Inspection on 07/06/07 for Granville Court 4

This inspection was carried out on 7th June 2007.

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 2 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 12/12/05

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 ADULTS 18-65 Granville Court 4 The Esplanade Hornsea East Yorkshire HU18 1NQ Lead Inspector Sarah Sadler Key Unannounced Inspection 7th June 2007 09:30 Granville Court 4 DS0000041493.V335865.R01.S.doc Version 5.2 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.V335865.R01.S.doc Version 5.2 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. Granville Court 4 DS0000041493.V335865.R01.S.doc Version 5.2 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.V335865.R01.S.doc Version 5.2 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). Date of last inspection Brief Description of the Service: 4 Granville Court is a purpose built care home offering up to 20 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, one of which is currently not being used. This means that currently there are 14 bedrooms available for use in the home. 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. However this is currently not in use. The home has a spacious courtyard area with seating that is enclosed and secure with good access, including for people in wheelchairs or with mobility problems. A new sensory garden is in place. 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. The weekly fees are £993.40, with additional charges for items such as toiletries and hairdressing. This information was provided by the registered manager at the site visit. Granville Court 4 DS0000041493.V335865.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report is based on information obtained from the pre-inspection questionnaire completed by the home, information received by the Commission for Social Care Inspection (CSCI) since the last inspection of the home and from the site visit to the agency on the 16th May 2007. This unannounced site visit was undertaken by one inspector over one day; the site visit commenced at 10.00 am and finished at 4.00 pm. Time was spent in the lounge of the two bungalows being used, observing everyday life. Staff interactions with service users were positive with staff talking and interacting readily with service users. People were relaxed in their home and appeared comfortable. Due to the specific communication needs of the service users no formal discussions were held between them and the inspector. Four staff and one visiting professional were interviewed and their positive comments are included within the report. A tour of the premises was undertaken and service users’ files and other records were examined. Questionnaires were sent to service users, their relatives/representatives, and health and social care professionals. One relative, one care manager and one health professional survey were received. All of these were positive regarding the standards within the home. Comments included; ‘ I cannot fault this service’, ‘I feel very confident about placing individuals in this service’, ‘ It is a very good care home’ and ‘ Genuinely interested in their clients’. No complaints have been raised and one compliment has been received regarding the good levels of care. Over the last year notifications about incidents in the home, including any accidents to the service users have been received by the CSCI as required by Regulation 37 of the Care Homes Regulations 2001. This helps to ensure that the CSCI is aware of incidents within the home, which may reflect on how well they are meeting the standards. What the service does well: Prior to entering the home, comprehensive assessments are undertaken of the individual service user. This ensures that the home is able to assess and confirm that it will be able to meet the identified needs. People have good opportunities and support to take part in social activities. Granville Court 4 DS0000041493.V335865.R01.S.doc Version 5.2 Page 6 Service users are able to access the primary health care team and other health professionals ensuring that their health care needs are met. There is a clear and user-friendly complaints procedure and complaints are taken seriously. This promotes openness and transparency, which helps service users and others to say if they are not happy with any aspect of the service. What has improved since the last inspection? What they could do better: Not all of the staff have undertaken mandatory training, for example, food hygiene and staff have not undertaken an induction to the home that meets the necessary requirements. Future training should include Equal Opportunities and Safeguarding Adults training. Having fully trained staff will assist the home to continue to fully meet the needs of the service users. The registered person must carry out monthly unannounced visits to the home to undertake an assessment of the home as per the requirements of regulation 26 of the Care Homes Regulations 2001. These visits enable the registered Granville Court 4 DS0000041493.V335865.R01.S.doc Version 5.2 Page 7 person to audit the home and to gain a clear picture of how the home is meeting peoples needs. Without these service users cannot be assured that the management of the home is aware of the standards in the home and that it can be effectively managed. This has been an ongoing requirement since the inspection report of May 2005. The registered manager should seek opportunities for service users to be further involved in the decision making processes in the home, including staff recruitment process. This would offer service users opportunities to develop their feelings of self worth and contribute to their involvement in the development of their home. 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. The summary of this inspection report can be made available in other formats on request. Granville Court 4 DS0000041493.V335865.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Granville Court 4 DS0000041493.V335865.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are assessed prior to entering the home, to ensure that the home can meet their needs. EVIDENCE: Of the service user files examined, two people have lived in the home for some time. Both of these people’s files included a copy of their Community Care Assessment (CCA), completed by the Local Authority. This assessment identifies the individual’s needs and provides the information required to develop a plan of care. The third person had moved into the home late last year. This person had a Community Care Assessment and Nursing Assessment undertaken on them. The Nursing Assessment had included information from several sources, for example, information from the staff at the last home the person lived in. The assessments that are completed ensure that the staff in the home are fully aware of the individual’s strengths and needs prior to the person moving into the home, and ensures that staff are confident in the meeting of these needs. Granville Court 4 DS0000041493.V335865.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 & 9 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are supported through systems of care planning and risk assessment to make choices and decisions affecting their lives. EVIDENCE: Each of the service users have individual files, which include a large amount of information relating to them, including care plan documents. The care plans identify areas of support required by the service users. These areas include; maintaining their personal health, diet and social activities. The care plans describe how this support is to be offered by the staff, and also links to other monitoring documents, which will provide information on how well these needs are being met. Comprehensive and clear care plans provide staff with the necessary information to competently support a service user in the meting of their needs. The care plans had, in addition been reviewed on a monthly basis, to reflect any changes in the service user or their needs, ensuring that the information Granville Court 4 DS0000041493.V335865.R01.S.doc Version 5.2 Page 11 they held was as up to date as possible and provides the care staff with the latest information regarding the service user when meeting their needs. When interviewed staff gave good examples of how people make decisions in their lives. These included; what time to get up or to go to bed, what to wear, what to eat and whether or not to take part in an activity. The individual daily diary notes also included details of the choices a person may make, for example, ‘Requested to go to bed at 18.30.’ Staff further discussed how they are aware of individual’s service users methods of communication and how this may be a straight forward as the way a persons behaviour may alter when offered a certain food to eat. By understanding the individual communication methods of the service users staff are able to as near as possible assist the service users to make positive choices in their lives as much as possible. Due to most of the service users level of learning disability, it is difficult for people to be involved in the more formal processes within the home. However staff related that the service users decide the day to day running of the home, as they decide when they are getting up or if they are going to go out or stay in for the day. This in turn affects the full planning for the home for the day. Supporting people with choices in their everyday lives provides people with some control in their lives. It is recommended that the home explore opportunities for less formal methods of greater involvement, including being involved in the recruitment of the staff that supports them. Service user files included risk assessments that related to a variety of areas in supporting the person with their lives. They covered, for example, the risk of using the kitchen to bake food and the risk of going out in a wheelchair. These risk assessments had been regularly reviewed and were up to date. This ensures that the latest information is available to the staff who support the service users, whilst reducing the risk of harm. Granville Court 4 DS0000041493.V335865.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14, 15,16,& 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users have opportunities for leisure activities in their home and local community. They are supported with maintaining relationships and in the meeting of their dietary needs. EVIDENCE: Service users are offered a variety of activities to help meet their social needs. Since the last inspection there has been an increase in both the staffing levels in the individual bungalows and in the amount of recorded activities, which take place on a daily basis for each service user. Records now reflect that people are offered, and if they wish to, undertake an activity both morning and afternoon. The activities are varied and are both within the persons own home and in the local community. Staff confirmed that they included; visits to line dancing, walks on the sea font and head massages. Granville Court 4 DS0000041493.V335865.R01.S.doc Version 5.2 Page 13 One service user had benefited greatly from the input of a health professional and the increase in activities within their day. They were offered more choice in their lives, including an increase in activities and, it was recorded, were now more settled and relaxed. Plans are in place to support the service users to undertake an annual holiday. Staff will support service users with this. However the cost of this is not included in the basic contract price for residing in the home, which may allow more flexibility and for service user to utilise their monies elsewhere. People are also supported to maintain family relationships. People’s files included details of visits from family and staff confirmed that relatives are welcome to visit at any time and that they support service users to maintain relationships by ensuring that they are kept up to date, invited to parties and are sent cards on special occasions, for example Christmas. The one relative survey returned confirmed in their answer that staff keep them up to date on information regarding their relative. There is now a policy in place to assist staff in supporting service users should they wish to develop an intimate personal relationship. People receive good support in the meeting of their dietary needs. Mealtimes were pleasant and unrushed with service users being offered good support with eating their meals. Where required, people had specialist equipment to assist with eating. Information had been sought from other professionals to assist people with eating and drinking, and some had specialist support plans in place. People’s dietary needs are assessed and if necessary records are kept of food and fluid taken by the service user. Two of the three service users’ files examined included up to date records of the individual’s weight, to assist staff in ensuring that people are receiving the right dietary intake and that their dietary needs are being met. Good support from both the staff team and other specialists as necessary helpa to ensure that these needs are well met. One persons weight chart clearly identified that this persons weight was to be assessed on a weekly basis. However the records reflected that this had on the whole been completed on a fortnightly or monthly basis. The registered manager addressed this on the day of the inspection. Up to date records assist in the monitoring or peoples dietary needs and may reflect an increase in need, which would require addressing and may otherwise be overlooked. Granville Court 4 DS0000041493.V335865.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People receive good personal support to access a variety of services to meet their health and medication needs. EVIDENCE: In discussion with the staff team it was clear that they had a good understanding the individual service users, including their likes and dislikes to be able to support them with their personal care in the way that the service user would choose. The information was included in both the persons ‘About Me’ book and in the daily notes. Examples of how this occurs included that one person likes music being played whilst they are being supported and that another person requires additional and sensitive support when their hair is washed as they do not enjoy this experience. Both of the professional surveys returned reflect that people felt that service users’ privacy and dignity is maintained, with one commenting ‘Dignity and Privacy appear to be of paramount importance’. The staff interviewed gave good examples of how they maintain this in everyday practice, including ensuring that doors are closed when personal care is being delivered. Granville Court 4 DS0000041493.V335865.R01.S.doc Version 5.2 Page 15 Service users access a range of health professionals to assist in the meeting of their health needs. Responses from health professionals confirmed that it was felt that the staff team work well in following instructions and sharing information to assist with this process. One person commented‘ I cannot fault this service’. The person interviewed also confirmed that there is a regular meeting of the health professionals and the home to ensure that information is up to date and shared to ensure that the procedures in place continue to be the best available to meet the health needs of the individual service user. These systems are supported by the staff ensuring that people’s health needs are documented and, on the whole, any changes recorded. Staff confirmed that ways that they support people in the meeting of their needs include; to report any changes and to ensure that people receive their prescribed creams. The service users all receive support from a registered nurse to meet their medication needs, with the comments in one survey confirming that the professional felt peoples medication needs are met. There are systems in place to facilitate this, which include recording of all medicines received, administered and disposed of in the home. There have been no medication queries or omissions since the last inspection. All medicines are stored appropriately and safely. There is a fridge for medicines requiring being stored at a low temperature. Whilst medicines are stored in the fridge regular checks are made to ensure that the fridge is operating at the correct temperatures. However this does not take place when the fridge is not in use. It would be good practice that temperature checks continue to be taken to ensure that any faults are discovered quickly to ensure that medication storage is not compromised. Granville Court 4 DS0000041493.V335865.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. . Systems are in place to enable people to raise complaint s, have these responded to appropriately and to protect people from harm. EVIDENCE: There are good complaints systems available and on display within the home, which support the service users or their representatives to be able to raise any concerns and be confident that these will be dealt with appropriately. The complaints systems are made up of two complaints procedures. The first is a comprehensive policy, which has been developed by the Local Authority. The second is an easy read version, developed in the home, which allows for clear direction if anyone, in particular a service user wishes to complain. Staff were confident in their replies that should they raise a concern with the senior staff then this would be dealt with appropriately. Although not all of the staff have undertaken training in protecting people from harm, all of the staff interviewed gave positive responses regarding their reactions should they believe a service user was receiving inappropriate treatment. Staff training in this area would increase people’s knowledge of how to handle such a situation and offer more support to service users. There are polices and documents in place including a copy of the Local Authority’s procedure ‘ the Protection of Vulnerable Adults’, to support the service users and staff with these issues should a concern arise. Granville Court 4 DS0000041493.V335865.R01.S.doc Version 5.2 Page 17 As the service user who had been assessed and agreed as in need of some restraint to keep them safe no longer resides in the home, the previous recommendation for keeping records relating to this is not necessary. Granville Court 4 DS0000041493.V335865.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users live in a warm and comfortable home. EVIDENCE: The registered persons have decided to stop using one of the bungalows for service user accommodation. This bungalow has not been part of the refurbishment plan completed since the last inspection and continues to require attention should it again be considered for residential use. The lounge and kitchen areas of the remaining two bungalows have been redecorated and refurnished and offer service users a comfortable and homely environment. The bedrooms are all single rooms, and have sinks but not en-suite w.c facilities. Service users are encouraged to have their personal possessions in their bedrooms, this allows people to have familiar things around them and Granville Court 4 DS0000041493.V335865.R01.S.doc Version 5.2 Page 19 helps promote a sense of individuality and feelings of ownership. As part of the ‘About Me’ books, people have identified which items listed in the National Minimum Standards are in place and which are not, with a reason being offered for why an item is not, for example, that it is the service users’ choice. Bedrooms are clean and comfortable, and in discussion with the registered manager it was agreed that these are nearing the time for refurbishment. There is one bathroom in each bungalow with assisted bathing facilities. There has recently been an issue with the water temperatures in the bathroom and this has been reported by the home to the appropriate section within the Local Authority. A visit has already been made to the home and this is being dealt with. To be able to ensure that service users receive a bath at the correct and safe temperature this work needs to go ahead without delay. In addition to the weekly checks of the hot water temperatures, the temperature is checked as each person is bathed. On the day of the visit the hot water was found to be close to 43° centigrade at both sink and bath outlets, which is the recommended temperature. The registered manager confirmed that there remains no evidence that the water system within the home meet the requirements of the Water Supply ( Water Fittings) 1999 Regulations to ensure a safe water supply for service users. Some of the bathrooms tiles were missing and it was agreed with the registered manager that the bathrooms are nearing the time for redecoration. There is a call bell system in place, which due to service user need is used by the staff only in an emergency to call for assistance. Aids and adaptations are provided and regularly serviced. The registered manager confirmed that the home utilises the support of the maintenance department of the Local Authority to ensure that the necessary checks are completed. The garden areas are well maintained and the courtyards are made attractive with planting and other garden features. A community group have recently developed the gardens further, with the sensory garden now being operational and a large tub being planted. The registered manager confirmed that a summerhouse is to be installed in the near future, which will assist service users to spend more time outside whilst also offering them protection from the sun. Granville Court 4 DS0000041493.V335865.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 & 35 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. . Service users are supported by improved numbers of staff that are well recruited and who have received some training. EVIDENCE: Staff were observed to have positive relationships with service users. Staff have a good understanding of the communication methods of the service users and their likes and dislikes, which assisted them in supporting service users to meet their needs. Duty rotas reflect that there has been an increase in staffing to 3 staff per day shift, and only a small amount of agency staff is used. The registered manager confirmed that when this occurred the home used the same staff to ensure continuity for service users. There continues to be 2 staff per bungalow overnight, with a ‘floating’ night staff available when needed. Granville Court 4 DS0000041493.V335865.R01.S.doc Version 5.2 Page 21 Staff files examined showed a satisfactory recruitment process, which endeavours to make sure that only suitable people are employed. All staff are subject to a probationary period. There is an induction programme that has yet to be started, which would ensure new staff members are given the right information to be able to do their jobs well and meet the training requirements of Skills for Care. This would ensure that staff have received induction training to the required level to be able to support service users appropriately. The registered manager has developed a training matrix and has utilised staff supervision sessions to determine what training staff have undertaken and what training they still require. This information is fed back to the Local Authority and courses are then offered to staff. Staff spoken to confirmed that they had undertaken a variety of training, which included Fire Safety and First Aid. All three surveys reflected that people felt staff were trained to look after people properly. However, not all of the staff have completed the mandatory training in Moving and Handling, Fire Safety, Food Hygiene, and Health and Safety. And the registered manager confirmed that no one has yet accessed training on Equal Opportunities; this has recently become available via an online course. There are 12 staff who have now completed their National Vocational Qualification (NVQ) level 2 in care, with a further 4 undertaking this. When complete this will mean that the home has reached the requirement for 50 of the staff team to be trained to this level. The registered manager is aware that the staff team require training to be able to maintain and up date their skills and knowledge to continue meeting service users’ needs. Staff files contained only a tick list of courses that the staff member had undertaken. The registered manager is aware that certificates of training provide a more substantial basis for ensuring that training has been undertaken, ascertaining peoples training needs, provides the dates for upgrading and ensuring that service users are supported by well trained staff. Granville Court 4 DS0000041493.V335865.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users live in a home that is well managed to ensure their health and safety and financial needs are met, whilst also offering them the opportunity to participate in its development. EVIDENCE: The registered manager is qualified and experienced. She has undertaken a variety of courses, which include Health Action Planning. There are staff meetings that support the staff to raise concerns and issues, with staff commenting that they felt able to raise any concerns with the manager, reflecting a management system that supports the staff in the meeting of service users’ needs. Granville Court 4 DS0000041493.V335865.R01.S.doc Version 5.2 Page 23 None of the service users manage their own finances and they are supported by good systems in place within the home. The system includes that receipts are collected for purchases and these reflected that the practice of staff utilising personal store cards for reward points no longer takes place. There continues to be a quality assurance system in place, which seeks the views of service users, staff and other stakeholders. It also includes an audit of the home. The registered manager confirmed that the quality assurance audit has started but is not yet complete for this year. A good quality assurance system ensures that people are able to comment on how well the home is meeting the aims and objectives, whilst also assisting in its future development. However the monthly visits required by the registered person under Regulation 26, of the Care Homes Regulations 2001, as a regular audit is not taking place. This leaves the management being unable to confirm fully that all standards are met and that service users are safeguarded. Service users are supported to be safe in the home by good Health and Safety policies and practices. There are a large variety of policies available via both the Local Authority and the NHS with staff currently updating themselves regarding these to ensure that they are aware of latest good practice in supporting people. Checks are undertaken and up to date records are kept on Gas Equipment, Electrical Wiring, Emergency Lighting and Portable Appliances (PAT). Fire checks are undertaken and fire fighting equipment and the fire alarm are also maintained to assist in ensuring that people receive the right support should an incidence of fire occur. There is evidence of up to date insurance for the home to ensure that people are protected should an incident occur. Granville Court 4 DS0000041493.V335865.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 1 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 1 X X 3 X Granville Court 4 DS0000041493.V335865.R01.S.doc Version 5.2 Page 25 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 YA33 Regulation 18 Requirement The registered person must ensure that all staff are adequately trained, to ensure the service user needs are met. 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. Timescale for action 07/12/07 2. YA39 26 07/07/07 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 Refer to Standard YA7 YA7 Good Practice Recommendations The registered person should explore more methods of involving the service users in decision making in their home. Service users’ involvement in the recruitment of staff should be further developed, to assist people to have more choice and control in their lives. Granville Court 4 DS0000041493.V335865.R01.S.doc Version 5.2 Page 26 3. 4 YA14 YA20 Service users should have their annual holiday included as part of the basic contract price of residing in the home. The registered manager should ensure that the temperatures of the medication fridge are taken at all times. This would assist in ensuring that any faults can be quickly found and dealt with. The registered person should ensure that the bungalow not in use is refurbished prior to service users recommencing residing in there. This would help to ensure that this area offers a comfortable home to those service users. The registered provider should continue to working towards of 50 of care staff in the home achieving a National Vocational Qualification (NVQ) 2. The registered person should be able to provide evidence that the home meets the Water Supply (Water Fittings) Regulations 1999. Reflecting a fully safe water system for service users. The registered person should ensure that all new staff have undertaken the induction to the Skills for Care requirements. This would facilitate them with some knowledge and skills in the meeting of service users needs. The registered person should ensure there is certified evidence of all staff qualifications. To assist in evidencing, auditing and future planning of training in the meeting of service users needs. The registered person should ensure that staff are trained in equal opportunities, providing them with knowledge and skill in this area to assist in the meeting of service users’ needs. The registered person should ensure that all staff are trained in ‘Safeguarding Adults’ procedure. This would assist with this process and support the service users should such an allegation occur. 5 YA24 6. YA32 7. YA30 8. YA33 9. YA33 10. YA33 11. YA33 Granville Court 4 DS0000041493.V335865.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V335865.R01.S.doc Version 5.2 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. 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