Inspection on 27/06/06 for Grindleford Avenue 2

This inspection was carried out on 27th June 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Grindleford Avenue 2 06/11/07

Grindleford Avenue 2 01/02/07

Grindleford Avenue 2 31/10/05

Grindleford Avenue 2 03/08/04

Grindleford Avenue 2 14/04/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Grindleford Avenue 2 New Southgate London N11 1JN Lead Inspector Anthony Lewis Key Unannounced Inspection 27th June 2006 08:55 Grindleford Avenue 2 DS0000010447.V289957.R01.S.doc Version 5.1 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 Grindleford Avenue 2 DS0000010447.V289957.R01.S.doc Version 5.1 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Grindleford Avenue 2 DS0000010447.V289957.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Grindleford Avenue 2 Address New Southgate London N11 1JN 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) 020 8368 5177 020 8368 5177 www.pentahact.org.uk PentaHact Miss Louise McInnes Care Home 4 Category(ies) of Learning disability (4), Physical disability (4) registration, with number of places Grindleford Avenue 2 DS0000010447.V289957.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Limited to 4 adults of either gender who have a learning disability (LD) and who may also have a physical disability (PD). One specified service user who is over 65 years of age may remain accommodated in the home. The home must advise the registering authority at such times as the specified service user vacates the home. Two specified service users who have dementia may remain accommodated in the home. The home must advise the registering authority at such times as either of the specified service users vacates the home. 31st October 2005 Date of last inspection Brief Description of the Service: 2 Grindleford Avenue is a purpose built bungalow, situated at the end of a culde-sac on a relatively new housing estate in New Southgate. The home accommodates four adults who have learning and physical disabilities. The home is owned and maintained by Sanctuary Housing Association and managed by PentaHact through a written agreement. The current group of residents have lived in the home since it opened in 1997. The home is specially adapted and furnished to meet the needs of residents with physical disabilities, whilst still providing a comfortable homely environment. The home consists of four double bedrooms, one bathroom, a shower room, a toilet, a lounge, a kitchen/diner and an office. The home has a well maintained back garden and a small front garden, with off street parking for several vehicles. Twenty-four hour care and support is provided. The home has a minibus, which provides access to a range of day care and leisure facilities. Public transport, shops and amenities are a short walk from the home. The fee for residents living in the home is £1,505 per week. The provider must make information available about the service, including inspection reports, to service users and other stakeholders. Grindleford Avenue 2 DS0000010447.V289957.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on Tuesday 27th June 2006 at 08:55am and was completed at 5pm. The registered manager was not available. However, the operations manager who visited the home at 9am was available from 9 – 11am and again from 3 – 5pm. One of the two support workers made herself available to answer some questions and locate some information. Two of the four residents were away on a seven day holiday at the time of the inspection. Since the previous inspection, the organisation has changed its name from PentaHact to Adepta. This was discussed at length with the operations manager. Evidence was gathered by viewing all of the residents’ and all of the staff files along with various safety certificates and other relevant files and documents. Evidence was also gathered through speaking briefly in private to two residents. Two care workers were spoken to separately and in private and later together with the operations manager. Residents and staff were indirectly observed throughout the day. An extensive internal and external tour of the home was conducted with one of the support workers. What the service does well: What has improved since the last inspection? Of the eleven requirements made at the previous inspection, nine have been met and two restated. The staff are ensuring that assessments of residents are being carried out and recorded and residents are being supported more to make decisions. Residents are being involved in the home more and they have been consulted about meals. The staff are ensuring that Medication Administration Record (MAR) sheets are being correctly completed and residents wishes in the event of them becoming terminally ill or dying are being recorded. The home has a complaints book/file. Missing information in a staff’s application form has been explained and recorded. All areas of the home are free from offensive odours. Grindleford Avenue 2 DS0000010447.V289957.R01.S.doc Version 5.1 Page 6 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. Grindleford Avenue 2 DS0000010447.V289957.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Grindleford Avenue 2 DS0000010447.V289957.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will 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. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is adequate. This judgement has been made from evidence gathered during the visit to this service. Thorough assessments are being carried out to ensure that the home can meet the needs of each prospective resident. EVIDENCE: Although there has not been any new residents who have moved into the home for more than two years, according to the operations manager, assessments of potential residents to the home are carried out by managers form the head office, using a “functional assessment procedure.” The functional assessment form for the most recent resident to the home was viewed, as per a requirement at the previous inspection, and contained comprehensive information on the resident’s life history, current living arrangements, spiritual, cultural and ethnicity, family relationships and physical and mental health needs. Grindleford Avenue 2 DS0000010447.V289957.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. 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. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 9. Qualities in these outcome areas are adequate. This judgement has been made from evidence gathered during the visit to this service. Residents’ health care needs are being met and although limited, they are participating in life in the home. However, everyday risks that residents may experience while out and about in the community and at home are not being recorded, which is potentially exposing residents to unnecessary risks. EVIDENCE: The care plans of all of the residents were viewed and all contained comprehensive information that covers all areas of their: social, personal and health care needs. Residents are being supported to access health care professionals to ensure that their present and changing health care needs are identified and relevant intervention is available when required. Grindleford Avenue 2 DS0000010447.V289957.R01.S.doc Version 5.1 Page 10 Although none of the residents have formed any close relationships, the operations manager stated that the two residents, who have gone on holiday together, have quite a good relationship and have gone away on holiday in the past. She went on to say that this was their own decision based on their likes and interests. Residents making their own decisions was a requirement at the previous inspection. The operations manager went on to say that staff supported the residents to decide where they wish to go on holiday by obtaining brochures and looking through them with the residents and ensuring that the residents’ interests and hobbies were taken into account when deciding. Although made a requirement at the previous inspection, most of the residents are limited in their participation in all aspects of life in the home due to their learning difficulty. However, according to a support worker, some residents help with the shopping, cooking and cleaning of their bedroom. A resident was observed clearing some utensils from the kitchen table after lunch. The support worker went on to say that some residents have limited Makaton sign language, which they sometimes use to communicate to the staff. The risk assessments of all of the residents were seen and although the risks covered were comprehensive in that the risk to the individual, the organisation and others were recorded, there was no information on many everyday community activity risks and how they would be managed by the staff such as: travelling on public transport, meeting people or when socialising. There was also not enough evidence to show that risk assessments are being updated regularly as per a requirement at the previous inspection. This requirement is revised and restated. Grindleford Avenue 2 DS0000010447.V289957.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. 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. The Commission considers Standards 12, 13, 15, 16 and 17 the 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, 16 and 17. Qualities in these outcome areas are poor. This judgement has been made from evidence gathered during the visit to this service. Residents are being supported to be active within their local community with appropriate leisure activities and relationships. However, residents’ rights are not being fully respected and they are being put at risk due to staff not following food hygiene policies and procedures. EVIDENCE: Although none of the residents are employed or take part in voluntary work, the staff ensure that the residents are supported to access various other activities such as attending day centres and college courses to aid their personal development. Through looking at care plans and talking to staff, it is apparent that residents are active in their local community. According to a support worker, residents are supported to go to various pubs, restaurants, day centre bowling and ensuring various other activities. Grindleford Avenue 2 DS0000010447.V289957.R01.S.doc Version 5.1 Page 12 On the day of the inspection, there were only two residents in the home. The other two residents were away on a seven day boating holiday with staff. According to the operations manager, one of the two residents on holiday enjoys boats and has a good relationship with the other resident who also wanted to go on the holiday. The operations manager said that none of the residents are in an intimate relationship but some have friendships and some have regular contact with members of their family, who visit them at the home, some regularly and others occasionally. Throughout most of the inspection, one resident, who is wheelchair bound, was observed watching television alone in the lounge. On occasions, the staff would pop into the lounge to see how the resident was. The other resident was in the kitchen or at times in the lounge using a stick to hit a musical instrument, with some staff support. The two staff on duty spent much of their time in the kitchen or lounge talking exclusively together. There was very little clear or meaningful interaction between the residents and the staff. After giving the residents their breakfast, the staff were observed preparing and eating food different from that of the residents while the residents sat alone in the lounge. These observations were discussed at length with the two members of staff and the operations manager near the end of the inspection. A requirement is made that the registered persons must ensure that a review of the day-to-day activities in the home is undertaken and recorded and that staff do not eat and interact exclusively with themselves. A tour of the kitchen was conducted with a support worker and later with the operations manager. The menu was viewed and showed more variety and creativity as per a requirement at the previous inspection. The food preparation boards were stacked together and not in dividers, increasing the possibility of cross contamination of foods. In the fridge, foods prepared or opened were in containers or their packets. They were not wrapped and there was no date to identify when they were opened or prepared or when they should be consumed by. A requirement is made that the registered persons must ensure that a review of food storage and food hygiene is undertaken and recorded. Grindleford Avenue 2 DS0000010447.V289957.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. 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 home’s 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. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21. Qualities in these outcome areas are good. This judgement has been made from evidence gathered during the visit to this service. Residents’ personal and health care needs are being supported and their wishes respected. EVIDENCE: All care plans and risk assessments viewed contained information on individual residents personal support needs and what they are capable of doing for themselves and what staff intervention is required. There is also equipment in the home such as wheelchairs, commodes and assisted baths to aid residents’ independents. Both members of staff were spoken to individually and in private about supporting the residents with their personal care needs. Both had an adequate understanding of the residents’ support needs and were able to describe how the residents receive personal support according to the resident’s individual needs. Grindleford Avenue 2 DS0000010447.V289957.R01.S.doc Version 5.1 Page 14 Residents’ health care needs are being monitored and professional intervention is sought when required. Their care plans contained information on their physical and mental health and records are kept of visits to health care professionals such as their GP, chiropodist, dentist or physiotherapist. At the previous inspection there were gaps where staff had not been recording when they had administered resident’s medication and a requirement was made. At this inspection, the Medication Administration Record (MAR) sheets of the two residents in the home were viewed and showed that staff have been recording medication administered appropriately. Another requirement that was made at the previous two inspections was that the residents’ wishes in the event of them becoming terminally ill and dying is recorded in their care plans. On looking through the care plans of all of the residents, they all have a record called “information required in the event of a tenant’s death,” within their file, this included information regarding the resident’s funeral arrangements. Grindleford Avenue 2 DS0000010447.V289957.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Qualities in these outcome areas are poor. This judgement has been made from evidence gathered during the visit to this service. Complaints are not being taken seriously and staff are not receiving adequate training to ensure that residents are protected from abuse. EVIDENCE: A staff member spoken to in private became very emotional and made a number of complaints. She said that although some of her complaints have been investigated in the past, they have not all been resolved. With her consent, her complaints were discussed at length with the operations manager who said that she would investigate them. An immediate requirement is made that the identified member of staff’s complaints are investigated and a record of the investigation and the outcome is recorded and retained for inspection. The home’s complaints file/book was viewed and contained detailed information regarding the complaints procedure and complaints made since the previous inspection, as per a requirement at the previous inspection. Although the home has the London Borough of Barnet’s Multi-Agency Adult Protection Policy and Procedure and one member of staff spoken to said that she received adult protection training in January of this year, there was no evidence in staff files, such as their certificate, to show that they have received adult protection training. A requirement is made regarding this. Grindleford Avenue 2 DS0000010447.V289957.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. 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. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Qualities in these outcome areas are good. This judgement has been made from evidence gathered during the visit to this service. Residents live in a safe, clean and homely environment, which has been adapted taking into account their individual and collective needs. EVIDENCE: A thorough internal and external tour of the home was conducted with a support worker and a brief tour was conducted later with the operations manager. All areas of the home were found to be safe. The damaged lino in the kitchen that was made a requirement at the previous inspection has been repaired. The home has been designed taking into account the residents’ needs, for instance, all areas are wheelchair accessible and the furniture is of a good quality. There is also an assisted bath to aid residents’ independence. Both residents were briefly spoken to individually in private. When asked if she was comfortable, one resident said, “yes” and nodded her head rapidly. The other residents said “I’m ok,” and then laughed. Grindleford Avenue 2 DS0000010447.V289957.R01.S.doc Version 5.1 Page 17 In addition to support staff, the home has a part-time domestic who ensures that all areas of the home are kept clean, tidy and free from any offensive odours, as per a requirement at the previous inspection. The laundry facilities are sited to the rear of the home, away from the kitchen, with adequate washing facilities, such as an industrial washing machine and dryer. Grindleford Avenue 2 DS0000010447.V289957.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. 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 home’s 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. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Qualities in these outcome areas are poor. This judgement has been made from evidence gathered during the visit to this service. Although staff spoken to had an adequate understanding of their roles and responsibilities, robust recruitment and training is not taking place and staff are not being appropriately supported. These deficiencies are putting residents at risk. EVIDENCE: Both staff on duty were spoken to independently and in privately at various times throughout the inspection. Near the end of the inspection, both staff were again spoken to at length with the operations manager present. Both staff were able to describe their roles and responsibilities and the needs of the residents. One member of staff stated that she is at present undertaking her National Vocational Qualification (NVQ) level 2. The other member of staff, who is quite new to the home, said that her (NVQ) registration was discussed with the registered manager and that she is hoping to undertake the training soon. Grindleford Avenue 2 DS0000010447.V289957.R01.S.doc Version 5.1 Page 19 The personal files of eight staff were viewed and although most contained the required information, there were a number of files that did not for instance, three Criminal Records Bureau (CRB) certificates were not available to view, two staff did not have photographs, and two staff did not have two references. The file for one member of staff was not available in the home and was brought from the head office by the operations manager. An immediate requirement is made that the registered person must ensure that all staff files contain the required information. A member of staff has supplied a written explanation for gaps found in her application form at the previous inspection. It was very difficult to obtain some of the information requested due to the chaotic state of the staff files and the filing cabinet, where files are stored. Files for staff who left the home many years ago were strewn within the cabinet. A recommendation is made that all staff files are sorted into a consistent and logical sequence and that old staff files are correctly stored. Although some staff files contained various training certificates such as: health and safety, food hygiene and moving and handling, some files contained insufficient evidence to show that staff have obtained the required training for the work that they do within the home. A requirement is made regarding this. Of the eight staff files viewed, there was no evidence that any of them have been receiving regular supervision. The last supervision record in one staff’s file was dated 25th August 2004 and two staffs’ last supervision record date back to 2005, there was no evidence to prove that they have received any supervision since 2005. A member of staff who has been working in the home since April 2006, said that she has not as yet received any supervision. A requirement is made regarding this. Grindleford Avenue 2 DS0000010447.V289957.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. 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 home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Qualities in these outcome areas are adequate. This judgement has been made from evidence gathered during the visit to this service. The registered managers has the required skills, experience and training to manage the home. The organisation is ensuring that the quality of service is being monitored to ensure the service’s continual development. However, inadequate health and safety inspections and tests are putting everyone in the home at risk. EVIDENCE: According to the operations manager, the registered manager has been managing various services since 2002. Certificates in his file show that he has successfully completed his National Vocational Qualification (NVQ) level 4, is a qualified counsellor and has an (NVQ) assessor award. When spoken to, the operations manager said that the manager has made many improvements since taking up the post late last year. Grindleford Avenue 2 DS0000010447.V289957.R01.S.doc Version 5.1 Page 21 Adepta has a quality assurance manager, whose duty it is to co-ordinate reviews of the quality of service provided, through sending out questionnaires to residents, staff and other stakeholders. The results of the questionnaires are forwarded to operations managers and registered managers who will structure their development plan according to the views and comments from the questionnaires. At the previous inspection, a requirement was made that an anonymous system is developed where staff do not fill in the questionnaires on behalf of the residents. This was discussed at length with the operations manager who said that no system has yet been devised but that she will review it and ensure that a method is devised. This requirement is restated. The home’s safety certificate and a number of files and documents were viewed. The London Fire and Emergency Planning Authority (LFEPA) visited the home on 7th March 2006 and no contraventions were found. A Portable Appliances Test (PAT) was carried out the day prior to the inspection and according to the operations manager the certificate is forwarded to the head office who will then forward it to the home. The last recorded fire safety test was carried out on 28th May 2006 and the last recorded fire drill on 15th October 2005. A gas safety inspection has not been carried out as per a requirement from the previous requirement. A requirement is revised and restated that the registered persons must ensure that safety inspections and fire tests are carried out regularly and the outcomes recorded, also that safety certificates are available in the home for inspection. Grindleford Avenue 2 DS0000010447.V289957.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 x 34 1 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 1 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 1 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 X X 1 x Grindleford Avenue 2 DS0000010447.V289957.R01.S.doc Version 5.1 Page 23 Yes Are there any outstanding requirements from the last inspection? 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 YA9 Regulation 13(4)(b) (c) Requirement The registered persons must ensure that risk assessments cover all aspects of risks to individual residents and is recorded in their care plan. (Timescale of 02/03/06 not met). This requirement is revised and restated. The registered persons must ensure that a review of the dayto-day activities within the home is undertaken and recorded and that staff do not exclude residents and interact exclusively with each other. The registered persons must ensure that a review of food hygiene is undertaken and recorded. The registered persons must immediately ensure that the identified member of staff’s complaints are investigated and a record of the investigation and the outcome recorded and retained for inspection. The registered persons must ensure that all staff receive adult protection training and that a DS0000010447.V289957.R01.S.doc Timescale for action 27/10/06 2 YA16 16 (2) (n) 08/09/06 3 YA17 16 (2) (g) (h) 22 (3) 28/07/06 4 YA22 21/07/06 5 YA23 13 (6) 18 (1) (c) (i) 27/10/06 Grindleford Avenue 2 Version 5.1 Page 24 6 YA34 19 (1) (a) (b) 7 YA35 18 (1) (c) (i) 8 9 YA36 YA42 18 (2) 23 (4) (a) (c) (iii) (iv) (v) (e) copy of their certificate is retained in their file. The registered persons immediately must ensure that robust recruitment procedures are followed and that all staff files contain the required information as set out in Schedules 2 and 4 of the National Minimum Standards. The registered persons must ensure that staff receive training appropriate to the work that they carry out and that evidence of their training is available for inspection. The registered persons must ensure that all staff receive regular recorded supervision. The registered persons must ensure that safety inspections and fire tests are carried out regularly and the outcomes recorded, also that a gas safety inspection is carried out and safety certificates are available in the home for inspection. (Timescale of 02/12/05 not met). This requirement is revised and restated. 07/07/06 27/10/06 27/10/06 28/07/06 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. Refer to Standard YA34 Good Practice Recommendations A recommendation is made that all staff files are sorted into a consistent and logical sequence and that old staff files are correctly stored. Grindleford Avenue 2 DS0000010447.V289957.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Grindleford Avenue 2 DS0000010447.V289957.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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