Inspection on 13/11/07 for Gravers Care Home Ltd

This inspection was carried out on 13th November 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Gravers Care Home Ltd 28/11/06

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 Gravers Care Home Ltd 17 Wigginton Road York YO31 8HG Lead Inspector David White Key Unannounced Inspection 13th November 2007 09:30 Gravers Care Home Ltd DS0000065690.V348996.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 Gravers Care Home Ltd DS0000065690.V348996.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. Gravers Care Home Ltd DS0000065690.V348996.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gravers Care Home Ltd Address 17 Wigginton Road York YO31 8HG 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) 01904 645510 01904 676323 Gravers Care Home Limited Mr Dale Andrew Graver Care Home 17 Category(ies) of Learning disability (17), Learning disability over registration, with number 65 years of age (17), Mental disorder, excluding of places learning disability or dementia (17), Mental Disorder, excluding learning disability or dementia - over 65 years of age (17) Gravers Care Home Ltd DS0000065690.V348996.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users to include up to 17 LD, up to 17 LD (E), up to 17 MD and up to 17 MD (E) up to a maximum of 17 service users. 28 November 2006 Date of last inspection Brief Description of the Service: The Gravers Care Home provides personal care and accommodation for up to 17 adults with mental health needs and/or mild learning disabilities. Gravers Care Home Limited took over the ownership of the home in October 2005. The home is located close to the centre of York and is within walking distance of York city centre and local amenities. The accommodation provided is mainly single bedrooms although there is one double bedroom, there are four bedrooms situated within two cottages at the rear of the property and a selfcontained maisonette in an adjoining property. There is a single bed sitting room with its own kitchenette and bathroom on the ground floor and a two bedroom self-contained flat on the first floor. The home has a large front garden with a summerhouse, and there is a paved patio area to the rear of the building. At the time of the site visit on 13th November 2007 the fees for the home were £550 per week upwards and did not include costs for hairdressing, chiropody and toiletries. The home has a statement of purpose that explains the aims, objectives and philosophies of the home and this is available in alternative easy read and picture formats. The most recent inspection report is made available to anyone who wishes to see it. Gravers Care Home Ltd DS0000065690.V348996.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection has used information from different sources to provide evidence for this report. These sources include: • • • Reviewing information that has been received about the home since the last inspection. Information provided by the manager on an Annual Quality Assurance Assessment questionnaire. Comment cards returned from seven people who live at the home, a relative and three care professionals who have contact with the home. We went to the home without telling them that we were going to visit. This report follows the visit that took place on the 13th November 2007. The visit lasted for 5.5 hours with 4 hours preparation time. Time was spent talking to three people who live at the home, three members of the care staff, and the person who was overseeing the home whilst the owners of the home were on holiday. Documentation was also looked at as part of the site visit. This all helped in gaining an insight into what life is like for people living in the home. A senior carer was available throughout the inspection and the findings were discussed with her along with the person overseeing the home. What the service does well: People like living in the home and receive a good standard of care from a caring and committed staff team who have a good understanding of their needs. One person said, “I am happy living here, the staff are excellent” and others said, “staff work very hard and are very friendly”, “staff are thoughtful and lovely people” and “it is one of the best places I have ever lived in”. Another person said, “because of the care I receive from staff when I have become unwell I have not needed to go into hospital and this has helped to improve my quality of life”. People are encouraged to make their own decisions and choices. This enables them to have control over their own lives and to live their lives as they choose. A good range of activities is on offer so that people can take part in things they enjoy doing both in and outside of the home. This enables people to pursue their interests and to develop their personal skills and knowledge. Gravers Care Home Ltd DS0000065690.V348996.R01.S.doc Version 5.2 Page 6 People feel that staff are good at respecting their privacy and dignity. One person said, “I receive support with bathing from a member of staff of a similar age and this helps to prevent any embarrassment”. People can maintain contact with their family and friends and have personal relationships. This helps people to see and keep in touch with others who are important to them. The home has a welcoming, relaxed and friendly atmosphere. This helps people to feel comfortable, safe and relaxed. The home is well managed in the best interests of the people who live there. People feel reassured that they will be properly looked after and any concerns will be properly acted on. They have regular meetings with staff and this enables them to be involved in decisions that are made about the home. What has improved since the last inspection? What they could do better: A better system could be put in place to make sure that medication is administered safely and alternative arrangements could be made for medications that need to be stored in a fridge. This will reduce the risk to people from possible medication errors. To keep people safe from the spread of fire, other arrangements could be put in place so that a fire door is not wedged open. Systems could be put in place to enable relatives and others who have involvement in the home to have their say about how the service is run. This will inform the home as to what they are doing well and of any areas for improvement. A cracked window in the kitchen of a self-contained flat could be repaired to provide more comfort and safety to the people who live in there. Risk assessments could show how decisions have been made in all cases where people may be restricted in what they are able to do. Gravers Care Home Ltd DS0000065690.V348996.R01.S.doc Version 5.2 Page 7 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. Gravers Care Home Ltd DS0000065690.V348996.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 Gravers Care Home Ltd DS0000065690.V348996.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. We have made this judgement using a range of evidence including a visit to this service. Proper pre-admission procedures are in place so people who are thinking of moving into the home can feel confident that their needs will be met. EVIDENCE: The home has a pre-admission policy that outlines the procedures to be followed when people are considering moving into the home. There have been no admissions since the previous inspection visit, however, proper preadmission procedures have been followed in the past to make sure that only suitable people are admitted to the home. Information about the person’s care needs is collected from all available sources such as the placing authority to support the home in their decision making about whether they have the skills and resources to meet the person’s needs. A survey returned by someone living at the home said that they had a weekend visit to the home before moving in. Staff confirmed that any person being considered for the home would be offered visits to the home before making a decision about moving there. Gravers Care Home Ltd DS0000065690.V348996.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 and 9 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People are encouraged to live their lives as they choose whilst taking into account any risks from this. EVIDENCE: Each person has a person centred plan that details how they wish to be supported in meeting his or her own objectives. This takes into account the person’s past history, their likes and dislikes and lifestyle preferences. The care plans are in simple language and clearly explain the actions that staff need to take so that people’s needs can be met. The plans focus on developing the independence, skills and strengths of each person. People spoken to said that they know what is written in their care plans and are involved in regular reviews of their care with staff, relatives and relevant others. People said that they are encouraged to make their own decisions and to plan their own daily routines and this could be observed at the time of the site visit. A survey Gravers Care Home Ltd DS0000065690.V348996.R01.S.doc Version 5.2 Page 11 returned by a care manager said, “staff are friendly and are aware of people’s needs”. Individual risk assessments have been carried out to promote people’s quality of life and to develop their skills. The assessments identify any risks to people and actions that are to be taken to minimise any risks. Good guidance is provided to staff about early warning signs to be aware of that may indicate that a person’s mental health is deteriorating and what to do if this happens. This is good practice as it means problems can be identified at an early stage and action can be taken promptly to help the person stay well. Risk assessments include information about why decisions have been made where people could be restricted in what they do. In one case a person had said that they would like to have a key for their bedroom but this was assessed as not being appropriate. However, there was no written information to show how this decision had been reached and agreed. Daily events are well documented so that staff are kept well informed of each individual’s progress. The home has informal handover periods between shifts and uses a message book so that staff are made aware of any changes to people’s care. Gravers Care Home Ltd DS0000065690.V348996.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, 15, 16 and 17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People enjoy a lifestyle to suit their preferences and there is a strong commitment to making sure that they have access to the local community and its facilities. EVIDENCE: Each person has an individual activity programme that enables people to pursue their chosen interests. Local community resources are used to provide people with opportunities for education, training and voluntary work. One person said that they felt a “sense of purpose” from being able to have a job and received some payment from this work. The home has good links with the local colleges where one person is doing a cookery course. Other people said they enjoyed their involvement with local day services and four people attend a local luncheon club. One person who attends a day service had gained Gravers Care Home Ltd DS0000065690.V348996.R01.S.doc Version 5.2 Page 13 several qualifications on the computer. Another person commented, “I have a busy week, there is no chance of being bored”. People have the opportunity to enjoy a range of outings. One person said that they had been on trips to Scarborough and Whitby and had enjoyed a holiday to Centre Parks earlier on in the year. Some people have their own bus passes so that they have easier and cheaper access to public transport and local attractions. One person said they enjoy going to the local pubs and cafes. People can see family and friends at any time and have personal relationships. One person said that she regularly met up with her boyfriend who could visit the home at any time. People said that they like the meals that are on offer at the home. The home has recently developed a healthy eating group who meet every week to discuss and plan menus. Most people are mainly choosing to eat the healthy menu option at mealtimes although alternative meals are available if people do not like what is on offer. People did say that it had been explained as to why a healthy diet could be beneficial to them but also said that they were not put under any pressure to eat healthier. One person was particularly pleased that she had lost some weight since the new menus had been introduced. During the time of the site visit people could be seen eating their meals in a relaxed and unhurried atmosphere. Gravers Care Home Ltd DS0000065690.V348996.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 and 20 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People’s personal and healthcare needs are well met although improvement is needed in one aspect of the medication practices to reduce potential risks to people from medication errors. EVIDENCE: Each person’s personal care plan describes how support is to be given in the way the person prefers. People said that support is provided in a “private and dignified way”. One person said, “I receive support with bathing from a member of staff of a similar age and this helps to prevent any embarrassment and makes me feel more at ease”. Staff could be seen to be treating people in a respectful way and always knocked on the door before entering someone’s bedroom. Specialist aids and equipment are available for people so that independence can be maximised. People can choose their own General Practitioner (GP) and have access to dental and chiropody services. A number of people at the home have involvement with local mental services and referrals are made to specialist Gravers Care Home Ltd DS0000065690.V348996.R01.S.doc Version 5.2 Page 15 services as needed. Staff support people where appropriate when attending health care appointments. Health care information is well documented in each person’s care records so that staff know the reasons for appointments and any actions they need to take. People said that they feel well supported by the staff team. One person said, “the staff team look after me very well and because of this I have not had to go into hospital for some time. Before I had no quality of life but because of the staff I now do”. A survey returned by another person at the home commented, “I can not fault the staff”. Health professionals commented that the home always contacts other agencies when support is needed. One said, “the home provides excellent support for individuals and offers a homely environment. Staff act as advocates for the individual when necessary so that their rights are protected”. A relative also expressed satisfaction with the care and services on offer at the home. None of the people living at the home are currently looking after their own medication. A risk assessment would be carried out on any person wishing to self-medicate to show that they are able to do this safely. Records of medication given are kept up to date and the home has systems in place for returning medications that are no longer needed back to the pharmacist. Staff who administer medication receive the appropriate training. People said that they see their GP when needed and have periodic reviews of the medication they are taking. The home has a system where particular members of staff are designated to prepare and administer medications to people. One of these staff said that on occasions the designated members of staff prepared medications in advance if the medication was due to be given at a time when another designated person was not on duty. This would mean putting the medication into individually labelled containers for another member of staff to give at a later time. This practice is called “secondary dispensing” and is unsafe as it could potentially cause medication errors. This was discussed with the staff team who said they would not do this any more. One person was prescribed eye drops and these were being stored in the kitchen fridge. It is recommended that a separate drug fridge that is lockable be used for this purpose and to store any other external solutions that may be prescribed for people so that they are stored safely and reduce possible risks to people’s health. Gravers Care Home Ltd DS0000065690.V348996.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 and 23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Clear complaints and adult protection policies and procedures are in place and understood by staff to safeguard people from possible harm. EVIDENCE: The home has a complaints procedure detailing how any concerns would be dealt with and people who live at the home and their relatives are given a copy of this. People know whom they would need to speak to if they wished to raise concerns and have confidence that any of their concerns would be properly dealt with. One person said, “staff do not look down on you, they are friendly and approachable and act on what you say”. The home has a policy and procedure in place on how to safeguard people from abuse and staff have attended abuse awareness training and receive updates. Staff spoken to had a good understanding of what abuse is and how to respond to it if it was happening. The home has a no restraint policy. Staff undertake annual training to learn techniques that are effective in calming down situations. Gravers Care Home Ltd DS0000065690.V348996.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People are living in a homely, comfortable and safe environment that suits their needs. EVIDENCE: Bedroom accommodation is over three floors in the main part of the home. There are four bedrooms that are situated within two cottages at the rear of the building and there is a self-contained maisonette in an adjoining property. There is a two bedroom self-contained flat on the first floor that is currently occupied by two people and a single bedded sitting room with a kitchenette and bathroom on the ground floor. Access to each floor is by stairs only so someone with mobility problems would have difficulty in accessing all parts of the building. There is a paved patio area at the rear of the building where some people sit out and this area is also used for smoking. There is also a summerhouse with heating in the front garden for this purpose. Gravers Care Home Ltd DS0000065690.V348996.R01.S.doc Version 5.2 Page 18 People said that they like their accommodation that is personalised to suit their individual tastes. Bedrooms are lockable and people can have their own keys so that their rights to privacy are maintained. Two lounges and a conservatory provide communal sitting areas for people some of who like to watch television. There are a number of bathroom, shower and toilet facilities that are accessible to people. One bathroom has specialist equipment to assist people with mobility problems. During a look around the environment it was observed that there was a crack to the window in the kitchen of the two bedroom self-contained flat. This was brought to the attention of the senior staff and arrangements are being put in place for the window to be repaired. The home is clean and tidy and a cleaner is employed to help maintain standards of hygiene and cleanliness in the home. Food hygiene standards are maintained and procedures are followed to reduce the risk from infection. Gravers Care Home Ltd DS0000065690.V348996.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. A caring and committed staff team make sure that people receive the care they require to meet their needs. EVIDENCE: The home has a welcoming and friendly atmosphere. Staff said that morale was good and this could be seen at the time of the site visit. The duty rosters show that there is always enough staff on duty and staffing levels are planned around the needs of people living in the home. There have been a recent number of staff changes, however, people who live at the home said that this had made no difference to the quality of care they were receiving and commented that the new staff are “very kind and helpful, as are all the staff”. People made various comments such as, “I am happy living here and the staff are excellent”, “staff work very hard and are very friendly” and “staff are thoughtful and lovely people, it is one of the best places I have ever lived in”. The staff files of the most recently appointed members of staff showed that proper recruitment procedures are followed with all the necessary checks in Gravers Care Home Ltd DS0000065690.V348996.R01.S.doc Version 5.2 Page 20 place prior to new staff starting work at the home so safeguarding people from potential harm. Staff said that they receive a range of training and this starts at the point of induction for all new staff who are subject to a three-month probationary period. Information provided by the manager prior to the site visit stated that he liaises with Skills for Care to make sure the home is meeting its staff training and development targets. Staff said that they have attended a one day course about one particular aspect of mental illness and this had helped to give them a better understanding of the needs of people with mental health problems. The home has an ongoing National Vocational Qualification (NVQ) programme to develop the knowledge and skills of the staff team. Regular staff meetings are held and staff said they are encouraged to contribute their views and opinions within this meeting. Arrangements are in place so that staff receive supervision. This provides support for staff in carrying out their jobs and enables any management issues to be addressed with individuals. Gravers Care Home Ltd DS0000065690.V348996.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People living at the home benefit from a well run service that puts their needs first. Whilst overall proper attention is given to people’s health and safety, one health and safety issue needs addressing to make sure fire safety is maintained. EVIDENCE: The registered manager is also a joint proprietor of the home. He is well experienced and qualified in management and care. The management has an “open door” approach and people living in the home and staff said that the management were “very supportive and approachable”. Gravers Care Home Ltd DS0000065690.V348996.R01.S.doc Version 5.2 Page 22 Systems are in place to seek the views of people who live at the home about the care and services they receive. Surveys are sent out to people every year and comments from these have been acted on. House meetings are held and records are kept from these to show how people have been involved in decision-making. Care plan reviews are regularly held for each person so that both they and their relatives can contribute to discussion about their care. At the present time there are no formal systems in place to obtain the views of relatives and other people who have involvement with the home such as care professionals. It is recommended that this be done so that the home knows how it is performing. Overall health and safety practices help to maintain a safe environment. There are regular fire safety checks and staff training. A fire risk assessment has been carried out on the premises. Health and safety certificates are up to date and staff receive a range of training about safe working practices. Hot water monitoring systems are in place to reduce any risks to people from scalding. Whilst looking around the environment it was observed that a wedge was being used by one person to hold open their lounge door in the two bedroom self contained flat. The person said that this was because she had experienced difficulty on one occasion in being able to open the door. However, this is unsafe and increases the risk from any fire spreading. Staff were unaware that this was happening and immediately took action to remove the wedge and arrangements were made for a joiner to come and look at the door and to rectify any problems that were preventing the door from opening and closing freely. Staff also agreed to look at safer alternatives that are approved by the fire authority if the person continues to wish to have the door held open. Gravers Care Home Ltd DS0000065690.V348996.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME 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 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Gravers Care Home Ltd DS0000065690.V348996.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 YA20 Regulation 13 (2) Requirement Arrangements must be put in place in order to make sure that medication prepared by one care worker is not then given to another care worker to administer at a later time. This will minimise risks to people from possible medication errors. Fire doors must not be wedged open. This will reduce the risk of harm to people from the spread of fire. Timescale for action 13/11/07 2 YA42 13 13/11/07 Gravers Care Home Ltd DS0000065690.V348996.R01.S.doc Version 5.2 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. Refer to Standard YA9 Good Practice Recommendations Risk assessments should be carried out to show how decisions have been made in all cases where people could be restricted in what they are able to do. Eye drops and any other external solutions should be stored in a separate lockable drugs fridge to reduce any risk of harm to people. The cracked window in the shared self-contained flat should be repaired so that the comfort and safety is maintained for people living in there. The quality assurance system should include the views of relatives and others who have involvement with the home. This will inform the home about what they are doing well and of any areas for improvement. 2. YA20 3. YA24 4. YA39 Gravers Care Home Ltd DS0000065690.V348996.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Gravers Care Home Ltd DS0000065690.V348996.R01.S.doc Version 5.2 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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