Inspection on 11/11/07 for Grennell Lodge

This inspection was carried out on 11th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Grennell Lodge 15/01/07

Grennell Lodge 15/11/05

Grennell Lodge 31/08/05

Grennell Lodge 02/03/05

Grennell Lodge 08/12/04

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Grennell Lodge 69 All Saints Road Sutton Surrey SM1 3DJ Lead Inspector David Halliwell Key Unannounced Inspection 11th September 2007 9:30am Grennell Lodge DS0000019093.V351568.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 Grennell Lodge DS0000019093.V351568.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 and Care Homes for Adults 18 – 65*. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grennell Lodge Address 69 All Saints Road Sutton Surrey SM1 3DJ 020 8644 7567 020 8644 2921 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) Care Unlimited Miss Teresita Calama-an Care Home 32 Category(ies) of Dementia - over 65 years of age (7), Mental registration, with number disorder, excluding learning disability or of places dementia (25) Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A variation has been granted to allow eight specified residents in the category of Mental Disorder, excluding learning disability or dementia over 65 years of age (MD(E)) to be accommodated. A variation has been granted to allow two specified residents in the Learning Disability category to be accommodated. 15th November 2005 Date of last inspection Brief Description of the Service: Grennell Lodge is located in the suburbs of Sutton. It is close to local amenities such as shops, newsagents, hairdressers, pubs and post office. There is a local bus service from outside the home, which will take passengers into the centre of Sutton. The home consists of a three-story building, plus a small mezzanine floor and a basement that is used for storage. Bedrooms are situated on all floors (except the basement). A shaft lift serves the basement and the ground, first and second floors, but not the mezzanine floor. There are a number of communal areas, including a smoking lounge, conservatory and a large sitting/dining room. There is garden to the rear of the house, in which there is a second conservatory and an occupational therapy room. The home provides care for 32 residents, 25 in the younger adult mental health category, and 7 in the older person dementia category. There is a mix of single and double bedrooms. The Manager told the Inspector that at the time of this inspection the average price of a placement within the unit is £670 pw for a single room and £630 pw for a shared double room. Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection visit undertaken by the new Inspector responsible for Grennell Lodge over a period of 2 days. As a result of the mixed categories of the home’s registration the Inspection covered all the key standards for both the National Minimum Standards for both younger and older adults. The inspection involved a tour of the home, a review of all the homes records and formal interviews with 2 staff and the Registered Manager. 6 residents were spoken with formally and more informal interviews were conducted with 2 other residents as a part of the tour of the home. 5 staff and 4 residents’ files were inspected as was the policies and procedures manual for the home. There have been 3 new residents admitted to Grennell Lodge since the last inspection and 1 new member of staff. The Human Relations Manager and the Quality Assurance Manager as well the 2 Proprietors were present on the 2nd day of this inspection and met together with the Inspector. They are to be thanked for their assistance and helpful support with the inspection. 2 new requirements have been made as a result of this inspection, 3 of the 4 previously set requirements have since the last inspection been met. 3 new recommendations have been made and all but one of the previous 8 recommendations have been met. Feedback on these requirements and recommendations was given verbally to the Proprietors, the QA Manager and the Manager at the end of the inspection visit. The Inspector found the residents and staff very helpful and they are to be thanked for the assistance that they gave him over the course of this inspection visit. The Inspector was impressed by the positive commitment and responsiveness of the Manager and of the staff group. What the service does well: The Proprietor informed the Inspector that the Agency successfully achieved an Investor in People Award 3 years ago. Following this inspection the Inspector believes this is still relevant today as a reflection of the attitude and commitment of the management and staff group. All the service feedback questionnaires received by the CSCI from residents, relatives and other people were very positive. Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Requirements and recommendations have been made in areas that require improvements and service developments, specifically they are: 1. That for each of the existing residents the new needs assessment format should be used so as to ensure that all the residents needs are being addressed. 2. That care plans need to set out in more detail to show how the residents social care and cultural needs are to be met. Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 7 3. That all staff be asked to read and discuss the homes’ policies and procedures and then to sign to say they have done so. This process should be updated for each member of staff every 2 years. 4. Supervision should be carried at least once every 4 – 6 weeks and a record completed in sufficient detail to ensure a useful record is maintained. 5. That certificated evidence is held on staffing files that evidences which training courses staff have attended and when the training was held. 6. That staff are offered training that is focussed on the needs of the older residents such as dementia and understanding mental health issues. 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. Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): AP 2 & OP 3 & 6 NMS Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The new and improved process of the assessment of social care needs should ensure that the social care needs of all the residents will be more fully met. EVIDENCE: Adults Standard 2 and Older Peoples Standard 3 – Over the course of the inspection the Inspector inspected 4 of the 29 resident’s files and found on each file an assessment of needs had been carried out by the home. These assessments have been based on information supplied by the referring professionals, usually care managers, and by the staff’s own assessment of the persons needs. Since the last inspection the assessment format has been Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 10 developed to expand the assessment of social care needs. There are 8 new areas of needs assessment that includes cultural and religious needs. This assessment tool should now provide a useful way of comprehensively ensuring all the residents or prospective residents’ needs are taken into account at the assessment stage. The Manager informed the Inspector that for each new admission to the home (3 since the last inspection) the new assessment format is being used, this however now needs to be used for all existing residents and this should be done at their next review. This is a requirement. At the last inspection some of the younger residents living at Grennell Lodge told the Inspector that they would like to see an expansion in the existing programme of social activities and entertainments within the home. Any expansion of the programme would need to be based on identified needs in the assessment process. Information gathered from a number of sources at this inspection indicates that the programme of activities has been expanded and that the home’s management team have taken a number of measures to ensure that the increased level of activities are matched to the assessed needs of the residents. The Inspector interviewed 6 residents formally and spoke to another 3 of the 29 residents over the course of this inspection. The growth of the activities programme in this way is welcomed by the residents and the Inspector. Older Peoples Standard 6 – This Standard refers to intermediate care and the Manager has informed the Inspector that Grennell Lodge does not offer intermediate care. This Standard cannot therefore be inspected. Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): AP 6, 7, 9 & OP7, 14, 33 NMS Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and social care needs are set out in individual care plans but there are further service developments that would improve how these needs could be better met by the Unit. Residents may be assured that they may make decisions about their lives as needed and that they will be helped to exercise choice and control about their lives. Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 12 EVIDENCE: Adults Standard 6 and Older Peoples Standard 7 – Over the course of this inspection the Inspector inspected 4 of the 29 residents’ files, spoke to 6 of the residents and interviewed 2 members of staff as well as speaking with the Manager. On the files inspected all of the documents set out under Schedule 3 of the NMS were seen by the Inspector and are being held on these files. As already indicated in the previous section the Inspector’s examination of residents’ files found that on each file needs assessments had been drawn up. Service user plans / care plans had been constructed from these needs assessments and the Inspector was impressed with the detail covered in the plans. All the care plans inspected were seen to be reviewed monthly, the date of the review being recorded on file. It was clear from the care plan records held on the files that all the appropriate people are usually involved in the care plan reviews including the resident and their relatives where appropriate or their representatives. The Manager informed the Inspector that after the initial placement of a new resident an intermediate care plan is now being drawn up before the 6-week review. After the 6-week review, the care plan is revised and then reviewed monthly. At the last inspection it was recommended that care plans needed to be set out in more detail as to how the residents’ social care and cultural needs are being met. Since that inspection some improvement has been made to the care planning process however it is felt that further work is still required in order to bring these plans up to the necessary standard. Care plan objectives need to be set out for each resident that identify how their assessed needs are to be met. These objectives should be specific, measurable, appropriate, realistic and set within a time frame. This will aid monitoring and review of these objectives and will help to deliver continuing and effective care to the residents. The development of the care planning process and care plan objectives should provide the focus and the starting point for extending the social care activities programme. At the last inspection it was recommended that the Proprietor set aside a budget that could be allocated to the Manager and the Activities Coordinator and with which they could extend the programme. At this inspection the Manager told the Inspector that although no specific budget has been devolved to the Activities Co-ordinator, they have do have regular meetings where any proposals are discussed and usually funding is available to ensure these needs are met. Grennell Lodge has an Activities Co-ordinator who the Inspector spoke to and who evidently works hard to provide a programme of activities which will both Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 13 meet the residents’ needs and provide them with an interesting range of appropriate and varied activities that is aimed at developing their skills and experience. A number of the residents spoken to by the Inspector said that they really appreciated this valuable input because it offers them the chance to do interesting things. They said they have appreciated the development of this programme over the last few months that now include more activities, outings and entertainments. It was again evident to the Inspector how very much appreciated the work of the Activities Co-ordinator is by the residents and by listening to both staff and residents it is clear that the impact of this work is very positive on the residents. Adults Standard 7 and Older Peoples Standard 14 – Staff were seen by the Inspector over the course of this Inspection to be interacting with the residents in a friendly and helpful manner and to be respecting the rights of residents to make their own decisions. Staff interviewed by the Inspector also indicated their awareness of the resident’s rights to make decisions about their lives wherever possible and that staff assistance should be focused on supporting this right wherever possible. The Manager, staff and residents all told the Inspector that they have regular meetings and the Inspector saw the minutes of these meetings that are now usually held bi-monthly. Residents are able to bring in articles of their own furniture and other possessions that help to make their rooms homely. Adults Standard 9 and Older Peoples Standard 7 – Risk assessments were seen on the residents files inspected, both as a pre-admission assessment tool and also post admission. They are being used to assist residents to be appropriately supported to take risks as a part of developing a more independent lifestyle wherever possible. These risk assessments are agreed with the service user and the relevant professionals. So residents can be assured that they will be supported to take risks where ever possible as part of developing a more independent lifestyle. Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. Service Users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): AP 12, 13, 15, 16 & 17 and OP 10, 12, 13 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 15 Residents are assured that they will be able to take part in appropriate activities within the unit. They will be supported in maintaining and developing appropriate relationships and that their rights and responsibilities will be respected in their daily lives. They are also assured that they will be offered a healthy, varied and nutritious diet. EVIDENCE: Adults Standard 12 and Older Peoples Standard 12 – Grennell Lodge has an activities officer who works with residents to develop a wide and varied programme of appropriate activities based on the residents needs and their care plans. Some of the residents do participate in activities and interests that are related to things they did before they entered the home. Residents told the Inspector that they enjoy these activities and the Inspector witnessed a number of residents wholeheartedly engaged in a variety of activities within the annexe that has been specifically set up for the purpose. The Manager told the Inspector that none of the residents attend any colleges or adult education. She also said that some of the residents do attend the Cheam Day Centre once or twice a week for activities related to the development of their daily living skills. The Manager told the Inspector that a Minister of a local Catholic Church visits the home on a regular basis and residents who wish to attend are offered Communion. A Church of England Vicar also attends the home regularly for those residents who would otherwise be unable to attend church outside of the home. There are no restrictions placed by the Manager on mealtimes, getting up, going to bed, bathing or going out and arrangements are made and agreed wherever possible by the residents with the staff to suit their needs, wishes and preferences. Adults Standards 13 & 15 and Older Peoples Standard 13 – The location of Grennell Lodge close to a bus stop assists residents in using public transport. However the home has 2 of it’s own vehicles which are used by staff to enable residents and residents to get out and about. Those residents who do go out of the home and who were interviewed said that this is often how they get out and about to go shopping or to see their friends and families. Some residents said that they do go to church and make use of day centre provision in and around Sutton. When the Inspector asked residents about going to cinema or theatres they were less than enthusiastic about using these forms of entertainment. Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 16 The Manager informed the Inspector that all residents are registered to vote and are encouraged to use their votes. Residents confirmed with the Inspector that they are supported and enabled to vote. There are no visiting times and friends and families are encouraged by the Manager and staff to attend the home. A record of visitors is kept in the main hall and the Inspector was asked to sign the record on the days of the inspection. Adults Standard 16 and Older Peoples Standard 10 – Policies seen by the Inspector to be established within the unit ensure that residents’ rights to privacy, respect and dignity are respected. Residents who were interviewed also confirmed that they felt staff respected these rights. Residents said that they have a key to their own bedrooms, their mail is unopened, their preferred form of address is used by staff and staff do knock on their doors before entering. The Inspector observed staff to be interacting with residents in a friendly and respectful manner. The Manager told the Inspector that all residents wear their own clothes. The staff induction process was reviewed by the Inspector and was seen to include the core standards of recognising and meeting the resident’s rights to: • Privacy • Dignity • Independence • Rights • Fulfilment • And choice. These core standards are also included in the Unit’s Statement of Purpose. There is a specific area for smokers and there are appropriate policies regarding drug and alcohol taking on the premises. Adults Standard 17 and Older Peoples Standard 15 – At the time of this inspection the permanent Chef was off sick due to a back injury and a temporary Chef had just been appointed. Food menus shown to the Inspector were varied, choices are provided and residents assist in the drafting of the food menus. No complaints about the meals arose during the inspection in fact all those residents interviewed said that they like the food provided at Grennell Lodge. It was noted that a wide range of meals were listed which cater for the multicultural needs and wishes of the residents. The Inspector asked the Manager if a dietician is used to advice on the menu planning in order to ensure that the food provided is always healthy and nutritious. The Manager said that a dietician is used in some cases where there is a specific need but not as a general rule. Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 17 The Manager said that a dieticians advice will always be sought if there is a problem or a risk identified and a specific example of this was shown to the Inspector for one resident who has multiple sclerosis and needs a very specific dietary intake and food preparation. At the time of this inspection the Inspector saw two mealtimes and the food was seen to be presented in a fresh attractive way that was enjoyed by the residents. Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 18 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) Service users retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicines. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): AP 18 & 20 and OP 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal and healthcare is provided according to residents individual needs. Clinical support for specific health care is provided by General Practitioners, District Nurses and by the psychiatric multi disciplinary teams as well as other specialist services such as chiropody, sight and hearing services thus ensuring that residents do have a good quality of life. EVIDENCE: Adults Standard 18 and Older Peoples Standard 8 – 4 residents interviewed confirmed that they receive their care in the way they prefer. Those residents, who were able to, said that they decide themselves about their daily routines Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 19 and care staff interviewed by the Inspector also confirmed this. Staff interviewed said that residents keep in regular contact with their General Practitioner and psychiatric team. The Manager informed the Inspector that all the residents are registered with dentists, opticians, chiropodists and community nurses in order to maintain their all round good health. This was confirmed by some residents and by information seen by the Inspector in their case files, which evidence it by the recording of their contact with these services. Records were seen by the Inspector that annual healthcare checks are routinely carried out by GPs thereby ensuring continuing good health. Adults Standard 20 and Older Peoples Standard 9 – At this inspection the Inspector looked at the home’s policies and procedures manual that contains all the appropriate policies for the control of medication. The Inspector reviewed the records for the administration of medication to 3 residents (MAR sheets) and these were seen to be appropriately completed and in line with the home’s policies and procedures. The Manager told the Inspector that only the senior staff who are registered nurses are allowed to administer medications to the residents. This was confirmed both by senior staff and the junior staff members. The Manager also told the Inspector that she checks the MAR sheet records weekly to ensure that they are completed appropriately by staff, so far these checks have not revealed any errors. A requirement made at the last inspection with regards to the MAR sheets being fully completed each time medication is administered has now been met. Also at the last inspection a requirement was made for clear and specific guidance to be drawn up in conjunction with the resident’s GP for each resident where PRN medication is being used. The Manager told the Inspector that since the last inspection this has been addressed and implemented together with the GP for the home. Also that photographs of each resident has been placed on the medication sheets so that all staff are sure that they are administering medication to the correct person. On inspection of the records the Inspector found evidence that these measures had indeed been implemented to a good standard. The guidance provided for PRN medication includes possible side effects for the resident concerned. A check carried out by the Inspector at this inspection to review the management of controlled drugs and other medicines remaining in the stores against the recorded levels proved correct and no errors were found in the system. The storage of medicines was seen to be completely appropriate including refrigerated cupboards where necessary and appropriate facilities and procedures for the storage and administration of controlled drugs which are used for some of the residents. Training in medication for staff is a part of the agencies training plan and the members of staff interviewed said that they had received this training. The Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 20 Manager told the Inspector that only trained staff are allowed to administer medicines to residents and that this training is refreshed every 2 years. At the time of this inspection none of the existing residents are able to administer their own medication. As a part of this inspection the Inspector spoke to the Home’s Quality Assurance Manager who informed the Inspector about the quality assurance process in use within the home. This is discussed in more detail later in this report under Standards AP 39 & OP33, however the area of medication management is a part of this process and practices are monitored monthly by the QA Manager. This is excellent since it is an important part of selfmonitoring and helps the home find out quickly if there are any errors in practice and enables effective solutions to be found. This has had a positive impact in that no errors were found at this inspection. The Manager informed the Inspector that all residents have access to other healthcare professionals including GPs, a chiropodist who visits every 3 months, a dentist and a dental nurse who visit also once every 3 months, physiotherapists, and an optician who visits six monthly. The Manager informed the Inspector that if the need arises for the residents to see these professionals earlier then this is arranged without a problem. Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 21 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): AP 22, 23 and OP 16, 17, 18 & 35. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Residents are protected from abuse, neglect and self harm by the policies and procedures of the home. Most staff now receive regular training in the protection of adults from abuse. EVIDENCE: Adults Standard 22 and Older Peoples Standard 16 – All those residents interviewed formally by the Inspector and those residents spoken with more informally, confirmed that they feel their views are listened to and are acted upon as appropriate. They said that if they had a complaint they do know the procedure to be followed and would talk to the Manager if they needed to. Staff interviewed confirmed with the Inspector that the residents would know how to complain if they needed to and gave the impression that the whole staff group would take any issues raised by residents seriously. The homes’ complaints policy was inspected and seen to comply with the standards expected. The complaints record was also reviewed by the Inspector and no complaints had been made since the last inspection visit. Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 22 Adults Standard 23 and Older Peoples Standards 18 & 35 – The Manager informed the Inspector that Grennell Lodge uses the L.B.Sutton’s adult protection policy and practice procedures. The Manager told the Inspector that since the last inspection there had not been any POVA issues raised in the home and that no referrals had been made via the procedures. The Manager told the Inspector that the training process is being updated and that as a result of the last inspection and the recommendation made, certain key areas of training including POVA training will be provided to staff every 2 years (this is discussed in more detail later in this report). The Manager told the Inspector that nearly all the staff group have received POVA training and that those who have not yet done so will be doing so in the near future. Records seen by the Inspector, specifically the new training matrix evidences that 90 of the staff team have received POVA training within the last 2 years. Staff spoken to at this inspection said that they had found the training useful and were aware of the key elements of the policy and procedures. The Inspector saw the allegations of abuse record; no allegations had been made since the last inspection. The policies and procedures manual for the home includes a whistle blowing policy and a policy on dealing with violence and aggression. Understanding the policies and procedures is a part of the staff induction process, which all new staff have to attend. At the last inspection the Inspector spoke with the Manager about the need for all staff to sign to say that they have read and been able to discuss the agencies policies and procedures and that this is recorded on file. Inspection of staff files this time showed that some staff have signed to say that they have read and understood some of the policies such as the policies for: • The Protection of Vulnerable Adults • Medication • Fire Safety • Handling finances • Supervision • Code of Conduct • Manual Handling. However inspection of the files showed that not all the staff had signed their agreement in this way and the Inspector was not assured that this process has been fully implemented. At the last inspection a recommendation was made about this that has only partly been met. Since it is important that all staff are aware of the agencies policies and procedures operating in the unit it is now a requirement that all staff at Grennell Lodge should have their Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 23 knowledge and understanding of the policies and procedures for the unit supported through discussion, monitoring and review at 1:1 staff supervision. The Manager told the Inspector that the home does look after resident’s money and acts as Appointee for some of the residents so that their money is safeguarded. At the last inspection the Inspector reviewed the financial records for these transactions and found that they were in order. All transactions were dated and signed for by both staff and residents to confirm satisfaction by all parties. The Inspector found no anomalies. The Manager showed the Inspector an inventory of resident’s belongings which is kept up to date by key workers for all residents’ belongings that are kept in their bedrooms and this is important since it helps to ensure the appropriate protection of residents’ personal property. Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 24 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): AP 24 & 30 and OP 19 & 26. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Residents are living in a clean, safe, hygienic, well-maintained environment, with access to safe, pleasant and comfortable facilities. Residents generally presented as well settled in their environment, and as being very satisfied with the communal and personal facilities provided. Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 25 EVIDENCE: Adults Standard 24 and Older Peoples Standard 19 – At this inspection the Inspector together with the Manager undertook a tour of the premises and reviewed all areas of the home to assess the quality of the environment and décor. The home was found to be generally clean and hygienic, free from offensive odours and safe. The home has a maintenance man who carries out routine maintenance for the property on a regular basis and this is evidenced with the good state of repair and condition of the home. At the time of this inspection he was seen fitting new fire doors, this had been a recommendation from the recent fire risk assessment carried out for the building. It should be said that the Inspector has on this inspection and at the last inspection found the premises to be in a very good state of repair and well maintained. The Inspector undertook a tour of all the rooms in the home together with the Manager. 3 resident’s bedrooms were inspected with the permission of those residents. They all told the Inspector that they are happy with their rooms. The Manager informed the Inspector that a fire risk assessment had been undertaken by a consultant from Flames Fire Safety in May 2007. The document was shown to the Inspector together with the action plan drawn up by the Manager in order to address all the risks and requirements identified in the report. The report was very comprehensive and detailed covering every aspect of the home and included a very useful summary and list of potential risks and recommendations. The Manager told the Inspector that since March 2007 most of the actions have been addressed and the Inspector at this inspection was able to see evidence of this. The completion of this work will help to ensure the safety and protection of the residents and the staff from the risk of fire. The homes fire alarm and emergency lighting systems are serviced regularly and the last checks carried out showed that everything was satisfactory. The report was seen by the Inspector. Evidence was shown to the Inspector by the Manager that the home’s fire fighting equipment was tested as satisfactory in March 2007. Adults Standard 30 and Older Peoples Standard 26 – The Registered Manager showed the Inspector the home’s infection control procedure, which seems to be effective. The Inspector also spoke with the QA Manager who informed him that the home has in place a contract to clear all the clinical waste. Staff interviewed confirmed that they are issued with appropriate clothing and equipment for them to carry out their work appropriately. Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 26 The laundry area is well laid out and there is an impermeable floor laid down to prevent water ingress and easy cleaning. Laundry is not taken through areas where food is prepared. The home has appropriate sluicing facilities and these were seen by the Inspector to be appropriate. Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 27 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): AP 32, 34, 35 & 36 and OP 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Residents can be confident that they are being supported by a competent and appropriately qualified staff team. Also that their needs will be met by appropriately trained staff. When arrangements are fully in place for the formal supervision and appraisal of staff residents will be able to be fully confident that they will benefit from a well supported and supervised staff group. The quality assurance processes being used in the home ensure that it is being run in the best interests of the residents. The health and safety of staff and residents is being promoted and protected. Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 28 EVIDENCE: Adults Standard 32 and Older Peoples Standards 27 & 28 – Over the course of this Inspection staff were seen by the Inspector to be approachable for residents and were also seen to take time to deal appropriately and sensitively with residents questions. The Manager showed the Inspector a staff rota for the week of the inspection which showed which staff were actually working and which shifts they were working. Grennell Lodge do have waking night staff on duty. The Manager informed the Inspector that they employ kitchen staff, cleaners and laundry staff. The Inspector spoke with a member of the kitchen staff. The Inspector spoke with the Manager about the levels of NVQ training for the staff group. Evidence has been provided that demonstrates that all the staff group will have completed their NVQ training at least at level 2 by the end of March 2008. If the planned training of staff materialises as is expected then the Standard will be met. This reflects positively on the management and on the staff commitment at Grennell Lodge in meeting the requirements of the Standards and in ensuring that residents are supported by competent and qualified staff. Adults Standard 34 and Older Peoples Standards 29 – As a part of this inspection the Inspector met with the HR Manager as well as with the Registered Manager of this unit. They informed the Inspector that the home does have a recruitment procedure, which is followed for all job recruitments. The HR Manager and the Registered Manager carry out staff interviews for Grennell Lodge. Inspection of 6 staff files by the Inspector confirms that suitable application forms are completed and held on file. 2 written references are sought including 1 from the last employer. The HR Manager said that if there are any areas of concern, these will be followed up with the referees. All staff are said to be issued with contracts of employment although documentary evidence was not available on the staffing files. The HR Manager and the Manager told the Inspector that in all cases enhanced criminal record bureau (CRB) checks are carried out by the agency for all new staff. Documentary evidence was made available at this inspection. A new matrix for CRBs held for all staff on the staffing files was shown to the Inspector. This information certifies that the appropriate checks have been completed. The HR Manager and the Manager both told the Inspector that it is now Company policy to renew all staff CRBs every 3 years and the Inspector saw that the matrix highlights when the renewal dates arise. Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 29 Copies of the staff CRBs was seen by the Inspector taken from the staffing files. They were appropriate and fit for purpose. The Manager informed the Inspector that all new staff have to complete a probationary period after which if all has gone well their employment becomes permanent. Adults Standard 35 and Older Peoples Standards 30 – The Manager informed the Inspector that there is an overall training and development plan for staff that is in the process of renewal and refreshment. The HR Manager and the Unit Manager are responsible for the training and development of staff. A new training matrix document currently near to completion was shown to the Inspector that will usefully set out against each member of staff all the training they have received. The Manager said that staff training needs are identified through supervision and staff are nominated for the next available training course. The HR Manager said that there is a training budget available which finances all the training provided. Those staff interviewed by the Inspector confirmed this process and said that they felt availability of training is good and that their needs are being met. The Inspector gained a very positive impression about the provision of training for Grennell Lodge staff and discussions held with the HR Manager about meeting the needs for staff training in NVQ also demonstrated a responsive and committed approach to the training and development of staff by this agency. The training programme includes all the essential areas of training and covers: • Fire safety • Moving and handling • First aid • Food hygene • Health and safety • Mental health awareness • Dementia awareness • Managing challenging behaviour • Adult protection / POVA • Medication • NVQ • Supervision practice • Chemical awareness Evidence seen by the Inspector showed that not all staff have undertaken recent training in the highlighted areas and so it is recommended that staff are offered training that is focussed on the needs of the older residents such as dementia and understanding mental health issues. Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 30 The Manager informed the Inspector that there is a structured induction programme, which all staff are expected to complete as the start of their employment at Grennell Lodge. Induction booklets were seen by the Inspector that evidenced the induction programme and which includes safe working practices, the role of the worker, the needs of the residents and residents, the service needs, information about the agency and the principles the agency has of care. The Training Matrix shows the dates when staff have completed their training courses including their induction at Grennell Lodge and it will provide a useful “aide – memoir” for the senior staff as to when refresher courses for the staff they supervise will be required. Some evidence in the form of training certificates were seen to be held on the staffing files and assurances were provided by both the HR Manager and the Unit’s Administrator that in future all the necessary certificated evidence for staff attending training will be held on the staff files. It is recommended therefore that certificated evidence is held on staffing files that evidences which training courses staff have attended and when the training was held. Adults Standard 36 and Older Peoples Standards 36 – The Manager informed the Inspector that care staff should now be receiving formal supervision at least once every 4 – 6 weeks and informal supervision more often, sometimes on a daily basis. The Inspector saw supervision records for staff that are held on their files. Supervision records however held on staffing files did not evidence that regular supervision of all staff is taking place in the required timeframe. As at the last inspection these records were very brief and they did not contain sufficient detail where discussions had been had with key working staff about the work they are doing with residents in meeting their care plan objectives. The detail of those supervision records seen need to include sufficient detail to be a useful record. Supervision sessions should include the monitoring and review of work objectives, the training needs required by the staff member in order to carry out their work and any other issues that have arisen in supervision. Both the member of staff and the supervisor do now sign off these records and evidence of this was seen by the Inspector. It is required that supervision is held regularly and as prescribed and that detailed supervision records for all staff at Grennell Lodge are maintained and kept on site. By doing so it should improve the quality of supervision and support offered to staff and the quality of care delivered to tenants. Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 31 Senior staff carry out supervision as well as the Manager. The Inspector spoke with the Manager about supervision practices and confirmed that supervision sessions held with staff should include the monitoring and review of all aspects of care practices, the philosophy of care in the home and also career and training development needs. Areas of discussion should also cover the monitoring and review of any individual work objectives that the staff member is expected to carry out. The supervision record should detail any agreements made, revised work objectives and key areas of discussion. At the last inspection the Inspector suggested to the Manager that all staff providing staff supervision should receive training on staff supervision so as to ensure that supervision and staff appraisals are carried out consistently and effectively. Since that inspection the Manager has said that some senior staff have received this training. This is a positive step forwards and should help improve the quality of staff supervision in the unit. Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 32 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. Service users live in a home which is run and managed by a person who is fit to be in charge of good character and able to discharge his or her responsibilities fully. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): AP 37, 39, 42 and OP 31, 33, 35 & 38. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Residents can be confident that they benefit from a well run home and that they have a Manager who is fit to be in charge of this home. Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 33 Residents may be confident that their views underpin all developments and monitoring of the home. Residents may also be confident that their rights and best interests are safeguarded by the home’s record keeping policies and procedures. EVIDENCE: Adults Standard 37 and Older Peoples Standards 31 – The Manager of Grennell Lodge has been in place for several years now and is an experienced Manager; she holds a Registered Managers award. The residents, carers and staff spoken to by the Inspector all felt that the home is being well run and evidence seen by the Inspector over the course of this inspection supports this view. The homes records and administration systems were seen by the Inspector to be in good order and overall the impression was very positive. The home’s Administrator was very helpful to the Inspector in providing information required as a part of this inspection. The Inspector was impressed with the excellent order of the files and how the right information was immediately to hand as required. As at the last inspection interviews with staff reflected a positive and caring approach towards the residents and implementation of new methods for daily living and a social care programme as well as for the development of a new quality assurance system impressed the Inspector that innovative and effective ways of working are being employed within this home. Residents can be assured that they are benefiting from a well run home. Adults Standard 39 and Older Peoples Standards 33 – Over the course of this inspection the Inspector was again fortunate to meet the Quality Assurance Manager for Grennell Lodge who was able to explain the quality assurance process in use at present. The QA Manager told the Inspector about a number of ways in which the home monitors itself and the services that it delivers to the residents. Monthly checks and audits are in place that cover all the key areas of service delivery. For instance (and as referred to earlier in this report) these checks include staff training, CRBs, medication practices, complaints, POVA issues and several other areas. A monthly report is completed and reviewed and the senior management team are obviously working hard to deliver high quality services and to make improvements where necessary. The impression gained by the Inspector over the last year is that Grennell Lodge’s senior management team and the care staff are positive in their attitude and responsive to any recommendations and requirements made by the Commission for Social Care Inspection reports to meet the National Minimum Standards. Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 34 Monitoring of this agency is also carried out through formal and informal consultation with residents and from visiting relatives and professionals. Feedback forms are issued and questions asked focus on the key principles of the service e.g. privacy, dignity, independence, choice, rights and fulfilment. The information and feedback gathered from these sources is then analysed together with information taken from complaints and concerns that have been raised and this forms the basis of an annual development plan that includes implementation targets, with dates as milestones that can be measured and monitored. Residents are provided with information about all aspects of this process via the notice board in the main hall, residents meetings and newsletters. The general feeling within the home was warm and congenial; both staff and management were open and communicative and little sense of anxiety was apparent with residents. Adults Standard 42 and Older Peoples Standards 38 – The Manager informed the Inspector that risk assessments are carried out for the building which identify all the risks and actions required to deal with them. Information was seen in the office to do with relevant Health and Safety legislation. Policies and procedures were also seen for Health and Safety, risk assessment, moving and handling and fire. The Manager informed the Inspector that all staff receive training in moving and handling, fire safety, first aid, food hygiene, and infection control. This was supported by staff interviewed who confirmed that they had received training in these areas and also by the training matrix. Up to date certificates were seen by the Inspector for: • Boiler / gas – 4.8.06 – no problems identified then, the Manager told the Inspector that a new test is due to be carried out this week. • Emergency lighting and fire alarm tested satisfactory– 4.07. • Nurse call system tested satisfactory – 4.07. • Fire equipment tested satisfactory – 5.07 • Portable electric appliances tested satisfactory – 3.07. • Lifts tested satisfactory – 8.07. • Electric system tested and certified satisfactory to 10.11 An accident record book is being used at the home to record any accidents and 5 accidents have been recorded since 19.7.07. These accidents seem to have a common theme that is mainly to do with one or two residents who have fallen. The Manager told the Inspector that as a counter measure taken in order to try to prevent these accidents continuing, a member of the care staff is always on duty in the main lounges. At the time of this inspection this was evidenced in that the Inspector did see care staff on duty in these rooms. The Manager also assured the Inspector that she is taking every precaution to ensure as few as possible accidents occur and that she is aware of the “pressure points”. She Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 35 explained that is why staff are now on duty in the main lounges to provide additional monitoring and support to the residents. Records were seen by the Inspector that evidenced these tests were being undertaken regularly and as required for: • Weekly fire alarm tests • Fire extinguisher checks • Emergency lighting tests. At the time of this inspection no fire doors were seen to be wedged open and the building appeared to be secure. Inspection of the 2 cupboards used to store COSHH substances found that these substances were being stored appropriately and safely, since the last inspection a COSHH notice has now been fixed to the cupboard doors which warns of the COSSH materials and the need to keep the doors locked. Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 36 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 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 3 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 2 CONDUCT AND MANAGEMENT Standard No Score 37 3 38 X 39 3 40 X 41 X 42 3 43 X 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Grennell Lodge Score 3 X 3 X DS0000019093.V351568.R01.S.doc Version 5.2 Page 37 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 YA2 Regulation 14 Requirement That the new assessment format is now used to re-assess the needs of all existing residents. Further work is required to bring the care plans up to the necessary standard. Care plan objectives need to be set out for each resident that identify how their assessed needs are to be met. These objectives should be specific, measurable, appropriate, realistic and set within a time frame. Supervision is carried at least once every 4 – 6 weeks and that a sufficiently detailed record is completed. Timescale for action 01/12/07 2. YA6 14 01/12/07 3. YA36 18 01/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 38 No. 1. 2. 3. Refer to Standard YA36 Good Practice Recommendations That certificated evidence is held on staffing files that evidences which training courses staff have attended and when the training was held. That staff are offered training that is focussed on the needs of the older residents such as dementia and understanding mental health issues. That all staff are asked to sign all the homes policies and procedures and this process is updated for each member of staff every 2 years. YA35 YA23 Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 39 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. Grennell Lodge DS0000019093.V351568.R01.S.doc Version 5.2 Page 40 - 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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