Inspection on 12/12/05 for Granville Court 4

This inspection was carried out on 12th December 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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Granville Court 4 23/09/08

Granville Court 4 07/06/07

Granville Court 4 04/05/05

Granville Court 4 25/11/04

Granville Court 4 16/07/04

Granville Court 4 20/01/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Granville Court 4 The Esplanade Hornsea East Yorkshire HU18 1NQ Lead Inspector Sarah Sadler Unannounced Inspection 12th December 2005 09:00 Granville Court 4 DS0000041493.V272469.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 Granville Court 4 DS0000041493.V272469.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 Older People and 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. Granville Court 4 DS0000041493.V272469.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Granville Court 4 Address The Esplanade Hornsea East Yorkshire HU18 1NQ 01964 532160 01964 534495 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) East Riding of Yorkshire Council Mrs Moira Gillyon Care Home 20 Category(ies) of Learning disability (24), Learning disability over registration, with number 65 years of age (20), Physical disability (24), of places Physical disability over 65 years of age (20) Granville Court 4 DS0000041493.V272469.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. To offer respite care to service users aged 16 - 18 (those in transition from childrens services to adult services). 4th May 2005 Date of last inspection Brief Description of the Service: 4 Granville Court is a purpose built care home offering up to twenty placements to adults both under and over the age of 65 years (male and female) who have a learning disability. The home is situated in the seaside town of Hornsea and is positioned close to the sea front, the local shops and amenities. Accommodation at the home is in three small units, called bungalows. Each service user has a single room. The bungalows have a lounge/dining area and a small kitchen on each unit and service users have access to a large communal activity room and a smaller snoozelem. This is a room that contains specialist equipment for sensory stimulation. The home has a spacious courtyard area with seating that is enclosed and secure with good access, including people in wheelchairs or with mobility problems. The home is owned by a multi agency organisation, which includes Social Services and the Local Health Authority, and is know as the Spice Trust Project. The registered provider is the East Riding of Yorkshire Council. Granville Court 4 DS0000041493.V272469.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was undertaken over one day by one inspector. The inspection was part of the annual inspection programme from April 1st 2005 to March 31st 2006. During the inspection a tour of the premises was undertaken, residents, and members of staff were spoken to. An amount of time was spent with residents, observing their everyday life. Some time was spent reading resident and other records within the home. The outcomes for all relevant National Minimum Standards for Older People and Younger Adults were assessed. What the service does well: What has improved since the last inspection? The information provided to service users and their representatives prior to entering the home is now comprehensive and will better assist with this process. The staff files now reflect that full recruitment practices are undertaken to assist in ensuring the protection of service users. There is now a staff training and development plan, which will assist in ensuring that service users are supported by a well trained staff team. The practices in the home now comply with the Local Fire Authority and assist in ensuring the safety of service users. Granville Court 4 DS0000041493.V272469.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. Granville Court 4 DS0000041493.V272469.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Granville Court 4 DS0000041493.V272469.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5 Service users are provided with information regarding living in the home, which will assist them in their decision making and choices. EVIDENCE: The registered manager has developed the statement of purpose to include all of the required information, including the qualifications and experience of the registered person. The registered manager has continued to develop the service users’ guide to include all available required information. The guide includes pictures relating to each section, and is written to assist service users in the reading of it. The registered manager also confirmed that they are hoping to develop the service user guide into a video format. Granville Court 4 DS0000041493.V272469.R01.S.doc Version 5.0 Page 9 All service users have received a Community Care Assessment and these may be complemented by Health Assessments to ensure that their needs are clearly identified prior to entering the home. The registered manager confirmed that the individual service users’ contracts are continuing to be developed and do not yet meet the requirements of the National Minimum Standards. Granville Court 4 DS0000041493.V272469.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) 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 Service users are supported to take risks and have their needs met, as they would wish. Service users are supported to make decisions in their lives. EVIDENCE: Service user files include a review sheet which addresses whether the care plan and risk assessments require alteration and review. These are completed on a monthly basis and were up to date. Files include risk assessments that assist the service users in their everyday lives, for example, the service users vulnerability whilst walking around. The registered manager confirmed that service users have not had any further involvement in staff recruitment or in consultation within the home. However this was due mainly to the high level of need of the service user and the Granville Court 4 DS0000041493.V272469.R01.S.doc Version 5.0 Page 11 associated communication needs. The registered manager further discussed how advocacy services may be used in the future to enable service users to be involved more in the home. The registered manager further detailed how one service user was able to be involved in deciding which member of staff was to be their key worker. The registered manager confirmed that all but two of the service users’ finances have now been transferred via the court of protection. The main records for finances are held with the Local Authority and only a small amount of finance records being kept within the home. Service users’ files are being developed to include an ‘About Me; booklet, which clearly details the needs and wishes of the service user. For example, ‘ My Best Day’, ‘My Birthday’. Granville Court 4 DS0000041493.V272469.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. Service Users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,15,16 Service users are not fully supported in their personal development and social activities. EVIDENCE: Granville Court 4 DS0000041493.V272469.R01.S.doc Version 5.0 Page 13 Service users and staff were observed to interact positively, with staff understanding individuals preferred methods of communication. Staff would readily chat with service users, ensuring that they were comfortable. Staff check with the service users before entering their rooms. A staff member confirmed that service users undertake a variety of activities, which include; watching videos, art sessions and that a ‘music’ man visits the home. The other staff member confirmed that service users undertake ‘ hand and foot massages, walks, and visits to a local tearoom. Service user files contained only limited information relating to the activities, which service users undertake. Of the 3 files examined only one file detailed that a service user had undertaken an activity in their local community over the last month. A service users’ care plan detailed that structured activities should be undertaken but no evidence was available that this was occurring. On a morning, staff support service users with their personal care needs on a 2:1 basis. As there are 2 staff on duty there were times when service users were on their own in the lounge of the home. With no staff time being available to undertake structured activities. The registered manager confirmed that the link with the local adult education centre and a policy on intimate personal relationships are currently being developed and service users are yet to access these. The sensory garden now includes a fountain and continues to be developed. The registered manager confirmed that the policy to support service users should they wish to develop an intimate personal relationship is still under review/ development. Granville Court 4 DS0000041493.V272469.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,21 Service users are supported and their wishes are taken into account in the meeting of their needs. EVIDENCE: Service user files include details of an annual health check and of any visits to or from other professionals, for example the psychologist. Charts are kept of individuals’ needs regarding their health, for example, epilepsy monitoring and weight monitoring. Service user ‘About Me’ books include details of ‘ what you need to know about me’ and ‘ how I communicate’. They also include some details of the service users’ wishes for if the service user becomes ill or passes away. Granville Court 4 DS0000041493.V272469.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16, 18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 16, 18 and 35 (Older People) 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 Service users are protected by the complaints and vulnerable persons procedures in the home. EVIDENCE: There continues to be a complaints procedure that assists service users and relatives to complain. The policy includes a copy of the Local Authority’s procedure which is complimented by the homes’ own procedure. This includes pictures and is written to enable easier understanding of the complaints process. Records of complaints are kept, with the details of the actions taken. No records are kept that reflect the outcome of the complaint and if the complainant is happy with the outcome. Both staff members were confident in the actions they would take should they be required to handle a complaint. There is a copy of the Local Authority’s policy ‘ The Protection of Vulnerable Adults’, a whistle blowing policy and a policy relating to the POVA scheme. The registered manager confirmed that no allegations of abuse have been raised. Both staff members reflected positively on the actions they would take should they suspect any abuse. Granville Court 4 DS0000041493.V272469.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,30 Service users live in a clean and comfortable home, which requires some maintenance, redecoration and repair. EVIDENCE: The registered manager confirmed that the home remains on a waiting list for redecoration and refurbishment. Granville Court 4 DS0000041493.V272469.R01.S.doc Version 5.0 Page 17 The external appearance of the home reflects that the paintwork is in need of attention and there are several areas throughout the home where paint and wallpaper have worn away. Some of the areas of the kitchen are now in need of attention as there were several kitchen drawer handles missing, and drawer fronts. Carpets are also marked. There are cleaners employed within the home, however the need for refurbishment now detracts from the cleanliness of the home. The lack of paintwork/ fixtures may also compromise the hygiene within the home. A member of staff confirmed that ‘ the general maintenance of the home is poor, the staff toilet has been broken for two weeks’. Another staff member stated that ‘ The environment could be better’ and also that ‘ the hoist is always breaking’. The service user rooms do not contain all of the required items and the registered manager confirmed that a form is being developed, which will identify the service users’ choices and reasons for this. A member of staff stated that the amount of hoisting required does at times cause problems for the staff team. No evidence was available that the home meets the Water Supply (Water Fittings) Regulations 1999. Granville Court 4 DS0000041493.V272469.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36 An appropriately recruited staff team supports Service users. The deployment, supervision and training of staff requires development in order to fully meet the needs of the service users EVIDENCE: The registered manager confirmed that the staff team continue to work to achieve their National Vocational Qualification (NVQ) level 2 and that the home have yet to achieve 50 of the staff team trained in this. However the registered manager confirmed that all the staff have either undertaken this training, have been registered to undertake it or have undertaken the Learning Disability award Framework Training (LDAF). One member of staff confirmed that they are undertaking the LDAF training. Granville Court 4 DS0000041493.V272469.R01.S.doc Version 5.0 Page 19 There is now a staff training and development programme, which details the training needs of the staff team and the individual staff members. The registered manager confirmed that some of the staff team have completed Moving and Handling training and that other staff members names have been forwarded to the training department to undertake this training. Staff files are now held within the home and include the recruitment details of the staff members. Criminal Record Bureau checks are undertaken on all staff commencing employment and that staffs that have been employed for some time have Police checks in place. The registered manager confirmed that staff supervision is continuing to be developed within the home and that the targets for 6 supervisions a year are not yet met. The staff members confirmed that they have been issued with and were aware of the General Social Care Council (GSCC) Code of conduct. The duty rota reflected that there is a qualified nurse on duty at all times. There are two staff on an early shift and two staff on a late shift and one member of staff overnight in each of the bungalows. The early and late shifts have a cross over period to allow for activities to take place. There are a total of 792 care hours per week. Granville Court 4 DS0000041493.V272469.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. Service users live in a home which is run and managed by a person who is fit to be in charge of good character and able to discharge his or her responsibilities fully. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40,41,42 Service users live in a home that is on the whole well run, but where health and safety needs are not fully met. Service users are not supported to be involved in the review and development of the home. Granville Court 4 DS0000041493.V272469.R01.S.doc Version 5.0 Page 21 EVIDENCE: The registered manager confirmed that she has not been absent from the home for more than 28 days and if this were to be the case then the Commission would receive notification. Also that they have now achieved the NVQ level 4 in management. The quality assurance system continues not to address all of the recommended areas. The registered manager discussed that due to the service users’ needs, consultation was very difficult and it was discussed that advocacy services may be appropriate. There are now regular fire drills taking place with appropriate records being kept. The registered manager confirmed that staff training in safe working practices is continuing and that the risk assessments for safe working practices continue to be developed. The registered manager also confirmed that visits as per the requirements of regulation 26 are not being completed. Staff now sign to say when they have read and understood a policy or procedure within the home. Communal records continue to be kept. Granville Court 4 DS0000041493.V272469.R01.S.doc Version 5.0 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 1 INDIVIDUAL NEEDS AND CHOICES CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 2 27 X 28 X 29 X 30 1 STAFFING Standard No Score 31 X 32 1 33 1 34 3 35 3 36 1 CONDUCT AND MANAGEMENT 37 1 38 X 39 2 40 3 41 2 42 1 43 x Standard No 6 7 8 9 10 LIFESTYLES 11 12 13 14 15 16 17 Score 3 2 2 3 x 3 1 X 2 2 3 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X 3 Granville Court 4 DS0000041493.V272469.R01.S.doc Version 5.0 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 Standard YA5 Regulation 4,5,17 Requirement The registered provider must ensure that the service users’ contract contains all of the required information. This is an ongoing requirement with a previous compliance date of 30th March 2004. The registered person must ensure that service users are supported to undertake educational and leisure activities. The registered person must ensure that the home is fit for purpose, well maintained. With furnishings and Fittings of a good quality. The registered person must ensure that the home is maintained to the standard to control the risk of infection. The registered provider must ensure that the home complies with the Water Supply (Water Fittings) Regulations 1999. This is an ongoing requirement with a previous compliance date of 25th February 2005. DS0000041493.V272469.R01.S.doc Timescale for action 30/03/04 2. YA12 12 12/03/06 3 YA24 23 30/03/06 4 YA30 13 30/03/06 5. YA30 13(3) 25/02/05 Granville Court 4 Version 5.0 Page 24 6. YA32 18 7 YA33 8 8. YA36 4,10,12,17,18. 9. YA37 26 10. YA42 12,13 11 YA42 12,13 The registered provider must ensure that staff are trained in the moving and handling of service users. This is an ongoing requirement, with a previous compliance date of 30/6/05. The registered person must ensure that the deployment of staff ensures the health and safety and leisure needs of the service users at all times. 4,10,12,17,18,21,22,24&26. The registered provider must develop and implement a programme of staff supervision and staff appraisal to fully comply with the requirements of the standard 36.1-36.8 of the National Minimum Standards and the associated Care Homes Regulations 2001.This is an ongoing requirement with a previous compliance date of 30th March 2004. The registered provider must ensure that the requirements of Regulation 26 visits are met. This is an ongoing requirement with a previous compliance date of 30/6/05. The registered provider must ensure that staff are trained in safe working practices. This is an ongoing requirement with a previous compliance date of 30/6/05. The registered provider must ensure that risk assessments for safe working practices are undertaken, in place home, and regularly reviewed. 30/06/05 12/03/05 30/03/04 30/06/05 30/06/05 30/03/05 Granville Court 4 DS0000041493.V272469.R01.S.doc Version 5.0 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Refer to Standard YA7 YA7 YA8 YA14 YA14 YA15 YA22 YA23 YA24 YA26 YA32 YA39 YA41 Good Practice Recommendations Service users involvement in the recruitment of staff should be further developed Advocacy services should be utilised to assist the service users in being involved in the home. Service user choices should be recorded in individual files. Service users should have their annual holiday included as part of the basic contract price of residing in the home. Service user leisure activities should meet service user wishes. A policy to support service users wishing to develop an intimate personal relationship should be developed. The outcome of complaints should be recorded. Service user finance records should be kept in the home. The furnishings and fittings should be reviewed and replaced as required. Service users’ rooms should include all the items required by the National Minimum Standard. The registered provider should consider how it would meet the requirement of 50 of care staff in the home achieve a National Vocational Qualification (NVQ) 2 by 2005. The quality assurance system should include all of the areas recommended by the National Minimum Standard. Communal records should not be utilised. Granville Court 4 DS0000041493.V272469.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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. Granville Court 4 DS0000041493.V272469.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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