Inspection on 15/01/07 for Grennell Lodge

This inspection was carried out on 15th January 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Grennell Lodge 11/11/07

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 15th January 2007 9:30am Grennell Lodge DS0000019093.V303410.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.V303410.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.V303410.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.V303410.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow eight specified service users 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 service users in the Learning Disability category to be accommodated. 15th November 2005 2. 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.V303410.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 4 staff, the Chef and the Registered Manager. 4 service users were spoken with formally and more informal interviews were conducted with 4 other Service Users as a part of the tour of the home. The Human Relations Manager and the Quality Assurance Manager as well the Proprietor were all present on the first day of this inspection and met together with the Inspector. They are to be thanked for their assistance and helpful support with the inspection. X new requirements have been made as a result of this inspection, the 3 previously set requirements have since the last inspection been met. X new recommendations have been made and the previous 2 recommendations remain in place as they have not yet been met. Feedback on these requirements and recommendations was given verbally to 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 commitment and enthusiasm 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 service users, relatives and other people were very positive. Grennell Lodge DS0000019093.V303410.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 which require improvements and service developments, specifically they are: 1. That the Manager review the format of the needs assessment tool being used by the Unit and that the section for assessing social care needs and cultural and religious needs is extended so that residents may have these needs more fully met. 2. That care plans need to set out in more detail how the service users social care and cultural needs are to be met. 3. That the Proprietor set aside a budget that could be allocated to the Manager and the Activities Co-ordinator and with which they could extend the social care activities programme. 4. That a residents meeting should be held at least once every two months. 5. A sample of medication charts were checked at this inspection to monitor progress in meeting the previously made requirement which was to ensure that the MAR sheets are being fully completed each time medication is administered or other action taken. This sample revealed that improvements have been made in this area but there were still 2 occasions where the MAR sheets had no entry or a record of what had happened after medication had been administered to the resident. 6. Clear and specific guidance drawn up in conjunction with the resident’s GP is now required for each resident where PRN medication is being used. 7. That all staff undertake POVA training at least once every two years from an authorised trainer. 8. 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. 9. 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. Grennell Lodge DS0000019093.V303410.R01.S.doc Version 5.2 Page 7 10. That all senior staff who provide supervision should receive staff supervision training and that this should be completed within the next 6 months. This should help to ensure consistency in the delivery of supervision. 11. That all staff should be given a copy of their supervision record following the supervision meeting. 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.V303410.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.V303410.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 NMS Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users can be assured that the home will meet their healthcare needs fully. Improvements to be made in the process of the assessment of social care needs will ensure that the social care needs of the younger residents will be more fully met. EVIDENCE: Adults Standard 2 and Older Peoples Standard 3 – The Manager informed the Inspector that for each admission to the home a full assessment is carried out of the persons needs. The referring Care Manager does this initially and then the Manager at Grennell Lodge carries out a further assessment of the person’s Grennell Lodge DS0000019093.V303410.R01.S.doc Version 5.2 Page 10 needs. Over the course of the inspection the Inspector inspected 4 of the 29 residents files and found on each file an assessment of needs as described by the Manager. The assessments of residents needs which are carried out by the unit are held on service user files and were seen by the Inspector at this inspection. The assessment format covers most of a residents healthcare needs however the assessment of social care needs was not as fully developed as would be expected and should also include the assessment of residents cultural and religious needs as well as their social needs. The development of identifying social care needs is especially relevant to the younger residents living at Grennell Lodge who were able to tell the Inspector that they would like to see an expansion in the existing programme of social activities and entertainments within the home. They evidently appreciate the current programme but expressed a wish for an extension of it. Any expansion of the programme should be based on identified social care needs. The Inspector interviewed 4 residents formally and spoke to another 4 of the 29 residents over the course of this inspection. It is strongly recommended therefore that the Manager review the format of the needs assessment tool being used by the Unit and that the section for assessing social care needs and cultural and religious needs is extended so that residents may have these needs more fully met. Grennell Lodge DS0000019093.V303410.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 adequate. This judgement has been made using available evidence including a visit to this service. Service users health and social care needs are set out in individual care plans but there are service developments (discussed below) that would improve how these needs are being met by the Unit. Residents and service users 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.V303410.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 8 of the residents and interviewed 3 of the care 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. However it is recommended that care plans need to set out in more detail how the service users social care and cultural needs are to be met. This also relates to a recommendation made under the previous section referring to the needs assessment process. 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 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 would like this programme developed further to include more activities and entertainments. It is evident 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. It is recommended that the Proprietor set aside a budget that could be allocated to the Manager and the Activities Co-ordinator and with which they could extend the programme. The Development of both the needs assessment process and the care planning process in the areas of social care and cultural needs should provide the focus and the starting point for extending the social care programme. Grennell Lodge DS0000019093.V303410.R01.S.doc Version 5.2 Page 13 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. At present residents meetings are held every 3 months but it is recommended that a residents meeting should be held at least once every two months so that resident participation in issues to do with the home can be more frequently discussed. The Inspector thought it positive that the Chef attends the residents meetings in order to receive feedback about the food provided and to hear what food residents would like to have provided in the future. The residents spoken to said they appreciated his attendance at that meeting because it gives them a chance to express their views. Service users 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 service users 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 service users 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.V303410.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.V303410.R01.S.doc Version 5.2 Page 15 Service users may feel 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 – As already stated Grennell Lodge has an activities officer who works with residents to develop a wide and varied programme of appropriate activities based on the service users needs and their care plans. Some of the residents do participate in activities and interests which 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 which 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 service users who wish to attend are offered Communion. A Church of England Vicar also attends the home regularly for those service users 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 service users in using public transport. However the home is lucky enough to have 2 of it’s own vehicles which are used by staff to enable residents and service users 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 service users 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.V303410.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. Service users confirmed with the Inspector that they are supported and enabled to vote although some residents said that they are not inclined to use their votes given the state of politics at present. 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 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 service users rights to privacy, respect and dignity are respected. Residents who were interviewed also confirmed that they felt staff respected these rights. At the last inspection a requirement was made under Standard 42 that related to health and safety issues with the existing locks being used and the possible impedance of residents being able to exit their bedrooms. These locks have now been changed with new locks being installed on all the bedroom doors. This enables residents to lock their doors but also allows staff to enter by the use of a master key. The requirement has now been met. 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 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 – Food menus shown to the Inspector by the Chef indicate that menus are varied, choices are provided and that service users assist in the drafting of the food menus. No complaints about the meals arose during the inspection in fact all those service users Grennell Lodge DS0000019093.V303410.R01.S.doc Version 5.2 Page 17 interviewed said that 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. 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 several mealtimes and the food was seen to be presented in a fresh attractive way that was enjoyed by the residents. Grennell Lodge DS0000019093.V303410.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 adequate. This judgement has been made using available evidence including a visit to this service. Personal and healthcare is provided according to service users 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 – Service users 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.V303410.R01.S.doc Version 5.2 Page 19 and care staff interviewed by the Inspector also confirmed this. Staff interviewed said that service users 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 as well 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. The Manager told the Inspector that residents may choose their key workers. Adults Standard 20 and Older Peoples Standard 9 – The home’s policies and procedures manual contains appropriate policies for the control of medication. The Inspector reviewed the records for the administration of medication to residents 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. A sample of medication charts were checked at this inspection to monitor progress in meeting the previously made requirement which was to ensure that the MAR sheets are being fully completed each time medication is administered or other action taken. This sample revealed that improvements have been made in this area but there were still 2 occasions where the MAR sheets had no entry or a record of what had happened after medication had been administered to the resident. The Manager assured the Inspector that this error will be rectified immediately and will not occur again. However the previous requirement has not yet been met and therefore remains. The Manager was asked by the Inspector with reference to the policy and procedures Grennell Lodge has in place to do with the administration of PRN medication. The Manager told the Inspector that the medication policy contains guidance in this respect. On inspection this guidance was found however this guidance is general and non-specific to the residents actually receiving PRN medication. It is important that in future staff who are administering PRN medication can be quite clear about the circumstances under which PRN medication should be given, and the potential risks and side effects of administering this medication for the resident. Clear and specific guidance drawn up in conjunction with the resident’s GP is now required for each resident where PRN medication is being used. The Inspector suggests that this guidance is held in the medication files together with the MAR sheets and so is readily accessible for staff and residents alike when needed. Grennell Lodge DS0000019093.V303410.R01.S.doc Version 5.2 Page 20 A check carried out by the Inspector on 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. None of the existing service users are able to administer their own medication. 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.V303410.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. Service users are protected from abuse, neglect and self harm by the policies and procedures of the home. All staff should receive regular training in the protection of adults from abuse. EVIDENCE: Adults Standard 22 and Older Peoples Standard 16 – All those service users interviewed formally by the Inspector and those service users 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.V303410.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. The Manager also told the Inspector that staff all have access to training for POVA and this was evidenced on the staff training matrix sheets provided. This useful information sheet sets out all the staff employed at Grennell Lodge and all the training that they have received. The information evidences that most staff but not all have over the last 2 years received training related to the protection of vulnerable adults and this is commended given the importance of this training. Three of the four staff interviewed by the Inspector said that they had attended the training the other member of staff had not. It is therefore recommended that all staff undertake POVA training at least once every two years from an authorised trainer. The Inspector saw the allegation of abuse record; no allegations had been made since the last inspection. The Manager confirmed this to the Inspector. 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. The Inspector asked the Manager whether staff are asked to sign to say that they have read and understood the policies and procedures for the home. The Manager said that this had been done in 2004 but not since that time. Evidence of this was shown to the Inspector. However since that time a number of new staff have been employed at Grennell Lodge and so they have not been a part of this process. Equally in 2004 not all policies and procedures had been signed by all staff to say that they have read and understood them. It is therefore recommended now 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. The Manager told the Inspector that the home does look after resident’s money and acts as Appointee for 8 residents. The Inspector reviewed the financial records for these transactions and found that they were in order. All transactions are 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.V303410.R01.S.doc Version 5.2 Page 23 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.V303410.R01.S.doc Version 5.2 Page 24 EVIDENCE: Adults Standard 24 and Older Peoples Standard 19 – The Inspector 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. Routine maintenance is carried out for the property on a regular basis and this is evidenced with the good state of repair and condition of the home. The Inspector undertook a tour of all the rooms in the home together with the Manager. 8 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 the last fire risk assessment that was undertaken by the LFEPA was carried out in March 2005. All the risks and requirements identified at that inspection have since been addressed and the Inspector at this inspection was able to see evidence of this. In addition to this and since that time Grennell Lodge have now contracted a specialist private contractor to carry out a fire risk assessment for the buildings. The homes fire alarm and emergency lighting systems are serviced regularly and the last check on 16th October 2006 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 May 2006. The Manager said that the last environmental health officers’ report was completed in March 2006 and all the recommendations had been met at the time of this inspection visit. The Inspector asked to see the weekly records for checks on water temperatures and the Manager provided the homes records for this. They revealed that these tests have been carried out each week as is required. Tests carried out all indicated that the hot water temperatures were within 45 degrees celcius. 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 HR 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.V303410.R01.S.doc Version 5.2 Page 25 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.V303410.R01.S.doc Version 5.2 Page 26 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 28, 29 & 30. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users 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 service users will be able to be fully confident that they will benefit from a well supported and supervised staff group. The quality assurances 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.V303410.R01.S.doc Version 5.2 Page 27 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 service users 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 formally with the Chef and other members of the kitchen staff. The Inspector spoke with the Manager and the HR 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 the year 2007. If the planned training of staff materialises as is expected then the Standard that requires that all staff hold an NVQ qualification at at least level 2 by the end of 2007 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 service users are supported by competent and qualified staff. Adults Standard 34 and Older Peoples Standards 29 – As already indicated in previous sections of this report 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 4 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 checks are carried out by the agency for all new staff; although documentary evidence was not available on the staffing files held in the central office. The Inspector was told that this information is held at HQ, he did however request evidence that these checks had indeed been carried out and the HR Manager was then able to fax through an up to date list of all the criminal record bureau clearance checks for existing staff. This information certifies that the appropriate checks have been completed, it is now required that documentary evidence is held in the Grennell Lodge office and that these enhanced checks are renewed every 3 years. Grennell Lodge DS0000019093.V303410.R01.S.doc Version 5.2 Page 28 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. The HR Manager and the Unit Manager are responsible for the training and development of staff. A training matrix document seen by the Inspector usefully sets 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. All of the 4 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 • NVQ 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 service users, the service needs, information about the agency and the principles the agency has of care. The Training Matrix shows the dates when staff completed their induction at Grennell Lodge and this was supported in interview with staff. Adults Standard 36 and Older Peoples Standards 36 – The Manager informed the Inspector that all care staff receive formal supervision at least once every 3 months and informal supervision more often, sometimes on a daily basis. The Manager showed supervision records to the Inspector. Grennell Lodge DS0000019093.V303410.R01.S.doc Version 5.2 Page 29 These records were very brief, they were signed by staff in agreement with the record made by their supervisor but the records were quite varied in their recording content, some not covering sufficient detail to form a useful record. 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, key areas of discussion and should be signed off by both the member of staff and the supervisor. Staff who are supervised should be given a copy of the supervision record which they may keep in their staff handbook file. The 3 care staff interviewed confirmed that they receive informal supervision on a regular basis and that formally they receive supervision approximately once every 2 – 3 months. Records seen by the Inspector did not bear out the stated frequency of supervision sessions. 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. Appropriately structured policies were seen by the Inspector for induction, training and supervision in the home’s policies and procedures manual. It is a requirement that following the inspection of this standard that: • Supervision is carried at least once every 4 – 6 weeks and that a record is completed in sufficient detail to ensure a useful record is maintained for both the staff and the management if the need arises in the future. • That all senior staff who provide supervision should receive staff supervision training and that this should be completed within the next 6 months. This should help to ensure consistency in the delivery of supervision. • That all staff should be given a copy of their supervision record following the supervision meeting. Grennell Lodge DS0000019093.V303410.R01.S.doc Version 5.2 Page 30 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. Service users 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.V303410.R01.S.doc Version 5.2 Page 31 Service users may be confident that their views underpin all developments and monitoring of the home. Service users 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 service users 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 positive. 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. Service users can therefore 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 fortunate to meet the Quality Assurance Manager for Grennell Lodge who was able to explain the quality assurance process in use at present. Monitoring of this agency, quality assurance, is through formal and informal consultation with service users 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 Inspector would like to commend Grennell Lodge on the excellent model for Quality Assurance and the detailed system that is in place for using the information gathered, to develop and improve services Grennell Lodge DS0000019093.V303410.R01.S.doc Version 5.2 Page 32 being provided and feedback given to service users on the progress made. 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 service users. 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. Electrical systems check – 10.11.06 – test undertaken by Apple, some requirements made which the Manager has already commissioned the unit’s electrician to rectify. Lift – tested on 9.11.07 all satisfactory. Portable electrical appliances – tested on 16.4.06 all satisfactory. An accident record book is being used at the home to record any accidents to staff although nothing had been recorded since the last inspection. 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, however a COSHH notice must be fixed to the cupboard doors which warns of the COSSH materials and the need to keep the doors locked. Grennell Lodge DS0000019093.V303410.R01.S.doc Version 5.2 Page 33 Grennell Lodge DS0000019093.V303410.R01.S.doc Version 5.2 Page 34 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 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 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 2 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 2 X DS0000019093.V303410.R01.S.doc Version 5.2 Page 35 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 YA41 YA21 Regulation 13(2) Timescale for action Medication: The medication chart 15/01/07 must be signed each time medication is administered or other action is taken. Previous timescale of 01/01/07 not met. Clear and specific guidance 01/03/07 drawn up in conjunction with the resident’s GP is now required for each resident where PRN medication is being used. That documentary evidence of 01/02/07 criminal record bureau checks is held in the Grennell Lodge office and that these enhanced checks are renewed every 3 years. 01/03/07 Supervision is carried at least once every 4 – 6 weeks and that a sufficient record is completed. That all senior staff who provide supervision should receive staff supervision training. That all staff should be given a copy of their supervision record following the supervision meeting. Requirement 2. YA20 13 3. YA34 19 4. YA36 18 Grennell Lodge DS0000019093.V303410.R01.S.doc Version 5.2 Page 36 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 YA33 Good Practice Recommendations Staffing: The home must ensure that at all times there are staff in such numbers and suitably qualified and experienced to meet the needs of services users and in particular there must be adequate arrangements to replace staff who are absent - without relying upon staff working excessively long shifts. Personal Development: It is recommended that staff increase the opportunities for service users to maintain and develop social, emotional, communication and independent living skills. That the Manager review the format of the needs assessment tool being used by the Unit and that the section for assessing social care needs and cultural and religious needs is extended so that residents may have these needs more fully met. That care plans need to set out in more detail how the service users social care and cultural needs are to be met. That the Proprietor set aside a budget that could be allocated to the Manager and the Activities Co-ordinator and with which they could extend the programme. That a residents meeting should be held at least once every two months That all staff undertake POVA training at least once every two years from an authorised trainer. 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. 2. YA11 3. YA2 4. 5. 6. 7. 8. YA6 YA6 YA7 YA23 YA23 Grennell Lodge DS0000019093.V303410.R01.S.doc Version 5.2 Page 37 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.V303410.R01.S.doc Version 5.2 Page 38 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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