Inspection on 12/07/05 for Grange House

This inspection was carried out on 12th July 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Grange House 11/05/07

Grange House 17/08/06

Grange House 17/01/06

Grange House 06/12/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Grange House 9 Grange Road Hayes Middlesex UB3 2RP Lead Inspector Robert Bond Unannounced 12 July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Grange House G61-G10 s48879 Grange House v233230 120705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Grange House Address 9 Grange Road, Hayes, Middlesex, UB3 2RP Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0208 813 5264 0208 813 5264 Milbury Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Grange House G61-G10 s48879 Grange House v233230 120705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th December 2004 Brief Description of the Service: Grange House is operated by Milbury who are a nationwide limited company who provide residential care to people with learning disabilities. Grange House is registered to provide care to five service users, and the homes speciality is to provide for people with autism. Grange House is a detached property on a quiet residential street in Hayes. The home is a short drive from the local amenties of Hayes town centre and its public transport links. The property has five single ensuite bedrooms, one of which is on the ground floor. The communal rooms are spacious and include a through-lounge, kitchen/diner conservatory, and a large secure garden with a large activities room at the end. The home has its own vehicle to take service users out. Grange House G61-G10 s48879 Grange House v233230 120705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During this unannounced inspection, the Inspector spoke to the three service users present, the acting manager, the deputy, and three other staff. There were two vacancies that are shortly to be filled. The home is fully staffed, except that no Registered Manager is in place. Additional staff are being recruited to support the two new service users. The Inspector toured the home, and examined various records including those of one service user chosen at random, in depth. The Inspector, who was on site for about five hours, inspected the home against 34 of the National Minimum Standards for Care Homes for younger adults. The Inspector found that 14 of the Standards (outcomes) were fully met, 10 were partly or almost met, and 10 were not met. This inspection report makes 29 requirements and 5 recommendations. This is a disappointingly high number of requirements. 5 of the requirements are carried over from the last inspection, as they have not been achieved within the timescale set. What the service does well: What has improved since the last inspection? What they could do better: The acting manager should put himself forward to be considered by the Commission for Social Care to be the Registered Manager. In addition to his Grange House G61-G10 s48879 Grange House v233230 120705 Stage 4.doc Version 1.30 Page 6 responsibilities for managing Grange House, he also manages a supported housing scheme, which is far from an ideal arrangement as the size of Grange House and the complex needs of its service users justify a full time dedicated manager. The range of activities for service users should be expanded further and more effort be put into creating Person Centred Care Plans. Staff will have to be trained in PCP methods and in good recording techniques. In many instances records were neither signed nor dated. One of the National Minimum Standards states that half of the care staff should have National Vocational Qualifications in care, but at Grange House the percentage of qualified staff is much lower than this, hence training must become a high priority, which will benefit service users. A robust internal audit system must be put in place in order to pick up and address many of the poor practice and poor recording issues that the Inspector noted. 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. Grange House G61-G10 s48879 Grange House v233230 120705 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Grange House G61-G10 s48879 Grange House v233230 120705 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 4 and 5. The outcome for Standard 4 is fully met. The outcomes for Standards 1, and 5 are not met. The outcome for Standard 2 is almost met. EVIDENCE: The home’s Statement of Purpose and their Service Users’ Guide are now out of date and have not been revised in order to keep up to date with changing circumstances. This must be done once a Registered Manager has been agreed. The Service User guide should also be produced in pictorial form so that prospective service users have a better idea what the home can offer and whether their individual aspirations and needs can be met. The Inspector examined an assessment done on an existing service user using the National Autistic Society proforma. It was neither signed nor dated. The validity of the assessment is very limited when it is not known who completed it (and hence their experience/qualifications in making assessment / judgements) and without a date the assessment cannot be adequately compared with the situation before or after its completion. The Inspector examined the assessment documents of a prospective service user who had been assessed by both their own care manager and by the home’s acting manager. That prospective service user was due to visit the home the day after the inspection. Her mother is involved in the process. The acting manager reported that a review would be held after three months of moving in, then six monthly. The Inspector observed that on file was a statement of the terms and conditions of one service user’s stay. There was a copy of the contract between Grange House G61-G10 s48879 Grange House v233230 120705 Stage 4.doc Version 1.30 Page 9 Milbury and a Local Authority for another service user. The National Minimum Standards require both documents to be in place for all publicly funded service users. Grange House G61-G10 s48879 Grange House v233230 120705 Stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 8, and 10 The outcome for Standards 6 is not met. The outcomes for Standards 8 and 10 are not fully met. EVIDENCE: The Inspector examined in detail one service user plan file using the case tracking methodology. The keyworker/linkworker system is used. Although the service user plan was labelled PCP, that is person centred planning, the Inspector considers that support and senior staff require additional training in the PCP method so that service user plans may be improved further and service users may fully benefit from the PCP way of working. The PCP Master Care Plan examined was not dated and not signed by its author, the manager, the service user (not possible in this case) or their representative. Standard (6.7) requires service user plans to be in a format that could be understood by service users. The acting manager is therefore recommended to ask Milbury whether they have a pictorial service user plan model that could be used at Grange House. Key workers prepare monthly reports, but they do not always show the year as well as the month, and are not signed so it is not clear who has prepared them. There is no evidence of consultation with service users or their representatives. On the file examined was a ‘goal plan’ but it was neither signed nor dated. A review for one service user is currently being set up and Grange House G61-G10 s48879 Grange House v233230 120705 Stage 4.doc Version 1.30 Page 11 letters have been sent inviting relatives, GP and care manager to it. However this is the first review that has been called in the 10 months that Grange House has been open. If a care manager has conducted any reviews, the minutes are not available in the home. Standard 6.10 requires reviews to be held at least six monthly. Evidence of service user involvement in the operation of the home was that ‘laundry’ appeared on their activity plans. No service user meetings or relative meetings are held. The latter is recommended. The main files are stored securely in the office and use a well-designed format. Working files are kept in the lounge but not securely hence the confidentiality outcome is not fully met. All care files must be kept secure and confidential (Standard 10.3). Grange House G61-G10 s48879 Grange House v233230 120705 Stage 4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15, 16 and 17. Outcomes for 12, 13, 15, 16 and 17 are fully met. The outcome for Standard 14 is almost met EVIDENCE: The acting manager reported that two service users used to attend day centres but the Millbury emphasis is now on in-house day care, hence the activity room. However two service users have been referred to Milbury’s own day centre in Harrow. Alternatively, an outreach worker from there could come to the home, it was suggested by the acting manager. Given the one to one staffing situation at Grange House, the support staff could lead activities if they have the skills and training to do so. During the inspection one service user was playing football in the garden with a member of staff, but a second was alone in her room and the third service user roamed the house unaccompanied. This is indicative of the need for further development of meaningful activities for service users. One service user goes to Southall College part-time. The home has its own vehicle and swimming, cinema, pub, walks, drives and outings were mentioned as happening No service user practices any religion. Relatives visit the home and service users go on Grange House G61-G10 s48879 Grange House v233230 120705 Stage 4.doc Version 1.30 Page 13 weekend leave. Service users’ privacy is maintained by staff knocking on doors. Mealtime was not observed but the menu was seen to include choices, and a record is now being kept of what is actually eaten if it varies from what appears on the menu. The acting manager has reduced the service users’ intake of crisps, sweets and fizzy drinks, restricting these to times the service users are on outings. The minutes of the staff meeting show that some staff challenged this but he is commended for introducing this initiative and standing his ground for the nutritional benefit and health of the service users. Grange House G61-G10 s48879 Grange House v233230 120705 Stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,and 20 The outcome for Standards 19 is almost met. The outcome for Standard 20 is not met. EVIDENCE: The service user plan examined by the Inspector included an assessment of health needs and a weight chart. However although designed to be used monthly, only one entry had been made this year. Weight records are an important means of monitoring service users’ health as per Standard 19.3. One GP covers the whole home. Riverside Centre (Hillingdon Council) provides six monthly psychiatrist consultations. A behavioural therapist is employed by Milbury whose services could be accessed if necessary. A reflexologist visits weekly. One service user has the use of a chiropractor (a private arrangement). No service user is able to self-medicate. The Inspector examined the medication storage facilities and the medication administration records. According to the records, one service user had not received his medication on one morning that week. The acting manager assured the Inspector the medication had been given but there was no entry on the MAR sheet to demonstrate the fact. The list of sample signatures (initials) was not up to date. The returned medication book had not been signed by Boots the Chemist’s pharmacist when collecting drugs from the home on 19th April 2005. The home’s deputy manager had signed the returned medication book in July Grange House G61-G10 s48879 Grange House v233230 120705 Stage 4.doc Version 1.30 Page 15 2005 in advance of the drugs being collected. This is not good practice and must cease. Drugs to be returned were not all stored separately from drugs to be administered. This is a requirement. Grange House G61-G10 s48879 Grange House v233230 120705 Stage 4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The outcome for Standard 22 was not met. The outcome for Standard 23 was partly met. EVIDENCE: One complaint had been recorded in the home’s complaints book. The complaint was not dated and the recording of the complaint was not wholly satisfactory. All complaints must be dated. Senior staff must be trained in how to record complaints. The acting manager must check the adequacy of recording at regular intervals. The complaints leaflet has had the address of the local CSCI office added, but not the telephone number. The complaints procedure should say that the CSCI might be contacted at any time regarding a complaint. Currently it only says that if the complainant is not satisfied by Milbury’s investigation, the complainant may then contact CSCI. The complaints procedure should be made available to service users in a format they can understand. The home has a copy of Milbury’s adult protection policy/procedure which is very thorough. The home also has a copy of Hillingdon Council’s adult protection policy/procedure which is out of date. The acting manager must contact Hillingdon Council’s adult protection co-ordinator in order to obtain their new policy/procedure and arrange for all the Grange House staff to be trained in its use. Grange House G61-G10 s48879 Grange House v233230 120705 Stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29, 30 The outcome for Standard 24 was almost but not fully met because of cleaning materials being left out and hot water temperatures exceeding the maximum allowed. The outcomes for Standards 25 to 30 were fully met. EVIDENCE: The Inspector toured the home including three bedrooms with the service users’ permission. The home is generally well designed, although the office is isolated and an occupant of the office cannot see what is happening outside. The acting manager reported that staff are reluctant to enter the office, hence the care running files are stored in the lounge. All furnishings and equipment are new and homely. Minimum room sizes are met. The home was seen to be clean throughout. In the kitchen, dishwashing and surface cleaning chemicals were not locked away, as required. In one bedroom, the hot water temperature was measured to be 45 degrees Centigrade. Grange House G61-G10 s48879 Grange House v233230 120705 Stage 4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35, and 36. The outcome for Standards 31 was fully met. The outcomes for Standards 33, 34 and 36 were partly met. The outcomes for Standards 32 and 35 were not met. EVIDENCE: Job Descriptions were seen for support workers, senior support workers and the deputy manager. A sample staff rota was examined that showed three support staff to be on duty during the day, with the manager as supernumerary, and two at night, one awake and one sleeping-in. The staffing level is currently being extended so that the support staff/service user ratio will remain at 1 to 1 when the number of service users rises to five. At the present time, only one staff member has obtained NVQs level 2 or 3 in care although three are undertaking the award. Standard 32 requires that 50 of care staff obtain NVQ level 2 or 3 by 31/12/05. The knowledge and competency of some of the support staff is brought into question by the low level of recording ability. Additional training in various aspects is required in order to fully meet Standard 33. Notes of a staff meeting held on 24th June were seen. The recruitment file of the latest recruit was examined. Although two references had been taken up, neither was from his last employer. The file did not contain the required photograph. The recruitment checklist was not dated. There was however a CRB disclosure, a POVA First check, and a signed and dated induction check list. However because of the omissions, Standard 34 Grange House G61-G10 s48879 Grange House v233230 120705 Stage 4.doc Version 1.30 Page 19 is not fully met. A training and development profile is required on each staff member and the home must develop an overall training and development plan in order to meet Standard 35. Staff supervision is now being undertaken but not at the required rate of at least six times per year, hence Standard 36 is not fully met. Grange House G61-G10 s48879 Grange House v233230 120705 Stage 4.doc Version 1.30 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39, 41, and 42. It was not possible to assess Standard 37, as the acting manager is not the Registered Manager. In terms of Standard 38, it is clear from the latest staff meeting minutes that the acting manager has communicated a clear sense of direction concerning service users’ consumption of ‘junk food’, but there are other aspects of poor practice yet to be tackled, such as poor recording and the absence of regular checks of service users’ weight. Many of the omissions the Inspector found should have been spotted and put right by checks undertaken by the acting manager and the Operations Manager during his monthly Regulation 26 visits. As Standard 38 also relates to ‘the registered manager, this Standard is not formally assessed either. Given the size and complexity of the management task at Grange House, the dual responsibility of also managing Ross Cottage is far from ideal and should be reviewed. The outcomes for Standards 39, 41 and 42 are not met for the reasons given below. EVIDENCE: Grange House G61-G10 s48879 Grange House v233230 120705 Stage 4.doc Version 1.30 Page 21 Minutes seen of a staff meeting dated 24th June 2005. Omissions in record keeping reported elsewhere in this report. The acting manager reported that he is also responsible for managing the supported housing scheme known as Ross Cottage. He also reported that in terms of quality assurance, service users have been surveyed concerning their wishes about activities. That is good, but a more formalised system of quality assurance to take into account the views of all stakeholders is required. This should then lead to the writing of an annual development action plan. Even more importantly, the acting manager and the Operational Manager must devise a system of internal selfmonitoring that picks up on many of the errors and omissions that the Inspector found. Until that is done Standards 39 and 41 are unlikely to be met. Regarding Health and Safety issues, that Standard is not met either because of the hot water and cleaning material issues raised above, and because the home’s record showed that no fire drills took place during October, November, December 2004 or January, February 2005. A manager must be put forward to be registered by the CSCI. Grange House G61-G10 s48879 Grange House v233230 120705 Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 2 x 3 1 Standard No 22 23 ENVIRONMENT Score 1 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 x 2 x 2 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 2 3 3 3 Standard No 31 32 33 34 35 36 Score 3 1 2 2 1 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Grange House Score x 2 1 x Standard No 37 38 39 40 41 42 43 Score x x 1 x 1 1 x G61-G10 s48879 Grange House v233230 120705 Stage 4.doc Version 1.30 Page 23 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 1 1 Regulation 4 5 Requirement An up-to-date statement of purpose is required The Service Users Guide must be updated, and produced also in a format bsuitable for the service users of the home The service users contracts, and their terms and conditions, must be individualised and clearly state the fees and list all additional charges not included in the fees. THIS IS RESTATED FROM THE LAST INSPECTION. THE TIMESCALE FOR ACTION OF 01/02/05 WAS NOT MET. Senior staff and support workers should be further trained in producing service user plans. Service users and/or their representatives must be consulted about the contents of service user plans. Evidence is required. Assessments must be signed and dated. Service users plans must be kept under review All care files must be kept secure and confidential Continue to research and develop activities for service Timescale for action 01/10/05 01/10/05 3. 5 5(b) &(c) 01/10/05 4. 5. 6 6 18 (1ci) 15 01/11/05 01/09/05 6. 7. 8. 9. 2 6 10.3 14 14 (1) 15 (2) (b) 17 16 (2) (n) 01/09/05 01/09/05 01/08/05 01/10/05 Page 24 Grange House G61-G10 s48879 Grange House v233230 120705 Stage 4.doc Version 1.30 10. 19.3 13 (1) (b) 11. 12. 13. 20 20 20 13 (2) 13 (2) 13 (2) 14. 15. 20 22 13 (2) 22 16. 17. 22 22 22 22 18. 19. 20. 22 23 23 22 13 (6) 18 (1c) 21. 24 13 (4) (a) users. THIS IS A PARTIAL RESTATEMENT FROM THE LAST INSPECTION REPORT. The weight of all service users must be recorded monthly and examined for any trends the record may show. The adminstration of all medication must be recorded. The list of sample staff signatures (initials) must be updated The returned medication book entry must be signed by the pharmacist and the homes representative at the time drugs are collected. Medication to be returned must be stored separately from medication to be administered. Contact details of the CSCI must be included in the complaints procedure. THIS IS RESTATED FROM THE LAST INSPECTION. THE TIMESCALE FOR ACTION OF 01/02/05 WAS NOT FULLY MET. Senior staff must be trained in recording complaints The complaints leaflet and policy/procedure must indicate that complaints may be referred to the CSCI by the complainant at any stage. The complaints leaflet must be made available to service users in a format they can understand. The acting manager must obtain Hillingdon Councils latest adult protection policy. The acting manager must arrange for all the homes staff to be trained in the application of Hillingdon Councils adult protection policy. All kitchen cleaning materials must be kept securely when not in use 01/08/05 01/08/05 01/08/05 01/08/05 01/08/05 01/09/05 01/09/05 01/09/05 01/10/05 01/09/05 01/10/05 01/08/05 Grange House G61-G10 s48879 Grange House v233230 120705 Stage 4.doc Version 1.30 Page 25 22. 23. 24. 25. 24 32 34 35 13 (4) (a) 18 (1) (a) 19 & Schedule2 18 26. 35 18 27. 39 26 28. 29. 42 37 23 (4c) 8 and 9 30. 34 schedule 2, 19 (5) (d) Hot water for service users use must not exceed 42 degrees Centigrade. 50 of the care staff must have an NVQ level 2 or 3 in care by the end of December 2005 A recent photogragh is required of all staff members Training and development assessments and profiles must be formulated for each staff member. THIS IS PARTIALLY RESTATED FROM THE LAST INSPECTION REPORT. THE TIMESCALE FOR ACTION OF 01/02/05 WAS NOT MET A training and development plan for the home overall is required, based on individuals training and developmemt needs, and the care needs of the service users. The senior management of Milbury must review the effectiveness of the current format of Regulation 26 visits that has failed to lead to action in improving the recording standards at Grange House Fire drills must take at least quarterly as per Milburys policy. A manager must be put forward to be registered by the CSCI, so that his fitness maybe determined. A reference from the last employer must be taken up when recruiting new staff. 01/08/05 01/01/06 01/09/05 01/10/05 01/11/05 01/10/05 01/09/05 01/09/05 01/08/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations G61-G10 s48879 Grange House v233230 120705 Stage 4.doc Version 1.30 Page 26 Grange House 1. 2. 3. 6 6 8 4. 5. 37 Investigate obtaining and using a pictorial service user plan model. Assessments, monthly reports, and service user plans should always be signed and dated. Where possible this omission should be corrected retrospectively. Once the home is full, consideration should be given to holding a meeting of service users relatives/representatives and to ask them if they would like these meetings to be regular occurrences. (this recommendation has now been made a requirement) The senior management of Milbury should review the desirability of one home manager managing two establishments. Grange House G61-G10 s48879 Grange House v233230 120705 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Ground Floor 58 Uxbridge Road Ealing London W5 2ST 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 Grange House G61-G10 s48879 Grange House v233230 120705 Stage 4.doc Version 1.30 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!