CARE HOMES FOR OLDER PEOPLE
Grenham Bay Court Cliff Road Birchington Kent CT7 9JX Lead Inspector
Christine Grafton Key Unannounced Inspection 13th November 2007 09:45 X10015.doc Version 1.40 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 Grenham Bay Court DS0000034959.V352428.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 Older People. 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. Grenham Bay Court DS0000034959.V352428.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Grenham Bay Court Address Cliff Road Birchington Kent CT7 9JX 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) 01843 841008 vanessa.cornfoot@highmeadow.co.uk Grenham Bay Care Ltd Miss Vanessa Hazel Cornfoot Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Grenham Bay Court DS0000034959.V352428.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP). The maximum number of service users to be accommodated is 34. Date of last inspection 22nd August 2006 Brief Description of the Service: Grenham Bay Court provides accommodation and care for older people. The home has 32 bedrooms, which are mainly used as singles, but there are 5 double sized rooms that can be used by people who wish to share. The majority of bedrooms are on the ground floor and most have ensuite facilities. There are a variety of lounge areas and there is a small garden to the rear. The home faces the sea in a residential area of Birchington, near Margate, within walking distance of most local amenities. The home has its own transport that can assist residents to access local shops and other places of interest in the area. There is unrestricted on road parking to the front of the property. Grenham Bay Court is owned by a private company that employs a manager who has the day-to-day responsibility for the home. Staff are on duty 24 hours a day, which includes a senior member of staff on all shifts during the day and two staff on wakeful duty at night. Senior staff are available on-call at night. Information provided by the registered manager in November 2007 indicates that the fees range from £336.00 to £625.00 per week dependent upon people’s needs and the bedroom occupied. Grenham Bay Court DS0000034959.V352428.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This report takes account of information received since the last inspection, including a visit to the home. An unannounced visit took place on 13th November 2007 between 09.45 hours and 17.45 hours. The visit included talking to the manager, five staff members, nine residents, one visitor, looking at some records and undertaking a partial tour of the home. Observations of the home routines, activities and staff practices were made. The home is owned by a company and during the visit, the company director (and responsible individual for the home) visited and also the Group Homes Manager and the Group Projects Manager called in at different times. Discussions with all of these people provided information that has been used to inform this report. At the time of the visit there were 31 residents living at the home. The atmosphere in the home was welcoming, calm and relaxed, and the home was clean and orderly. There has been a change of manager since the last inspection. The manager has been in post a year and was registered in September 2007. Residents and staff spoken to during the visit indicated that the home is run to a good standard. The manager submitted an annual quality assurance assessment prior to the visit and the information provided was useful in the planning of the visit and has been used in the assessment of this service. What the service does well:
Residents were appreciative of the wide variety of opportunities available for them to participate in activities within the home and to go on outings in the home’s minibus. There is a designated staff member who organises activities throughout the year. Musical entertainers regularly visit the home and there is a full Christmas programme arranged. Various outings have taken place during the summer months, including meals out and shopping trips. A number of residents were enjoying a group activity of ‘motivated movement’ during this visit and there was lots of fun and laughter. The home makes sure that the admission process for a new resident is planned in a way that supports them to settle in. Prospective residents are given Grenham Bay Court DS0000034959.V352428.R01.S.doc Version 5.2 Page 6 written information about the home and encouraged to visit as many times as they like before making the decision to move in. Residents spoken to on this occasion said that they like the staff and that all the staff are friendly and helpful. They feel staff listen to them and that if a complaint was made, it would be dealt with appropriately. Residents are encouraged to make comments about the home and any suggestions made are acted upon. For example, the residents asked for new lights with fans in the main lounge and these have been provided. They have chosen the colour they want for the new lounge carpet, which is due for replacement in the New Year. The majority of residents spoken to said they like the food provided at the home. Residents are given a choice of food at all meal times. Meals are unhurried and served in pleasant surroundings. The home is clean, comfortable and well-maintained. There is an ongoing improvement programme of redecoration and maintenance that ensures a homely environment for residents live in. What has improved since the last inspection? What they could do better:
Although there are some things that the home does well that result in good outcomes for residents, there are two important areas that although current practice has resulted in adequate outcomes for residents, need to be improved to provide an overall good quality in all aspects of the care and service provided to residents.
Grenham Bay Court DS0000034959.V352428.R01.S.doc Version 5.2 Page 7 Since the last inspection, appropriate vetting and recruitment practices have not been consistently followed. Some staff have been employed in the home without all the proper checks completed. This has the potential to place residents at risk of being cared for by people that might be unsuitable. The management must ensure that a robust recruitment process is followed to safeguard residents. Each resident has a care plan that provides some information about them, but the care plans require improvement to make sure they cover all needs in enough detail, particularly regarding health matters and risks. This is important so that staff can provide residents with the right care, that there is no confusion and that the care provided to residents is consistent. The home’s smoking policy needs to be reviewed to ensure it complies with current legislation and respects rights of residents who do not smoke to enjoy a smoke free atmosphere in all areas of the home. This is because the room designated for smoking has doors that open directly onto other areas that residents use, including one bedroom. The management have an annual development plan for the home that recognises areas for improvement and as well as the changes already made, there are plans to continue to develop the home for the benefit of residents. The manager made a commitment to address the recruitment issue promptly, to review the care plans over the next few months and seek advice from the relevant authority about the smoking policy. 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. Grenham Bay Court DS0000034959.V352428.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Grenham Bay Court DS0000034959.V352428.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5 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. Prospective residents are provided with all the information they need to make a fully informed decision about moving into the home. The pre-admission assessment process has been developed and ensures that the person’s needs can be met upon moving into the home. It is not the general policy of the home to admit residents for intermediate care, so standard 6 was judged as not applicable at this inspection visit. EVIDENCE: The home’s statement of purpose and the service users’ guide have been reviewed and updated. They provide the reader with a real ‘sense’ of the home. Copies of both documents are kept by the visitors’ book in the entrance hall, with a copy of the last inspection report, the home’s magazine and
Grenham Bay Court DS0000034959.V352428.R01.S.doc Version 5.2 Page 10 newsletter. Copies of the service users’ guide are also kept in each of the lounges where they can be easily seen. Residents are provided with a contract, or statement of terms and conditions of residence, specifying the fees, services provided, any additional charges and their rights and responsibilities. The home has a pricing model that specifies how the weekly fees are calculated and provides a comprehensive scale of charges. Trial visits are encouraged wherever possible. The manager carries out pre-admission assessments of prospective residents at their own home, or previous abode; or sometimes this is done as part of the trial visit. Copies of care management assessments are obtained where possible. The pre-admission assessment records have been developed since the last inspection and provide a better indication of the person’s needs, so that the right care can be planned and any necessary equipment is available on admission. The assessment documentation covers issues of equality and diversity, such as religion, beliefs and sexual preference. A recently admitted resident described moving into the home, which had involved two visits beforehand. They said that they liked the home on the first visit and decided there and then they would like to move in, but at that time the only room available was on the first floor. As they wanted a ground floor room, there was a waiting period during which time they had been invited for another visit. The person said that staff in the home had been very supportive in helping them to settle in. Observations of practices in the home during the visit, discussions with residents and staff and records seen confirm that staff have the skills to deliver the care to meet residents’ needs. Grenham Bay Court DS0000034959.V352428.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 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. Inconsistencies in the care planning system means that staff are not always provided with all the information they need to satisfactorily meet residents’ needs. This has the potential to place some residents at risk of their health care needs not being met. Residents are protected by the home’s procedures for managing their medication. EVIDENCE: The care of five residents was case tracked, including a new resident and some residents with complex needs. Whilst basic care plans are in place, with some needs identified, these were not ‘person centred’ and did not show any resident involvement in the care planning, or cover some of the complex individual needs identified in the assessment documentation.
Grenham Bay Court DS0000034959.V352428.R01.S.doc Version 5.2 Page 12 One resident’s care plan had a number of missing elements that were discussed with the manager, these included: the lack of information about continence management, stoma care, skin integrity, pressure sore risk and nutritional and dietary needs, all of which had briefly been identified in the assessment documentation, but had not been picked up and transferred into a plan of care. The use of a pressure relieving mattress and visits by community nurses had not been mentioned in the care plan. Discussion and observation identified that this person’s needs were being adequately met, but this is dependent upon the verbal transfer of information between staff. Without written instructions for staff there is a risk of inconsistent care and that this person’s needs might not be met. Other care plans looked at covered the same needs, for example, such needs as: assistance with bath, strip wash daily and hair wash once a week. Other individual needs such as: mobility, risk of falls, wheelchair use and how to assist with moving and handling, did not have action plans for staff to follow to promote consistent care. The care plan documentation did contain informative personal profiles, details of family involvement and interests & activities. Monthly reviews are recorded by key workers and provide brief details of any changes. Daily records contain details of the support provided and give an indication of healthcare needs being followed up. Doctors’ visits are recorded, but there was little evidence of contacts with other health care professionals, although the manager said that residents have access to these. The home has a comprehensive medication policy and written procedures, including an ‘as required’ protocol. Discussion with the deputy manager indicated that appropriate procedures are followed. The lunchtime medication round was observed to be carried out appropriately. A sample of the medication records was checked and were appropriately signed and up to date. Since the last inspection, the medication storage area has been changed. The medication storage area is now more centrally placed. There is enough space for the two medication trolleys and two wall-mounted purpose made metal cabinets the medication fridge and records. Staff were seen treating residents with kindness and respect. Residents commented that the staff are very helpful and confirmed that their dignity is respected when assistance is provided. Residents spoken to felt that their care needs were being met. Grenham Bay Court DS0000034959.V352428.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 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. Residents are provided with plenty of opportunities to take part in a range of meaningful activities and are enabled to exercise choice in their daily lifestyles. Meals are provided in pleasant surroundings and offer both choice and variety with special diets catered for. EVIDENCE: An activities coordinator works part time and organises individual and group activities with residents in the home, plus some minibus outings. Outside musical entertainers visit fortnightly and other events are organised throughout the year. Minibus trips during summer months included: two fish and chip lunches out at Sandwich and a pub by the River Stour, a Strawberry Tea and two shopping trips a month to a local supermarket. Indoor activities include: Christmas card making, a Christmas cake decoration demonstration, games and quizzes.
Grenham Bay Court DS0000034959.V352428.R01.S.doc Version 5.2 Page 14 A full programme of activities has been arranged for the Christmas period, including: a production by a theatre group, carol singers and a Christmas tea at a local school. During the afternoon of the visit, the activities coordinator led an activity of ‘motivated movement’, which a large group of residents were clearly enjoying. This was followed by a visit by a clergyman, who held a religious service, which a number of residents were joining in. Residents spoke of their enjoyment in participating in the activities organised. Residents said they have lots of visitors to the home. Residents confirmed they are encouraged to exercise choice in all aspects of their daily living. Information in the home’s annual quality assurance assessment indicates that staff have had training on the Mental Capacity Act and that residents have assess to independent advocates. The majority of residents spoken to said that the food is good, that they have plenty to eat and hot and cold drinks whenever they want. Menus offer two choices of main meal with a starter and choice of dessert. The four-week menu plan is displayed in the entrance hall and indicates a varied nutritious diet. Staff confirmed that special diets are catered for. The two separate dining areas are arranged with linen tablecloths, napkins and a large selection of condiments. The front dining areas have large picture windows that overlook the sea and provide a very pleasant setting. Residents were seen enjoying a leisurely lunchtime meal and some spent time chatting together at the meal tables. Grenham Bay Court DS0000034959.V352428.R01.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 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. Residents know that their complaints will be listened to and acted upon. Policies and procedures are in place to safeguard residents from abuse, but shortfalls in recruitment practices places them at possible risk of harm. EVIDENCE: The home’s complaints procedure has recently been reviewed and updated and is prominently displayed. This has been written in clear, jargon free language and provides all the information people would need if they wished to make a complaint. It is available in audio and large print upon request. Residents spoken to said they knew who to talk to if they had a complaint and they made positive comments about the home. There has been one complaint received by the home since the last inspection, which was satisfactorily concluded. The staff-training matrix indicates that the majority of staff have attended training on adult abuse. Written guidance on abuse is included in the staff policies and procedures file, a copy of which is kept in the staff room and staff confirmed that they had read the guidance and attended training on abuse.
Grenham Bay Court DS0000034959.V352428.R01.S.doc Version 5.2 Page 16 The home’s annual quality assurance assessment states that it has a solid preemployment and selection procedure. However, evidence seen at this visit indicates that this is not always followed and therefore places residents at risk of being cared for by people who might be unsuitable. (See Staffing Section). Grenham Bay Court DS0000034959.V352428.R01.S.doc Version 5.2 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 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. Residents live in a clean, comfortable, well-maintained environment and benefit from the ongoing improvement programme of redecoration, routine maintenance and adaptations. EVIDENCE: An accompanied tour of all communal areas of the home was made and a sample of bedrooms was viewed. Lounges, dining rooms and bedrooms are decorated and furnished to a good standard. Building maintenance is ongoing. All areas of the home seen at the time of the visit were clean, odour free and in a good state of repair. Residents spoken to said they like their bedrooms, which are all individual and personalised. The majority of bedrooms are on the ground floor and most have ensuite facilities. First floor bedrooms are in two separate wings, one of which can be accessed by a stair lift.
Grenham Bay Court DS0000034959.V352428.R01.S.doc Version 5.2 Page 18 Since the last inspection, work has been started on the installation of a new shaft lift. However, this has been delayed due to unforeseen circumstances beyond the control of the home. Discussion with the Projects Manager for High Meadow Group indicated that the building schedule has now been amended and after a health and safety review, it is planned to resume this work after the Christmas period. The work will also include a new connecting corridor between the two wings at first floor level and the creation of a new wet room shower facility on the first floor. Improvements completed during the past twelve months include: new light fittings in the main lounge, with fans added at residents’ request and there are plans for a new carpet, which residents have chosen the colour; the upgrading of one of the adapted bathrooms; the provision of attractive new bed linen and the manager stated that some new bedroom furniture was due to be delivered the week following this visit. Currently there is only resident who smokes. The library lounge has been designated as the area where this resident may smoke. It was discussed to review the home’s smoking policy, as this room has several doors leading off, including one bedroom. The manager said she would seek advice from the environmental health officer regarding this. The home has appropriate procedures in place to prevent the spread of infection and protect residents. These include proper clinical waste disposal, a sluice machine for the cleaning of commode pans, an industrial washing machine with sluice cycle and water-soluble bags for soiled articles. During the past year, the staff-training matrix indicates that fifteen staff, including the manager, have undertaken infection control training. Grenham Bay Court DS0000034959.V352428.R01.S.doc Version 5.2 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 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. The numbers and skill mix of staff on duty are sufficient to meet the needs of residents living in the home. However, recruitment practices do not ensure that residents are always appropriately protected. EVIDENCE: The staff rota indicates an average of six carers on duty in the mornings and four in the afternoons, plus a housekeeper and laundry assistant weekday mornings and additional staff on duty every day for cooking. The activities coordinator works two and a half days a week. The manager is supernumerary and there is also a part-time administrator and a maintenance person on duty five days a week. On the morning of the visit there were six carers on duty who were appropriately deployed between the various different areas of the building. Observations of residents’ dependency levels, discussions with the manager, staff and some residents and an analysis of the rota, indicate that staffing numbers are sufficient to meet residents’ needs. Residents spoken to made some positive comments about this, for example: “They look after us well”;
Grenham Bay Court DS0000034959.V352428.R01.S.doc Version 5.2 Page 20 “the girls are usually there if you want them”; “the staff are lovely, very helpful”. The home’s annual quality assurance assessment indicates that only six out of a permanent staff group of seventeen have completed their National Vocational Qualification (NVQ) in care level 2. This has been identified as an area for improvement and as new staff complete their thirteen-week induction programme they are expected to commence working towards their NVQ level 2. The staff-training matrix indicates that sufficient staff are trained in fire safety, first aid, food hygiene, health and safety, infection control and moving and handling. The home’s annual quality assurance assessment states: “We have a solid preemployment procedure in place which ensures that the service users cared for are safeguarded at all times. We have a robust selection procedure in place ensuring the team maintains the right skill mix”. However, evidence at this visit indicates this not to be the case. At the last inspection a recommendation was made to keep interview records and to review staff files to make sure that they contain all the information specified in the regulations. Interview records are now being kept. However, of the four staff files viewed it was found that although there is a procedure for the checking of references and obtaining criminal record bureau (CRB) checks and protection of vulnerable adults (POVA) register checks, this had not been properly followed in two cases. The company head office deals with some recruitment checks, including the CRB and POVA checks and there is a system in place to demonstrate dates these are requested and returned. In one case, reference request letters and the CRB application form had not even been sent out, but the person was working as one of the designated carers on duty. The manager stated that the person had completed three induction days (off-rota) and the day of the visit was their first day on duty for care, working with an experienced carer who was supervising them. This places residents at risk, as without any references or a POVA First check there was no way of knowing whether the person is suitable to work with vulnerable people. There were no references in two more staff files checked and in the fourth file, although references had been obtained before the person started work, the POVA First request and confirmation date was twelve days after their start date. A requirement has been given regarding recruitment and the manager indicated she would ensure that action is taken to address the shortfalls promptly. Grenham Bay Court DS0000034959.V352428.R01.S.doc Version 5.2 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 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. The home is run in the residents’ best interests. The manager is supported by the company’s senior management team and between them they make sure that residents benefit from the management style that has been created. Residents’ and staff views are regularly sought, listened to and used to inform the home’s business plan. EVIDENCE: A new manager has been registered since the last inspection and has the relevant qualifications and skills. Residents’ comments indicated that the manager is very approachable and has created an open, positive atmosphere
Grenham Bay Court DS0000034959.V352428.R01.S.doc Version 5.2 Page 22 at the home. Staff spoke of feeling supported by management and of enjoying their work at the home. Staff and residents were observed to be relaxed and confident in their interactions with the manager. The home’s quality monitoring systems include: quality assurance questionnaires, a newsletter, residents’ meetings, staff meetings and the Group Homes Manager’s monthly unannounced visit reports. Copies provide an indication that standards in the home are monitored internally. However, the reports are very brief and if developed could provide better evidence of this monitoring process. The Group Homes Manager said he would consider this. Previous inspections have confirmed that there are appropriate procedures in place to record any monies held on behalf of residents, including details of expenditure. Staff are trained in safe working practices. Information in the home’s annual quality assurance assessment indicates that the home’s equipment has been serviced and all maintenance and safety checks are up to date. Grenham Bay Court DS0000034959.V352428.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 Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Grenham Bay Court DS0000034959.V352428.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 OP7 Regulation 15 Requirement Implement care plans that are drawn up from a comprehensive assessment and provide the basis for the care to be delivered. Care plans must provide clear information for staff on the assessed health care, personal care and social needs of the residents and provide them with accurate and up to date guidance to ensure all needs are met. 2 OP29 19, Sch.2 The registered persons must not employ a person to work at the home unless s/he is fit to work at the care home and information is obtained as specified in Schedule 2. People must not start working at the home with residents unless they have been properly vetted to protect residents. Recruitment checks must include 2 references and CRB/POVA checks.
Grenham Bay Court DS0000034959.V352428.R01.S.doc Version 5.2 Page 25 Timescale for action 31/01/08 20/11/07 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 Refer to Standard OP19 Good Practice Recommendations To consult with the environmental health officer regarding compliance with the new smoking regulations. Grenham Bay Court DS0000034959.V352428.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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
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