Inspection on 14/04/04 for Grindleford Avenue 2

Care Homes For Adults (18 ­ 65)Grindleford Avenue 2New Southgate London N11 1JNAnnounced Inspection14th April 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Grindleford Avenue 2 Address New Southgate, London, N11 1JN Email address Tel No: 020 8368 5177 Fax No: 020 8368 5177Name of registered provider(s)/company (if applicable) PentaHact Name of registered manager (if applicable) Miss Louise McInnes Type of registration Care Home No. of places registered (if applicable) 4Category(ies) of registration, with (number of places) Learning disability (4), Physical disability (4) Registration number G080000175 Date first registered 30th July 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 19th March 2004 YES NO 19/1/04 If Yes refer to Part CGrindleford Avenue 2Page 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 314th April 2004 09:30 am Tom McKerveyID Code104975Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMichael CanningGrindleford Avenue 2Page 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers AgreementGrindleford Avenue 2Page 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Grindleford Avenue 2. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Grindleford Avenue 2Page 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. 2 Grindleford Avenue is a purpose built bungalow, situated at the end of a cul-de-sac in a relatively newly developed general needs housing estate. The home accommodates four younger adults who have a learning and a physical disability. The building is owned and maintained by Sanctuary Housing Association, and managed by Pentahact through a written agreement. Pentahact, which is a Barnet based organisation, also manages several other special needs projects in the borough. The current group of service users have lived at the home since it opened in 1997.The bungalow is specially adapted and furnished to provide a functional yet comfortable environment. The home comprises of five bedrooms, including a bedroom for staff who undertake sleep-in duties. There is an office, shared lounge, kitchen and dining room. To the rear and side of the building, there is a paved area and garden. The toilet and bathroom facilities are equipped with aids and adaptations to meet the needs of people with physical disabilities. The home provides twenty-four hour care and support, and the homes minibus provides access to a range of day care and leisure facilities. There is good public transport, and shops and other amenities are close by. The stated aims of the service are; To provide a home for four people, based on the concepts of Community Presence, Relationships, Choice, Competence, Respect and Dignity.Grindleford Avenue 2Page 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This announced inspection took place over a period of seven hours. The home had undergone several changes of manager over the past year. The current manager has been in post since October 2003 and has not yet been registered. The inspector was assisted in the process by the acting manager and the staff, who cooperated fully in the inspection. There were four service users living at the home, all of whom were seen during the inspection. All of the service users have difficulties with verbal communication. However, it was apparent that the staff were able to understand the service users wishes and were meeting their needs appropriately. Service users appeared to be generally well cared for, apart from the fact that two service users needed a shave, and some service users who had epilepsy, did not have their seizures recorded. The home was generally in a good state of repair, but some maintenance issues were identified. At the last inspection, fourteen requirements had been made, eight of which had been restated from previous inspections. At this inspection, seven previous requirements have been restated and a further seven added, two of which required immediate action. It is a major concern that so may requirements have been restated, especially regarding staff records. The organisation needs to be aware that enforcement action will be taken if this situation persists. Choice of Home (Standards 1-5) Four of the 5 standards assessed, were met. The home has an appropriate Statement of Purpose and Service Users Guide. Service users have a full assessment before being admitted to the home. The home has the capacity to meet service users needs and trial visits are offered to prospective service users. Contracts need to include financial information and to be signed by service users or their representatives. Individual Needs and Choices (Standards 6-10) Three of the 4 standards assessed, were met. Service users are enabled to exercise choice. Risk assessments are carried out to protect service users. Information about service users is held confidentially. Care plans must be reviewed at least every six months. Grindleford Avenue 2 Page 6 Lifestyle (Standards 11-17) All of the 7 standards assessed, were met. Service users are offered opportunities for personal development and take part in fulfilling activities. The service users are well integrated into the local community and participate in leisure pursuits. Service users are able to receive visitors without restriction and to visit friends and relatives outside the home. The independence of service users is promoted. Meals are well balanced and nutritious. Personal and Healthcare Support (Standards 18-21) None of the 4 standards assessed, were met. Two service users had not received the full range of personal care on the day of the inspection. Not all service users who had epilepsy, had seizure monitoring charts in place. There was no record of medication disposed of and the temperature of the medication cupboard was not monitored. Not all service users wishes in relation to their death were recorded. Concerns, Complaints and Protection (Standards 22-23) One of the 2 standards assessed, was met. The home has a logbook and procedure for dealing with complaints. There was a discrepancy in the records of one service users personal finance record. Environment (Standards 24-30) Six of the 7 standards assessed, were met. The home meets the requirements for sufficient space in bedrooms. Bedrooms have appropriate fittings and furniture for the comfort of service users, and were decorated to individual taste and lifestyle. There were sufficient toilet and bathroom facilities provided. A range of fully accessible communal areas is provided. Hoists and adaptations were available to assist service users who had physical disabilities. The home was clean and tidy and free from offensive odours. There were some maintenance issues to be addressed. Staffing (Standards 31-36) Five of the 6 standards assessed, were met. Staff have clearly defined job descriptions and are competent to meet service users needs. There are sufficient staff on duty at all times. There is a staff training programme in place, and staff receive regular supervision. Staff records at the home were incomplete Conduct and Management of the Home (Standards 37-43) Two of the 7 standards assessed, were met. There is an open and inclusive management style in the home. The home has appropriate policies and procedures in place. The acting manager must apply for registration. A quality assurance audit must be carried out. The home must carry out regular fire drills and put the insurance certificate on display. Monthly health and safety checks must be recorded. A finance and development plan for the home must be available for inspection.Grindleford Avenue 2Page 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action 1 5(1)(b)(c) YA5 The registered person must ensure that all contracts are signed by the service user or their representatives and that all contracts contain the information set out in Standard 5. The acting manager must ensure that all care plans are reviewed at least six-monthly. The registered person must ensure that a record is maintained of medication which is disposed of. The registered person must ensure that all service users wishes in the event of their death are recorded. 15/2/042 315(2) 13(2)YA6 YA2029/2/04 15/2/04412(3)YA2129/2/04523(2)YA24The registered person must ensure that a 26/1/04 planned maintenance programme for the home is available for inspection. The registered person must ensure that staff records contain all the information as set out in Schedule 2 (4.6), of the regulations and are available for inspection at the home. The registered person must ensure that a quality assurance system is implemented. 15/2/04617(2) Sch 2 & Sch 4.(6)YA34724YA3915/2/04Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented Grindleford Avenue 2 Page 8 No.Refer to StandardGood Practice RecommendationsCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)Grindleford Avenue 2Page 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 5(1)(b)(c) 1 YA5 The registered person must ensure that all contracts are signed by the service user or their representatives and that all contracts contain the information set out in Standard 5. This requirement is restated from the previous inspection. 2 15(2) YA6 The registered person must ensure that all care plans are reviewed at least six-monthly. The registered person must ensure that all service users receive all personal care that is required on a daily basis. The registered person must ensure that epilepsy seizures are monitored on appropriate charts. 30/6/0430/6/04312(1)(b)YA1831/5/04417 Sch 3(j)YA1931/5/04513 (2)YA20The registered person must ensure that a record is kept of medication which is disposed of, and that the temperature of the medication 31/5/04 cupboard is monitored to ensure that it does not exceed 25°C. The registered person must ensure that all service users wishes in the event of their death are recorded. This requirement is restated from the previous inspection.12(3) 6YA2131/5/04Grindleford Avenue 2Page 10 717 Sch 4.9YA23The registered person must ensure that records of service users personal finances are accurately maintained. The registered person must ensure that the maintenance issues set out in the commentary are addressed. This requirement is restated from the previous inspection.31/5/04823(2)YA2430/6/0417(2), 19 9 Sch 2 & Sch 4.6YA34The registered person must ensure that staff records contain all the information as set out in Schedule 2 and 4.6 of the regulations are available for inspection at the home. This is an immediate requirement. The registered person must submit an application to the Commission for Social Care 31/5/04 Inspection, to be appointed as the manager of the home. The registered person must ensure that a quality assurance system is implemented. This requirement is restated from the previous inspection. The registered person must ensure that regular fire drills for service users are held and that the homes liability insurance certificate is up to date and displayed in the home. The registered person must ensure that monthly health and safety checks are carried out and recorded. The registered person must ensure that a business and financial plan for the home is available for inspection.108(1)YA3724 11YA3931/5/041213 (4)(c)YA4131/5/041313(4)(c)YA4231/5/041425YA4331/7/04RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. Grindleford Avenue 2 Page 11 No.Refer to Standard *Good Practice Recommendations* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: YES YES YES YES YES NO NO NO YES NO NO YES YES YES NO NO NO YES NO YESGrindleford Avenue 2Page 12 Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs)3 X X NO NO YES NO 12 X 14/4/04 9.30 7The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Grindleford Avenue 2Page 13 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to `test drive the home. Each service user has an individual written contract or statement of terms and conditions with the home.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. 1340.00 1340.00 Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are Toiletries, holidays 3 Key findings/Evidence Standard met? The Statement of Purpose was seen and was found to meet this standard. The Service Users Guide has been produced in pictorial form to aid the understanding of the service user group.Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? No new service users have been admitted to the home since the original group moved in. The current service users files contained full assessments by care managers and health personnel.Grindleford Avenue 2Page 14 Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The home accommodates four service users, one who is over 65 years of age, and two who have a diagnosis of dementia. From discussion with the acting manager, examination of the case records and observation of the service users, the inspector was satisfied that the home meets the assessed needs of the client group.Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? No new service users have been admitted to the home in recent years. However, the acting manager stated that prospective service users would be offered trial visits to he home before moving in. This is also stated in the homes Statement of Purpose. The home does not provide for emergency admissions.Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 1 Key findings/Evidence Standard met? At the last two inspections, requirements were made for service users contacts to include service users rights and responsibilities in a format that the service users could understand. It was also required that service users contracts contained information about the fees charged and that they were signed by the service users or their representatives. These requirements were not complied with and an immediate requirement to address this issue was made.Grindleford Avenue 2Page 15 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 2 Key findings/Evidence Standard met? The inspector saw all the care plans. These were comprehensive. The service users have an annual care review, which is attended by care managers and relatives. However, there was no evidence to indicate that the plans were being reviewed at least sixmonthly. This requirement is restated from the previous inspection.Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? The case files contained very good, comprehensive, risk assessments for each service user. Guidance was included for staff about the action to take to minimise risks. The home is exploring the use of advocacy services to ensure that service users rights are protected in relation to restrictions resulting from the risk assessments.Grindleford Avenue 2Page 16 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 3 Key findings/Evidence Standard met? The inspector was shown minutes of service users meetings, which indicated that service users had opportunities to participate in the running of the home. Records were seen of keyworker and service user sessions where service users were consulted about a wide range of issues and their views sought.Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 3 Key findings/Evidence Standard met? As stated above, risk assessments were documented for each service user. These covered bathing for service users who had epilepsy and risks associated with events happening outside the home. Case files contained information about service users likes and dislikes.Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 3 Key findings/Evidence Standard met? The home has a policy on confidentiality of information. The acting manager and the staff were able to demonstrate a sound knowledge of the principles of confidentiality and all records were stored securely. Partner agencies had been sent a statement about the homes policy.Grindleford Avenue 2Page 17 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate, personal, family and sexual relationships. Service users rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met? The service users care plans, which were seen, indicated that they were involved in a range of activities within and outside the home. Examples included; life skills training in their various day centres. There was evidence of input from psychologists and speech therapists, which addressed specific needs.Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 3 Key findings/Evidence Standard met? None of the service users are able to engage in employment or work placement schemes. Each service user has a daily programme, which involves activities within and outside the home. Examples include, massage, music therapy and sensory arts. These activities are recorded in each service users daily diary.Grindleford Avenue 2Page 18 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 3 Key findings/Evidence Standard met? The home has its own transport which enables the service users to engage in community activities, such as, visits to local shops, library and pubs. One service user is supported in attending church regularly. The acting manager stated that relationships with neighbours were cordial and that the home was regarded as an integral part of the local community.Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 3 Key findings/Evidence Standard met? Service users were seen to have a full daytime programme as commented above. Indoor activities include board games, television and music. Some service users were seen to also have their own television and games in their rooms. An outside entertainer provides a music session. All service users had a holiday away last year, and the acting manager stated that another is being planned for this summer. Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Most of the service users have regular visits by families, the records of which were seen. There were records of service users going out to stay with their relations and of visits to friends who were also service users in other care homes. The acting manager described the visiting policy as open and non-restrictive.Grindleford Avenue 2Page 19 Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? The service users living at the home all have difficulties with verbal communication. However, the inspector was satisfied in observing how the staff interacted with them, that service users wishes were understood and were acted on. Staff were observed to address service users appropriately with respect. One service user who smokes, is assisted by staff to do so, away from other service users. The smoking activity has a recorded risk assessment.Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? The inspector was shown the menus provided at the home. These were in pictorial format to enable service users to choose their preferred meals. Service users were seen to be well nourished. No service users were receiving any special diet at the time of the inspection, but the inspector was told that dietetic services were available should this be necessary.Grindleford Avenue 2Page 20 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · Service users receive personal support in the way they prefer and require. Service users physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the homes policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 2 Key findings/Evidence Standard met? Community healthcare professionals provide nursing care, when necessary. Staff were seen giving personal care in an appropriate and sensitive manner. Staff records were seen to show that they had received appropriate training for meeting the service users needs. Two male service users appeared not to have had a shave at the time of the inspection. The acting manager must ensure that male service users are supported to be clean-shaven, unless they express a wish not to. Such wishes need to be recorded. Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) 2X2 Key findings/Evidence Standard met? The accident book was inspected and seen to be appropriately recorded. There were records of appointments with a range of healthcare professionals in the case files. Two service users who had epilepsy, did not have charts to monitor the frequency of fits. The acting manager must ensure that all seizures are recorded.Grindleford Avenue 2Page 21 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 2 Key findings/Evidence Standard met? A number of issues raised at the last inspection have now been addressed. The records of administration of medicines showed that two staff signed. Medication being returned to the pharmacy was recorded. Staff records showed that staff had training in medication. An inspection of the medication charts showed no disparities in the administration records. A requirement is made to monitor the temperature of the medication cupboard to ensure that it does not exceed 25°C. A record of the medication disposed of, must be maintained. This requirement is restated from the previous inspection.Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 2 Key findings/Evidence Standard met? The policy on bereavement states that the Commission for Social Care Inspection must be informed about the death of a service user and that medication must be retained for seven days. However, although one service users wishes were recorded, the home has not yet ascertained the wishes of all service users or their representatives about funeral arrangements. This requirement is restated from the previous inspection.Grindleford Avenue 2Page 22 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days X X X X X X 100 3 Key findings/Evidence Standard met? A complaints book is now available. There were no entries in the book and the acting manager stated that no complaints have been received about the service. The complaints procedure has been amended to include the information required by this standard.Grindleford Avenue 2Page 23 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YESX2 Key findings/Evidence Standard met? The home has the local authoritys adult protection procedure. Staff records confirmed that they are receiving training in abuse awareness. An examination of the service users personal cash held in the home, showed a minor discrepancy between one service users records, compared with the actual balance. A requirement is made that the discrepancy is corrected so that the correct amount is reconciled, and that financial records are properly maintained.Grindleford Avenue 2Page 24 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · Service users live in a homely, comfortable and safe environment. Service users bedrooms suit their needs and lifestyles. Service users bedrooms promote their independence. Service users toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 2 Key findings/Evidence Standard met? Sanctuary Housing Association is responsible for maintaining the building. A tour of the premises was undertaken. The requirements made at the last inspection were addressed. Window restrictors had been repaired. A carpet, which was required to be replaced, had been shampooed instead. The inspector was satisfied with this. The following maintenance issues were identified: The floor of the laundry room is in need of repair. One toilet needs to be redecorated, and the extractor fan was not working. At the time of the inspection, the grass needed to be cut. A requirement is made to address the above deficits. The home still does not have a maintenance and renewal programme. This requirement is restated from the previous inspection.Grindleford Avenue 2Page 25 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite YES NO NO 4 X X X 4 4X X X X3 Key findings/Evidence Standard met? All service users have their own room. All bedrooms meet the minimum space requirements.Grindleford Avenue 2Page 26 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 3 Key findings/Evidence Standard met? All four bedrooms were seen. They were furnished and fitted in a manner, which meets the requirements of this standard. The bedrooms were differently decorated and the acting manager stated that service users had been consulted about the décor, in accordance with their tastes and wishes.Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? The home has three toilets and a separate bathroom which contains an assisted bath. There is also a separate sit-down shower facility. All facilities have lockable doors to ensure privacy, with an override facility in case of emergencies.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 3 Key findings/Evidence Standard met? The home is purpose-built to provide spacious communal facilities which are easily accessible by wheelchair users. The lounge and dining areas were bright and pleasantly decorated. The furniture was in good repair and comfortable. The garden area was screened to provide privacy.Grindleford Avenue 2Page 27 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 3 Key findings/Evidence Standard met? The home is well equipped with hoist and other appropriate adaptations to support service users who have a physical disability. Records showing that equipment was regularly serviced were available for inspection.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? At the time of the inspection, the home was very clean and tidy and free from offensive odours. A cleaner is employed for 10 hours per week.Grindleford Avenue 2Page 28 StaffingThe intended outcomes for the following set of standards are: · · · · · · Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the homes recruitment policy and practices. Service users individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 3 Key findings/Evidence Standard met? Four staff files were seen. They contained job descriptions, which in discussion with the staff, they described as accurately identifying their roles and responsibilities.Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 3 Key findings/Evidence Standard met? This standard was assessed through discussion with the staff, observation, and reading case files and daily records. The staff were able to give a clear description of their roles and responsibilities. The inspector observed that the staff appeared to have good relationships with, and understood the needs of the service users. Staff records showed that they had received appropriate training. .Grindleford Avenue 2Page 29 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme X 4 X 229 X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X 259 X 259 Nursing X X XXX3 Key findings/Evidence Standard met? The staff rotas were seen. They showed that two staff worked on each daytime shift. At night, there was a waking night staff. The home meets the minimum staffing levels required by this standard. The acting manager stated that one member of staff is currently training on NVQ level 3 and two staff are soon to commence NVQ level 2. The home is aware of the requirement to meet the target of 50 of the staff to be trained at NVQ level 2 by 2005.Grindleford Avenue 2Page 30 Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 1 Key findings/Evidence Standard met? Four staff files were seen. While most of the information required by the standard was in place, the records were incomplete. In some files, there was no birth certificate, proof of identity, and only one reference. This is now a serious concern as this requirement has been restated at several past inspections. An immediate requirement was made to ensure that all the information outlined in Schedules 2, and 4.6 of the regulations is entered in staff files. Continued failure to comply with this standard will result in enforcement action being taken. Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? The inspector was shown a training programme for staff up to December 2004. Staff training records showed that they had been given an appropriate induction and training to equip them for their roles. The subjects covered in the TOPPS foundation programme had been undertakenStandard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? Staff records confirmed that staff receive supervision at least every six weeks. This was also confirmed by staff in discussion with the inspector. The staff told the inspector that they found supervision to be a valuable support in their work. Performance issues are addressed, as well as training needs and personal issues in the supervision sessions.Grindleford Avenue 2Page 31 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self- monitoring, review and development by the home. Service users rights and best interests are safeguarded by the homes policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. NO2 Key findings/Evidence Standard met? The acting manager has been in post since October 2003. He stated that he is currently halfway through NVQ level 4. He has not yet applied for registration. A CRB check for the acting manager was seen. However, as part of his application to be registered as the manager, he needs to have another CRB check processed through the Commission for Social Care Inspection. A requirement is made to address both these issues.Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The home has had several changes of management recently. Nevertheless, in discussion with a group of staff, the inspector was satisfied that this standard was met. The staff stated that the acting manager was approachable and supportive. The records of staff minutes were seen and indicated that staff were able to express views and opinions about the service and that these were acted on.Grindleford Avenue 2Page 32 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 2 Key findings/Evidence Standard met? The inspector is aware that Pentahact has undertaken a major quality assurance initiative throughout the organisation. While this home has not yet been audited, the inspector saw evidence that this is booked for May 2004. The registered person is required to carry out the audit, publish the findings and send a copy to the Commission for Social Care Inspection. This requirement is restated from the previous inspection.Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 3 Key findings/Evidence Standard met? A sample of the homes policies and procedures was seen, including those which needed addressing from the last inspection. These were found to be in order.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 2 Key findings/Evidence Standard met ? The certificates of fire, electric and gas installation checks were seen. The water test for legionella was completed. Fire logs confirmed that weekly tests were carried out. There were records of fire drills held. However it was some time ago and another one should be held by the end of May 2004, and at least three monthly in the future. Fridge and freezer temperatures were recorded. COSHH substances were securely stored The homes liability insurance certificate had recently run out of date. However, during the inspection, the acting manager contacted the head office and was assured that the insurance had been renewed. A requirement is made that a valid insurance certificate is displayed at the home.Grindleford Avenue 2Page 33 Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? The records of health and safety training for staff were seen. The last fire safety inspectors inspection was in 2002. Dorgard closures were fitted on some doors and were in order. Monthly health and safety checks were not recorded.Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 1 Key findings/Evidence Standard met ? There was no information available at the time of the inspection to assess this standard. The budget for the home was not seen. It is a requirement that a financial and business plan for the home is available for inspection.Grindleford Avenue 2Page 34 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Regulation Manager DateTom McKervey Mandy Jobling 24 May 2004Signature SignaturePublic reports It should be noted that all CSCI inspection reports are public documents.Grindleford Avenue 2Page 35 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection of 2 Grindleford Avenue conducted on 14 April 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possible NO COMMENTS HAVE BEEN RECEIVED FROM THE PROVIDER AND AN ACTION PLAN HAS BEEN REQUESTED.Grindleford Avenue 2Page 36 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 21 June 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationNOAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action plan Other: Please produce an action plan within 7 days of receipt of this report.YESGrindleford Avenue 2Page 37 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I Cedric Frederick of PentaHact for 2 Grindleford Avenue confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on 14 April 2004 and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I Cedric Frederick of PentaHact for 2 Grindleford Avenue am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on 14 April 2004 for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Grindleford Avenue 2Page 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. 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!