Inspection on 15/08/06 for Grevill House

This inspection was carried out on 15th August 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Grevill House 23/10/07

Grevill House 14/02/06

Grevill House 20/07/05

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

CARE HOMES FOR OLDER PEOPLE Grevill House 279 London Road Charlton Kings Cheltenham Glos GL52 6YL Lead Inspector Ms Eleanor Fox Key Unannounced Inspection 15th August 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Grevill House DS0000064592.V306935.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Grevill House DS0000064592.V306935.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grevill House Address 279 London Road Charlton Kings Cheltenham Glos GL52 6YL 01424 512964 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) The Orders of St John Care Trust Mrs Joy Rosemary Warren Care Home 65 Category(ies) of Old age, not falling within any other category registration, with number (65) of places Grevill House DS0000064592.V306935.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Temporary Variation - One named service user under the age of 65 years. The home will revert to the original service user category when the named service user no longer resides at the home. Temporary Variation - One named service user under the age of 65 years. The home will revert to the original service user category when the named service user no longer resides at the home. 14th February 2006 Date of last inspection Brief Description of the Service: Grevill House is a purpose built Care Home, providing nursing and personal care to 50 residents over 65 years of age. The home is managed by the Orders of St John Care Trust. Grevill House is situated in the village of Charlton Kings, approximately 2 miles from Cheltenham Town centre. The home has 50 single rooms, with comfortable homely communal accommodation on both floors. A shaft lift has been installed for easy access to the upper floor. Although only two of the rooms have en suite facilities, there are several assisted bathrooms and separate toilet facilities throughout the home. Some of the bedrooms at the front of the property have the benefit of a small balcony. An additional superb independent facility known as the Ashley Intermediate Care Centre provides intermediate care for 15 service users. All the large comfortably furnished bedrooms have en suite facilities and the service users have the benefit of sunny open plan communal rooms. They have access to full rehabilitation support services during their short stay in the unit. The property is surrounded by landscaped gardens. The provider supplies information about the home, including the most recent CSCI report in a file at the entrance of Grevill House. Current fees range from £352.70 to £693. Hairdressing, chiropody and any personal items are charged extra. Grevill House DS0000064592.V306935.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. One inspector undertook this unannounced inspection of Grevill House and the Ashley Intermediate Care Centre over two days in August. During the visit, she chose five of the residents in the main home and two service users in the Intermediate Unit for close scrutiny. She spoke to each of these people, read their care records and other relevant documents, visited their bedrooms and observed their interaction with members of staff. One person had recently been admitted to the home; another had developed a serious infection and a third was confined to bed; she was able to observe the special care that was required by each of these people. The inspector read selected personnel and recruitment records, walked around both buildings and observed the service of two meals during the inspection. She also spoke with some of the staff who were on duty on these two days. Finally, she talked to the Manager, the administrator and to the acting unit manager of the Ashley Intermediate Care Centre, particularly in relation to general management issues. All were open and most cooperative in providing information as requested. Prior to the inspection, CSCI surveys had been provided for residents, relatives and members of staff to complete. Comments from those who have responded have been reflected in the content of this report. What the service does well: The home provides a well organised intermediate care facility to assist service users in the transition to independent living. Each person who spoke to the inspector was most appreciative of the care they had received there and one lady spoke of her delight about being able to return to her own home the following day. Members of staff working in both areas have a welcoming friendly approach, respecting each person’s privacy and dignity. This was strongly confirmed by the people, who spoke to the inspector with one lady saying, “The staff are kindness itself”. Grevill House DS0000064592.V306935.R01.S.doc Version 5.2 Page 6 Residents are given the opportunity to take part in a wide variety of activities including a choice of outings, if they wish to. A good choice of food is offered in this home. Any complaints or concerns are addressed in a timely and appropriate fashion. Both buildings are well maintained and were fresh and clean on this visit. Quality Assurance processes are handled well in this home. Residents’ and their relatives’ satisfaction with all the facilities are monitored on a regular basis. What has improved since the last inspection? What they could do better: 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. Grevill House DS0000064592.V306935.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Grevill House DS0000064592.V306935.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The provision of a consistent assessment process and an urgent review of the published literature about the home would assist prospective residents to make an informed decision regarding their admission and give them assurance that their needs will be met. An invitation to visit the property does assist them in the decision-making process. Service users requiring intermediate care are provided with the care and support they need to return to independent living. EVIDENCE: A selection of comprehensive written information about the facilities is provided to prospective residents. However, the Statement of Purpose and Service User Guide have still not been fully reviewed and updated to reflect the management and other changes at the home. Assurances have been provided that the new brochures will be published shortly. Grevill House DS0000064592.V306935.R01.S.doc Version 5.2 Page 9 Discussion with members of staff and observation of the records of those residents selected as part of a case tracking exercise showed that assessments are undertaken of each prospective resident to ensure that the home is able to meet his or her particular needs. Written records are normally maintained of the processes. Some of the completed documents plus copies of the Social Services Assessments and other available information were all filed in the residents’ files. It was explained that residents admitted under the “Rapid Response Scheme” sometimes were admitted with very limited details although this shortfall is normally addressed shortly after arrival. Nevertheless this does create difficulties for the nurse admitting the resident and can result in some of the residents’ initial needs not being met. One lady, the daughter of a prospective resident, described the reception she had received when she visited the home. The staff had been very friendly and reassuring, answering all her questions and generally putting her mind at rest about her Mother’s impending move. Intermediate care is provided in the Ashley Intermediate Care Centre. This purpose built unit was opened three years ago and has been designed, equipped and staffed to provide short-term intermediate care to service users who require rehabilitation prior to returning to independent living in the community. The service users have the support of a fully multi-disciplinary staffing team. The decision has now been made to appoint a registered nurse to manage this area of the home. The successful applicant will commence duties in September. Grevill House DS0000064592.V306935.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Some further improvements in the care planning systems would provide clearer information to staff, to ensure that they are able to care for all the residents’ needs. On the whole, the medication systems in place ensure that residents are not put at any risk of potential errors. Care is delivered in a manner that preserves the residents’ privacy and upholds their dignity. EVIDENCE: Grevill: Five care plans were selected for inspection; each one contained a plan of care based on a full care needs assessment. However, the instructions varied in clarity and content with some providing appropriate guidance and others less instructive. One person had had a history of falling but the staff had not been alerted to this risk; in contrast, a very thorough plan had been prepared for another lady to address maintaining a safe environment. A gentleman had Grevill House DS0000064592.V306935.R01.S.doc Version 5.2 Page 11 been identified as ‘at high risk of developing a pressure sore’ but there was no care planning to address this need. Although reviews had been undertaken, they did not always reflect changes in the resident’s condition: two people had suffered significant weight loss in recent months but this was not mentioned in the nutritional care plans and no amendments had been made to the content. Another person was now nursed on bed rest but this was not mentioned in her care planning guidance with the comments suggesting that she was still fully mobile. Ashley Intermediate Care Centre: Two care plans were selected in this specialist area. Progress has been achieved in preparing appropriate and personalised care plans but these still require further development to ensure that each service user’s particular care needs are addressed. The new unit manager is addressing this shortfall. Records are maintained in each service user’s bedroom, giving them ownership of the content. There were records to show that people living in both areas receive timely care and support from other healthcare professionals as required. Details of any care provided by community nurses were clearly recorded. One person had had recent visits from the “Tissue Viability Nurse”, the “Diabetic Nurse” and the “Heart Specialist Nurse”. Grevill: Observation of the medication storage areas and the medication administration sheets relating to five selected residents, showed that medications are ordered, stored and administered correctly. The staff have access to comprehensive ‘Medication Policies’ and a recently published reference publication is readily available for staff use. A full medication audit of the facility was undertaken in June. Ashley Intermediate Care Centre: Additional facilities for the storage of medications have now been provided in the office area although the majority of the service users are self-medicating and keep their drugs in the locked facilities within their bedrooms. It was observed, however, that handwritten medication administration sheets in this area were not all signed or supported by a further signature. Members of staff working in the Ashley Intermediate Care Centre have been booked to undertake further accredited medication administration training in the near future. Staff were observed addressing the people living in both areas in a courteous but friendly manner. Each person who spoke to the inspector was very positive about the staff with one person describing the care she received as, “Splendid, they are wonderful to me”. Grevill House DS0000064592.V306935.R01.S.doc Version 5.2 Page 12 Grevill House DS0000064592.V306935.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Opportunities are provided for varied and stimulating activities and social contacts, as desired. A reasonable choice and variety of meals ensures residents normally receive a nutritious and balanced diet. EVIDENCE: Residents at Grevill House are given the opportunity to take part in a variety of activities, which are advertised in the main hall. These include trips out in the minibus to places of interest in Gloucestershire and to the coast. One person spoke most enthusiastically about a recent outing, which he had clearly enjoyed. The home had just had a successful fete to raise funds. On the second day of the inspection a number of residents were observed enjoying a film in the dining room. Residents’ personal interests and also their participation in any form of activities are recorded in their care files. Grevill House DS0000064592.V306935.R01.S.doc Version 5.2 Page 14 Friends and relatives visited people in Grevill house and Ashley Intermediate Care Centre throughout the inspection; one lady went out to lunch with her daughter and another was taken out for a walk in her wheelchair. A newsletter is distributed to ensure that visitors are aware of any planned events at the home. Some had assisted at the recent fete. Residents are given the opportunity to make choices about what they will eat and how they will spend their days. Information is provided on how to source advocacy, if it is required. Support is being sought for one resident at the current time. The service of two meals was observed during the inspection. The mid day meal was provided in one of the dining rooms or taken to residents’ bedrooms in a hot trolley. A choice of menu was offered; soft drinks were also served to each person if desired. Five members of staff sat and assisted some of the residents with their meal, providing gentle encouragement if required. Dietary supplements were also provided to some people. Service users at the Ashley Intermediate Care Centre are provided with meals from the main kitchen. They are also given an opportunity to do some light cooking as part of the rehabilitation process. Grevill House DS0000064592.V306935.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. A satisfactory complaints system enables residents and their families to feel assured that their views would be listened to and acted upon. Residents are offered a good level of protection against abuse. EVIDENCE: Grevill House provides clear guidance for anyone wishing to make a complaint about the service. Since the last inspection there have been six formal complaints, one of which was sent to the Commission for Social Care Inspection. All were fully investigated and appropriate action taken to address and rectify the issues raised. One resident who was questioned confirmed that if she had any concerns, she always spoke to one of the nurses and “they sorted everything out for her”. The home has comprehensive written policies to address all types of abuse; members of staff have also attended recent training workshops on these topics. Each newly appointed member of staff signs an undertaking that they will neither assist in the making of or benefiting from service users’ wills. POVA (Protection of Vulnerable Adults) legislation is correctly followed at Grevill House. Grevill House DS0000064592.V306935.R01.S.doc Version 5.2 Page 16 Grevill House DS0000064592.V306935.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. A safe and well maintained environment provides the people living in Grevill House and the Ashley Intermediate Care Centre with a good standard of accommodation. EVIDENCE: Both properties are well maintained and have been designed and furnished to meet the needs of the people living there. The Ashley Intermediate Care Centre is of a particularly good standard with attractive furnishings and ample room for the service users to participate fully in all the rehabilitation processes. Both buildings are surrounded by landscaped gardens. Sturdy garden furniture is provided for those people who wish to sit outside. A visit was made to the bedroom of each person who had been selected for case tracking. In Grevill, each room had been personalised with photographs, treasured possessions and in some cases, some small items of furniture. Grevill House DS0000064592.V306935.R01.S.doc Version 5.2 Page 18 All the rooms in the Ashley Intermediate Care Centre are of a good size and each has en suite facilities. Although the service users only stay for a limited period, the rooms are homely and comfortable. Both properties were clean and free from offensive odours. One person was suffering from an infection; thorough infection control processes were being followed and the staff on duty were fully aware of the protocols to observe. The home has clearly detailed infection control policies, which are readily available to all grades of staff. The laundry is equipped with industrial style machines; it was tidy and organised. Grevill House DS0000064592.V306935.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. People living here receive care from a stable workforce but improved training and recruitment practice would help to ensure residents are fully protected. EVIDENCE: On the first day of the inspection there were two nurses and ten carers on duty to look after the forty-six residents living in the home; the four empty rooms were due to be filled in the coming week. In addition, the administrator, cook and two kitchen assistants, plus three domestic assistants were working in Grevill House. A nurse and six carers were due to be on duty in the evening and a nurse and three carers overnight. Most people felt that that these numbers were just about adequate to care for the needs of the residents in the home although there were some members of staff who felt that additional assistance would be beneficial. Some staff commented that there were difficulties in covering laundry duties at the weekend. In the Ashley Intermediate Care Centre there is normally a care leader with two carers on duty throughout the day; one care leader and one carer are allocated to this area overnight. Assistance is available from the main home if required. An experienced trained nurse has been appointed to become the unit manager of the Ashley Intermediate Care Centre, commencing in September. Of the thirty-five carers employed at the home, three have achieved a National Vocational Qualification, Level 3 in Care and a further seven people have Grevill House DS0000064592.V306935.R01.S.doc Version 5.2 Page 20 completed Level 2. Two carers are undertaking the training at the current time and it was confirmed that additional members of staff are prepared to commence the course. The personnel files relating to four members of staff employed since the last inspection were seen on this visit. One of these people also described the recruitment processes in her case. In each instance, the prospective employee had completed an application form providing details of his or her employment history; records had been made of the interview processes; correct POVA (Protection of Vulnerable Adults) and CRB (Criminal Record Bureau) screening had been completed for each person. Two written references had been provided for the majority of applicants but in one case only one written reference had been obtained. This was identified to the Manager and the requisite reference will be obtained. It was difficult to establish when some members of staff had commenced duties, as this information was not in the records. The records show that all mandatory training continues to be addressed in a timely manner. Members of staff working in Grevill House have also attended additional specialist training appropriate to their roles. Some specific training needs have been identified in the Ashley Intermediate Care Centre; these are now being addressed. Grevill House DS0000064592.V306935.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. There are management systems in place to ensure that the financial interests, and the health, safety and welfare of people using the service are safeguarded; however these would benefit from further development and improvement. EVIDENCE: An experienced trained nurse manages Grevill House; she recently completed the Registered Manager’s Award. At the current time there is no deputy appointed to the home but the post is being advertised. An experienced trained nurse has also just been appointed as Unit Manager of the Ashley Intermediate Care Centre. The home is currently undertaking an audit of residents’/relatives’ satisfaction with all aspects of Grevill House’s services. Some completed forms were read Grevill House DS0000064592.V306935.R01.S.doc Version 5.2 Page 22 during the visit. When the results have been collated, any areas for improvement will be identified and addressed. Residents’ satisfaction with meals plus the occurrence of any complaints, concerns or accidents are also monitored on a monthly basis. A medication audit was completed in June. The home was successfully audited for the ISO 9001 quality award in late 2005. The Care Services Manager also visits the home on a monthly basis to check standards. The Administrator continues to take responsibility for the personal monies for the majority of the residents in the home; the records relating to the five residents selected for case tracking were checked on this occasion. It was observed that correct records are maintained and that individual secure storage is provided. It was confirmed that residents’ status in relation to ‘Power of Attorney’ is not always ascertained at this home but this shortfall will now be rectified. It was clear from the completed questionnaires and staff records that some of the staff were being adequately supervised; others, however, were unable to confirm this. One person said that, “In nearly three years I have only had two supervisions”. Records were provided to show that statutory maintenance/inspection of equipment and services is arranged in a timely fashion. Where faults are identified, they are rectified as necessary. Fire prevention management and training of staff appears to be addressed correctly. An Environmental Health inspection took place in March; issues highlighted for improvement have now been corrected. It was confirmed that two incidents involving the use of the lift and the use of showers which had occurred in the last six months had not been reported to the Commission for Social Care Inspection, as is required. Grevill House DS0000064592.V306935.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 1 x 2 x 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x 3 x x 3 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 2 1 x 2 Grevill House DS0000064592.V306935.R01.S.doc Version 5.2 Page 24 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 OP1 Regulation 6(a & b) Requirement The Statement of Purpose and Service User Guide must be reviewed and updated to reflect the changes in the home. A copy must be provided to the Commission. (This requirement has been repeated from the last inspection). The care needs of each resident must be fully assessed and a record made of the processes, prior to admission to the home. (This requirement has been repeated from the last two inspections). Care plans must be provided to address residents’ care needs, particularly in relation to pressure relief and maintaining a safe environment. (This requirement has been repeated from the last inspection). The person making the record in the drug administration documentation must sign any handwritten amendments. These must also be countersigned by DS0000064592.V306935.R01.S.doc Timescale for action 31/10/06 2. OP3 14(1a) 01/09/06 4. OP7 15(1)&(2) 31/10/06 5. OP9 13(2) 01/09/06 Grevill House Version 5.2 Page 25 6. OP29 Schedule 2.3 7. 8. 9. OP29 OP35 OP36 Schedule 4.6 Schedule 3.3b 18(2) 10 OP38 37(1e) another witness. Two written references must be obtained prior to the commencement of employment (This requirement has been repeated from the last inspection). A record must be maintained of the date on which each member of staff commences employment. A record must be maintained of each person’s status in relation to ‘Power of Attorney’. Supervision processes must be undertaken regularly. (This requirement has been repeated from the last two inspections). CSCI must be informed in writing about any event in the care home which adversely affects the well-being or safety of any service user/resident. 01/09/06 30/09/06 30/09/06 30/09/06 01/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP28 OP36 Good Practice Recommendations At least 50 of care staff should be trained to NVQ in care, level 2 or equivalent. Supervision processes should be undertaken six times a year Grevill House DS0000064592.V306935.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Grevill House DS0000064592.V306935.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!