CARE HOME ADULTS 18-65
Granville Road 75-77 Wood Green London N22 5LP Lead Inspector
Susan Shamash Key Unannounced Inspection 18th April 2006 3:00 Granville Road 75-77 DS0000010723.V288181.R01.S.doc Version 5.1 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 Road 75-77 DS0000010723.V288181.R01.S.doc Version 5.1 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 Road 75-77 DS0000010723.V288181.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Granville Road 75-77 Address Wood Green London N22 5LP 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) 020 8888 4189 020 8888 4189 HAIL (Haringey Association for Independent Living Limited) Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Granville Road 75-77 DS0000010723.V288181.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 3rd October 2005 Brief Description of the Service: 75 - 77 Granville Road is a registered care home providing personal care for six younger adults with learning disabilities. Circle 33 Housing Association owns the property and the care and support are provided by Haringey Association for Independent Living (HAIL), an independent sector provider offering a range of accommodation for people with a learning disability in the London Borough of Haringey. The home is a large converted domestic building with three floors. The ground floor comprises the main communal areas and one resident bedroom. The second and third floors contain the remaining resident bedrooms with an additional activity/therapy room recently created on the second floor. There are adequate bath and toilet facilities in close proximity to the residents’ bedrooms. The home is situated in a quiet residential road within easy reach of Wood Green shopping centre and a range of multicultural resources in the vicinity. The stated aim of the home is to provide twenty-four hour support and care for six people with a learning disability to live as independently as possible within the community of Wood Green. Weekly fees as at 04/05/06 are £1149.39 inclusive although on rare occasions additional charges are made for specialist care negotiated with social services. Granville Road 75-77 DS0000010723.V288181.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over approximately five and a half hours and was carried out as a routine unannounced visit to the home. The inspector received assistance from the deputy manager, who was available within the home throughout the inspection. The inspector also had the opportunity to speak to another three staff members independently and one resident. The inspector spent some individual time with five other (less verbal) residents. A tour of the premises took place and care records were inspected. What the service does well: What has improved since the last inspection?
Eight requirements were made at the previous inspection of which six were met and two were partially met. The complaints book for the home had been updated to include more details, such as people involved in the complaint, timescales for action, and feedback to the person who complained. This further ensures that complaints are responded to appropriately.
Granville Road 75-77 DS0000010723.V288181.R01.S.doc Version 5.1 Page 6 A number of minor maintenance issues had been addressed within the home to ensure the comfort of residents including repairs to two bathroom walls and repainting of the medication cabinet. Some soft furnishings had been provided in the therapy room at the home so that residents can use it comfortably, and further cushions are to be provided. As recommended, a new mattress had been provided in the staff sleeping-in room and measures had been taken to ensure the comfort of the resident who prefers to sleep with their head against their bedroom wall. Finally reports of unannounced visits to the home by the responsible individual were being sent to the CSCI on a monthly basis to ensure that standards of care at the home are maintained adequately. What they could do better:
Two requirements made at the last inspection have not yet been fully met and have been restated in this report, with a new timescale for compliance. Unmet requirements impact upon the welfare and safety of residents. Failure to comply by the revised timescale will lead to the Commission for Social Care Inspection considering enforcement action to secure compliance. It remains required that further risk assessments must be undertaken for residents, to ensure their safety, and all risk assessments must be reviewed at least six-monthly. It is also required that the identified resident should be able to attend church regularly and be provided with a bigger table as agreed at their most recent review meeting. Work to repair the ground floor bathroom wall must be completed, and the wall should be appropriately reinforced as far as possible. The banisters on the stairwells in the home must also be prioritised for repainting and accumulated rubbish in the rear garden should be disposed of. The number of staff working on each shift at the home should be reviewed again to ensure that residents have sufficient opportunities to go out in the community when they wish to. An application must be made to register a manager for the home with the CSCI. It is recommended that problems with working relationships between senior management and staff members in the home be addressed. Granville Road 75-77 DS0000010723.V288181.R01.S.doc Version 5.1 Page 7 Quality assurance audits must be undertaken at least annually, and appropriate procedures must be put in place to set up and manage residents’ bank accounts to ensure safe handling of residents’ money. It is recommended that incident records should include details of preventative actions to be taken to prevent further reoccurrences when appropriate. All hazardous chemical should be locked away when not in use, emergency lighting in the home should be tested at least monthly, and self-closing doors, at least weekly (e.g. during the weekly fire alarm tests). 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 Road 75-77 DS0000010723.V288181.R01.S.doc Version 5.1 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 Road 75-77 DS0000010723.V288181.R01.S.doc Version 5.1 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3. New residents are only admitted following detailed assessments, and thus the home is able to meet the needs of all residents in the home effectively. EVIDENCE: There had been no changes to the residents living in the home since the previous inspection. Records maintained within resident files showed that their needs had been assessed comprehensively prior to admission. There was also evidence that their needs were being reassessed on a regular basis. Inspection of care plans and observation of support provided to residents within the home indicated that their disparate needs continue to be met effectively. Granville Road 75-77 DS0000010723.V288181.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9. Residents’ needs, choices and aspirations are generally assessed and monitored sufficiently to ensure that they can be met effectively. However there remains room for improvement in the way the home addresses their changing needs within risk assessments to ensure that support provided is responsive. Mechanisms are in place to ensure that residents are involved in all aspects of home life and that they are encouraged to be as independent as possible, in accordance with their wishes. EVIDENCE: Satisfactory individual care plans are in place for residents although a computerised recording system has ceased to be used to record shift support plans. A new format is being used to produce a ‘life story’ book for each resident alongside person-centred plans and reviews. As required at the previous inspection all care plans had been reviewed and updated within the last six months. Granville Road 75-77 DS0000010723.V288181.R01.S.doc Version 5.1 Page 11 Whilst a number of written risk assessments were available for all residents, discussion with the deputy manager and staff regarding residents’ individual needs in addition to observation of interactions within the home, indicated that these still did not cover all specific risks for which preventative action was being taken (e.g. a resident who frequently damages property in the building and taps in individual residents’ bedrooms being turned off due to repeated flooding incidents). The requirement made at previous inspections regarding risk assessments is therefore restated. Where limitations on a resident’s freedom are deemed necessary (e.g. their right to have running water in their bedroom), the recorded agreement of the resident (if possible or next of kin), their social worker and the home manager should be obtained and this must be reviewed periodically. Minutes of resident meetings indicated that they were encouraged to participate in making decisions about the home, including holiday destinations and food to be available on the menu. Observation of staff/resident interactions such as encouraging resident involvement in setting the table for a meal, also indicated that they are encouraged to be involved in household routines, thus practicing independent living skills. However they advised that they were not forced to engage in activities in which they did not wish to participate, thus ensuring that their choices were respected. Granville Road 75-77 DS0000010723.V288181.R01.S.doc Version 5.1 Page 12 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. Residents have a wide range of opportunities to take part in age, peer and culturally appropriate activities within and outside of the home, and support is provided in maintaining family contacts and developing independence skills. The home is creative and innovative in supporting residents with educational, vocational and leisure activities and ensuring that their rights and responsibilities are respected. However occasionally inadequate staffing numbers may minimise opportunities for residents to go out in the local community. Residents appear to be involved in and satisfied with the provision of food at the home, which consists of a varied and nutritious diet that takes account of cultural preferences. EVIDENCE: Granville Road 75-77 DS0000010723.V288181.R01.S.doc Version 5.1 Page 13 Residents’ activity charts, care plans and daily notes indicated that a wide range of activities were available to residents both within and outside of the home. Various games and jigsaw puzzles are available in the home, in addition to a recently refurbished therapy room, equipped with a wide selection of multisensory equipment. Four of the six residents were attending day activities during the early part of the inspection, at various day centres within the local area. Activities at these centres included music, arts and crafts and swimming. One resident is attending an access to further education course for people with profound and complex learning difficulties at a local college. Each resident had a weekly rota of chosen activities within their care plan. The manager advised that no residents have jobs or are involved in employment related programmes, however one staff member had previously arranged for and supported a service user, who expressed an interest in becoming a nurse, to have a day’s work experience in a residential care home for older people, which had been a huge success. A new Turkish-speaking staff member had commenced work at the home and is now key-working the Turkish-speaking resident, to ensure that their needs are met. In addition all members of the staff team have learned rudimentary words in Turkish. Staff continue to support one resident in attending a Hare Krishna temple and a Hindu temple periodically. However, although it was agreed at one resident’s most recent review that they should attend church on a weekly basis, this had not yet been arranged. A requirement is made accordingly. There was evidence within care plans, and through observation of the evening routines in the home, that residents are encouraged to be involved in the dayto-day tasks of shared home living. Residents spoken to had enjoyed previous holidays with the home and were looking forward to another holiday this year. Staff and residents advised that trips were arranged within the local community to visit restaurants, the pub and local shopping facilities. However these were dependent on their being sufficient staff on duty in the home, and were therefore not always possible. A requirement is restated under Standard 34 accordingly. Menus seen were appropriate and indicated a range of balanced meals. Food was appropriately stored and in date, and the kitchen was clean and tidy. Residents spoken to and observed during the mealtime, indicated that they enjoyed the food served within the home. Staff spoken to were very aware of residents’ individual preferences and cultural requirements regarding diet. Granville Road 75-77 DS0000010723.V288181.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Residents receive appropriate physical and emotional support in line with their preferences, and are adequately protected by systems in place for administering medicines. EVIDENCE: Resident files inspected showed regular input from a variety of health professionals. These included psychiatry, psychology, speech and language therapists as well as appointments with GPs, opticians and dentists. The inspector spoke to several staff members and observed the interactions of staff and residents prior to the early evening meal in the home. Staff were seen to interact appropriately and sensitively with residents, treating them with dignity and encouraging them to be independent where possible, whilst providing support when needed. In conversation, staff spoke enthusiastically about their work, and were well informed and skilled in working with residents with profound learning disabilities. Staff were also seen to knock and wait for an answer prior to entering residents’ rooms, toilets and bathrooms as appropriate. Granville Road 75-77 DS0000010723.V288181.R01.S.doc Version 5.1 Page 15 Residents’ current medication and MAR charts were inspected and were complete and up to date as appropriate. As noted at the previous inspection, all staff administering medication within the home had undertaken appropriate training in August 2004. Granville Road 75-77 DS0000010723.V288181.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Residents’ views are acted upon, and an improvement in the recording of complaints ensures that complaints are addressed appropriately within set timescales. Residents are protected from abuse and self-harm, as appropriate, with staff very aware of the need to monitor changes in the behaviour of residents who are non-verbal, and thus particularly vulnerable. EVIDENCE: The home has a satisfactory complaints policy, however at the previous inspection the complaints record maintained at the home was not sufficiently detailed. An improvement was noted in this area so that actions taken, those involved, timescales by which the complaint was investigated and feedback provided to the complainant are all recorded. No complaints regarding the home had been received since the previous inspection. Care plans and resident meeting minutes indicated that residents’ views are listened to. Discussion with staff members and observation of procedures within the home, indicated that staff are familiar with the adult protection policy for the home and that records are maintained as required. Granville Road 75-77 DS0000010723.V288181.R01.S.doc Version 5.1 Page 17 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 and 30. The environment in which residents live is bright, comfortable and safe, and the home is commended for innovative refurbishment of a spare room into a therapy room. Bedrooms reflect residents’ individuality and choices as appropriate. The home is maintained to a satisfactory level of cleanliness, however a resident’s specific furniture need and a small number of maintenance issues must be addressed to ensure the comfort of residents and staff. EVIDENCE: Residents live in an environment that appears to meet their needs with personalised rooms and sufficient toilets and bathrooms. All residents’ rooms were inspected and found to be personalised and decorated appropriately. As recommended at the previous inspection, solutions had been sought to ensure the comfort of the resident who rests their head against their bedroom wall when lying in bed. As specified at a recent review meeting for an identified resident, it is required that a larger table be provided in their bedroom, for their use. Granville Road 75-77 DS0000010723.V288181.R01.S.doc Version 5.1 Page 18 The décor of the bathrooms on the first and ground floor following refurbishment, including stencilled designs on the walls, remains pleasant and bright. The deputy manager advised that, as required at the previous inspection, a hole in the ground floor bathroom wall (caused by the door handle) had been repaired. However further damage had recently been sustained to this wall, and this was in the process of being repaired. A new requirement is made accordingly. As required the medication cupboard on the ground floor had been repainted, giving it a brighter interior. It is required that the banisters on the stairwells in the home be prioritised for repainting. In the last year, an empty room on the top floor of the home had been refurbished and converted into a therapy room for residents. It includes vivid murals on the walls, painted by staff, and a wide range of multi-sensory equipment. As required at the previous inspection a number of soft furnishings had now been provided in this room, so that the room is now more comfortable for residents. As recommended a new mattress had been provided for staff in the sleeping-in room. Staff indicated that there had been intermittent problems with regard to the availability of hot water in the home, but that this had been addressed. Inspection of hot water temperature and temperature records indicated that there was no longer a problem with the home’s supply of hot water. The garden was in a reasonable condition, however a requirement is made regarding the need to remove accumulated discarded items from this area. Granville Road 75-77 DS0000010723.V288181.R01.S.doc Version 5.1 Page 19 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. Residents are protected by a robust recruitment procedure, and are supported by staff who are experienced and receive appropriate training and supervision to meet their needs. However sufficient staff are not always available to ensure that residents can make full use of community facilities, particularly in the evenings and at weekends. EVIDENCE: Three staff files were inspected and included information specified under the care homes regulations. Enhanced CRB disclosures had already been provided to the inspector for the most recently employed staff members and as-andwhen staff employed at the home, as required following the previous inspection. Inspection of staff files and discussion with three staff members indicated that residents are supported by an effective and competent staff team, who have attended a wide range of training courses. Regular supervision sessions are arranged to support staff as appropriate. However observation of the staff rota and discussion with staff also indicated that there remain regular times when only two staff members were on duty (particularly in the evenings and at weekends) so that there were not sufficient staff to take residents out into the community if they so wished. Granville Road 75-77 DS0000010723.V288181.R01.S.doc Version 5.1 Page 20 At the previous inspection it was required that the number of staff members scheduled to work in the home be reviewed, with particular consideration given to residents’ needs for attending community activities. Feedback to the inspector in the action plan from this inspection indicated that at least three staff members are provided in the mornings and two in the afternoons and evenings. However discussion with staff and observation of interactions within the home indicated to the inspector that two staff members on duty may not be sufficient to meet the needs of all residents at the home. There are at least two residents who require one-to-one support when in the home and a number of other residents who may exhibit challenging behaviour therefore requiring a high level of support at these times. It is therefore required that a further review of the staffing levels in the home be conducted with particular consideration given to residents’ needs for attending community activities in the evenings and at weekends. Granville Road 75-77 DS0000010723.V288181.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42. The home continues to be well organised, and a new manager has been appointed, however failure to register a manager for the home places residents at risk of an inadequately run service. Monitoring systems are in place to safeguard residents and their views are taken into account. However this is compromised by insufficient quality assurance systems and an inappropriate procedure for managing residents’ finances. The health and safety of residents is generally promoted and protected effectively, although there is room for improvement in the storage of hazardous chemicals and some fire safety checks. EVIDENCE: The new manager who had commenced work at the home on the day of the previous inspection, remains in place at the home, however she was not on shift at the time of the inspection. Granville Road 75-77 DS0000010723.V288181.R01.S.doc Version 5.1 Page 22 Although an application pack to register as manager had been requested from the Central Registration Team of the CSCI, no application had as yet been submitted. A requirement is made accordingly. Feedback from a number of different staff members spoken to individually, indicated that there were some problems with the relationship between senior management and staff members in the home. It is recommended that this be addressed. As required at the previous inspection monthly visits were being undertaken by the area manager for the home, to monitor the standards of care in the home, and reports of these visits were being sent to the home and the local CSCI area office on a monthly basis. The deputy manager advised that the previous quality assurance framework was no longer being used at the home, however she was not aware of any other system replacing this. The registered person must ensure that a quality assurance audit is undertaken or the home at least annually. Monies maintained for safekeeping on behalf of residents within the office, were stored appropriately. Records for three residents were inspected and found to match the amounts stored for them in each case. However the inspector was concerned to learn that a bank accounts had been set up on behalf of a resident in the name of an unregistered staff member within the home ‘Re:’ the particular resident. It was of particular concern that bank statements for this resident were being received at the staff member’s home address. The staff member told the inspector that auditors had come to their home address to view these records although they ensured that all statements were brought straight to the home’s office for safekeeping. Discussion with the responsible individual for the provider organisation indicated that this system had been set up as a result of instructions from the court of protection on behalf of this resident. However it was noted that this arrangement is not satisfactory, and places the resident at risk. A requirement is made accordingly. Satisfactory records of incidents and accidents occurring at the home were maintained, with significant events notified to the CSCI. However it is recommended that incident records should include details of preventative actions to be taken, to prevent further reoccurrences when appropriate. Maintenance records and safety certificates were inspected and generally found to be appropriate. As required at the previous inspection a current electrical installation certificate was available for the home. Current and satisfactory gas safety, portable appliances, legionella and fire equipment servicing certificates were in place. Weekly fire alarm testing and regular fire drills were carried out as appropriate.
Granville Road 75-77 DS0000010723.V288181.R01.S.doc Version 5.1 Page 23 However it is required that emergency lighting in the home be tested at least monthly and self-closing doors be tested weekly (e.g. during the weekly fire alarm tests). Granville Road 75-77 DS0000010723.V288181.R01.S.doc Version 5.1 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 3 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 3 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X 1 2 X Granville Road 75-77 DS0000010723.V288181.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA9 Regulation 13(4b) 14(1a2a) Requirement The registered person must ensure that further risk assessments are undertaken for service users so that all preventative action taken to avoid risks is recorded, and these must be reviewed at least sixmonthly. Where limitations on a resident’s freedom are deemed necessary (e.g. their right to have running water in their bedroom), the recorded agreement of the resident (if possible or next of kin), their social worker and the home manager, should be obtained. (Previous timescales of 24/06/05 and 25/11/05 partially met). The registered person must ensure that the identified service user is able to attend church regularly and is provided with a bigger table as
DS0000010723.V288181.R01.S.doc Timescale for action 16/06/06 2 YA13YA26 16(2c3) 02/06/06 Granville Road 75-77 Version 5.1 Page 26 3 YA24 23(2d) agreed at their most recent review meeting. The registered person must complete works to repair the ground floor bathroom wall, and ensure that it is appropriately reinforced as far as possible. The banisters on the stairwells in the home must also be prioritised for repainting, with a schedule provided to the inspector for when this will be undertaken. The registered person must ensure that accumulated rubbish in the rear garden is disposed of. The registered person must ensure that staffing numbers within the home are reviewed with particular regard to providing sufficient staff so that service users’ have opportunities to attend community activities in the evenings and at weekends. (Previous timescale of 16/12/05 partially met). The registered person must ensure that an application is made to register a manager for the home with the CSCI. The registered person must ensure that a quality assurance audit is undertaken at least annually. The registered person must ensure that appropriate procedures,
DS0000010723.V288181.R01.S.doc 26/05/06 4 YA24 23(2o) 26/05/06 5 YA33 18(1a) 16/06/06 6 YA37 8 9 16/06/06 7 YA39 24 30/06/06 8 YA41 20 26/05/06 Granville Road 75-77 Version 5.1 Page 27 9 YA42 13(4a) as detailed in a letter to follow from the CSCI, are in place to set up and manage service user’s bank accounts. The registered person must ensure that all hazardous chemicals (COSHH materials) are locked away when not in use. Emergency lighting in the home must be tested at least monthly and selfclosing doors must be tested at least weekly (e.g. during the weekly fire alarm tests). These tests must be recorded. 05/05/06 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 YA37 YA41 Good Practice Recommendations It is recommended that problems with working relationships between senior management and staff members in the home be addressed. It is recommended that incident records should include details of preventative actions to be taken to prevent further reoccurrences, when appropriate. Granville Road 75-77 DS0000010723.V288181.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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