5.0 Page 19 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): 31, 32, 33, 34, 35, 36 Residents benefit from a sufficient number of staff who have a good understanding of their needs. Residents would be better protected by improvements to the systems for staff recruitment, training and supervision. EVIDENCE: Staff showed a good understanding of residents’ needs and the homes philosophy and values. Residents benefit from good support and interaction. Staff communicate well with each other when handing over information between shifts. Regular monthly staff meetings are held. The home has a stable staff team. Previous inspection identified the need to review the range of appropriate and up to date training received by members of staff. Training certificates were seen, some of which were out of date. Current training offered to staff includes care planning, fire, breakaway techniques and medication. Some staff are undertaking an infection control course tomorrow. It was identified that although some staff had been trained in first aid, only one was an ‘appointed person’. Athough a hoist is used for two residents when bathing, not all staff have received manual handling training relating to people (as opposed to objects); not all staff who prepare meals have been trained in food hygiene; no specific training in learning difficulties or mental health is provided. Induction training was provided, although records did not comply with TOPSS Granby Place DS0000059719.V261451.R01.S.doc Version 5.0 Page 20 specifications. Staff training continues to need review to ensure that the needs of residents are fully met. Currently one support worker has obtained an NVQ level 2 qualification from a total staff team of eight. It was mentioned that a further three individuals are currently undertaking NVQ level 3 with another one in the process of NVQ level 4. Previous inspection identified problems for members of staff undertaking an in-house assessed NVQ scheme. Since the last inspection no progress has been made. It continues to be the case that in-house support and assessment has been withdrawn with no replacement provided. This had led to a delay of several months and uncertainty about verification of previous work for the staff concerned. The senior support worker stated that staff undertook regular recorded one-toone supervision and an annual appraisal, which they found helpful. At the time of inspection, residents’ needs were met by the number of staff on duty. There are usually two staff during the day with one ‘sleeping-in’ at night. Staffing hours are recorded on a roster together with the arrangements for oncall back up. The manager works with the direct care of residents and has some ‘supernumerary’ days for management and administration. The senior support worker explained that additional staff are provided for activities and trips out organised by the home. Staff support residents with cooking, cleaning and laundry tasks wherever possible. No ancillary staff are employed by the home. A procedure is in place to ensure that the home appoints suitable staff who can support the needs of residents. Staff files evidenced that pre-employment checks had been undertaken, although one did not contain any reference to a criminal records bureau check. The home’s application form did not contain the facility for the self-disclosure of any cautions. All documentation was photocopied and not original. Granby Place DS0000059719.V261451.R01.S.doc Version 5.0 Page 21 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, 38, 39, 40, 41, 42 Residents benefit from a well run home, although their interests would be better promoted by a review of quality assurance and record keeping. EVIDENCE: The manager is currently undertaking the Registered Manager’s Award. The manager works with the direct care of residents in addition to ‘supernumerary’ days for management and administration. Previous inspection identified that the manager would review and improve a number of issues associated with the direct care of current and future residents; the manager was not submitting reports at reasonable intervals to the Commission based on review and improvement of the quality of care at the home. This could not be fully assessed on this occasion, as the manager was not present. There is an open and inclusive atmosphere in the home. Residents are comfortable chatting and spending time with staff. Residents’ meetings and staff meetings are held monthly. Granby Place DS0000059719.V261451.R01.S.doc Version 5.0 Page 22 Records showed some gaps in care planning, risk assessment, staff recruitment and hot food temperatures. Records are stored securely. The home’s accident and incident book needs updating to the newer format that preserves confidentiality. The home has a designated member of staff who is responsible for health and safety. They are currently in the process of auditing fire doors. It was mentioned that they undertook regular checks of residents’ rooms and the staff call system. The home’s business accounts were not inspected on this occasion. Granby Place DS0000059719.V261451.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 2 3 3 2 Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 2 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 2 3 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Granby Place Score 3 3 2 4 Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 2 3 X DS0000059719.V261451.R01.S.doc Version 5.0 Page 24 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 YA1 Regulation 4&5 Requirement The registered person shall compile a statement of purpose and produce a service users’ guide in relation to the care home. In that, the organisation is currently liaising with the Commission regarding this issue. The home’s statement of purpose and service users’ guide were not available for inspection on this occasion. This requirement has been repeated from inspection dated 16th July 2005. 2 YA6YA41 12 & 15 The registered person shall ensure that the home promotes the health and welfare of service users and provides a written care plan as to how these needs are to be met. In that, care plans must be provided for each resident. Documents must be readable, in good order, kept up to date, completed with sufficient detail Granby Place DS0000059719.V261451.R01.S.doc Version 5.0 Page 25 Timescale for action 31/01/06 28/02/06 and appropriate to the needs of the resident. This requirement has been repeated from inspection dated 20th July 2005. 3 YA9YA41 13(4) (a)(b)(c) The registered person shall ensure that avoidable and unnecessary risks to the health and safety of service users are identified and as far as possible eliminated. In that, written risk assessments must be undertaken, kept up to date, completed with sufficient detail and appropriate to the needs of the resident. 4 YA24 23(4)(b) The registered person shall, after 23/12/05 consultation with the fire authority, provide adequate means of escape. In that, the procedures for evacuation and methods used to secure external fire exit doors must allow for adequate means of escape in the event of a fire. 5 YA26 16(2)(c) 31/01/06 The registered person shall provide adequate furniture in rooms occupied by service users. In that, the suitability of armchairs for individual residents could not be assessed on this occasion. This requirement has been repeated from inspection dated 16th July 2005. 6 YA34YA41 19 (2) 17(2) 4:6 The registered person must ensure that records concerning persons working in the care home comply with schedules 2 DS0000059719.V261451.R01.S.doc 28/02/06 31/01/06 Granby Place Version 5.0 Page 26 and 4. In that, evidence of criminal records bureau checks must be kept within the home. 7 YA35 18(1)(c)(i) The registered person shall ensure that staff working at the home receive training appropriate to the work they are to perform. In that, a review must be undertaken to ensure that appropriate training is provided to meet the needs of all residents, including first aid, manual handling, food hygiene, learning difficulties and mental health. 8 YA36YA35 18 (2) The registered person shall ensure that persons working in the care home are appropriately supervised. In that, whilst it is acknowledged that a process is in operation, supervision must ensure that all the training needs of staff are identified, such as the necessary provision of assessment for NVQ qualifications. This requirement has been repeated from inspection dated 16th July 2005. 9 YA39 24 The registered person shall establish and maintain a system for reviewing and improving the quality of care at the home. The registered person shall supply to the Commission a report in respect of any review conducted. In that, this could not be fully assessed on this occasion, as the Granby Place DS0000059719.V261451.R01.S.doc Version 5.0 Page 27 31/01/06 31/01/06 31/01/06 manager was not present. This requirement has been repeated from inspection dated 16th July 2005. 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 YA2 Good Practice Recommendations It is recommended that the home’s pre-admission assessment format should be reviewed to ensure that all items listed within Standard 2 are included. It is recommended that the personal contracts for new residents are reviewed and, if necessary, updated so that the contracts reflect the reasons why the service user is receiving residential care. It was unknown at the time of this inspection whether this had been undertaken; documentation was not available. This recommendation has been repeated from inspection dated 16th July 2005. 3 YA14 It is recommended that residents have the option of a minimum seven-day annual holiday outside of the home, included within the basic contract price. It is strongly recommended that the home should use the MAR sheets provided by the supplying pharmacist for the signature of staff administering medication. (A separate record for staff witnessing administration can be maintained if necessary.) It is strongly recommended that the complaints procedure should be provided in a format that can be easily understood by residents. This issue has been repeated from inspection dated 16th July 2005. Granby Place DS0000059719.V261451.R01.S.doc Version 5.0 Page 28 2 YA5 4 YA20 5 YA22 6 YA24 It is recommended that, with regard to the back garden: • • The fence should be repaired. The safety and security of residents should be reviewed as the back garden is not enclosed and opens directly onto the car park and service road, leading to the main road. 7 8 YA26 YA32 It is strongly recommended that all residents’ bedrooms should be provided with a washbasin. It is recommended that a minimum of 50 of the staff team should complete an NVQ level 2 qualification as soon as possible. It is strongly recommended that, with regard to staff recruitment files: • • Documents kept at the home should be originals and not photocopies. The application form should contain the facility for the self-disclosure of any police cautions. 9 YA34 10 11 YA35 YA41 It is recommended that the home’s recorded induction training should comply with TOPSS specifications. It is recommended that, with regard to record keeping: • The home should obtain an updated format for the recording of accidents and incidents that preserves confidentiality. The temperature of all hot food tested should be recorded. • Granby Place DS0000059719.V261451.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Granby Place DS0000059719.V261451.R01.S.doc Version 5.0 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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