Inspection on 30/05/06 for Grosvenor Lodge

This inspection was carried out on 30th May 2006.

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

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

Other inspections for this house

Grosvenor Lodge 28/09/07

Grosvenor Lodge 18/10/05

Grosvenor Lodge 23/05/05

Grosvenor Lodge 03/02/05

Grosvenor Lodge 28/09/04

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

CARE HOMES FOR OLDER PEOPLE Grosvenor Lodge 40 Old Shoreham Road Hove East Sussex BN3 6GA Lead Inspector Melanie Freeman Key Unannounced Inspection 30th May 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Grosvenor Lodge DS0000014201.V292900.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Grosvenor Lodge DS0000014201.V292900.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Grosvenor Lodge Address 40 Old Shoreham Road Hove East Sussex BN3 6GA 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) 01273 739739 01273 739739 Mrs M Holliday-Welch Mrs Kim Long Care Home 31 Category(ies) of Dementia (31) registration, with number of places Grosvenor Lodge DS0000014201.V292900.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is thirtyone (31). Service users must be older people aged sixty-five (65) years or over on admission. Service users with a dementia type illness only to be accommodated. Date of last inspection 18th October 2005 Brief Description of the Service: Grosvenor Lodge is a privately owned residential home for up to thirty-one older people who have dementia. The home’s provider also owns a further three registered homes for older people within the Sussex area with each home being a standalone business. The home is a large detached property situated in Hove on the main A270. It is located near to local amenities such as shops, cafes and bus routes into Brighton and Hove. The home is presented across four levels, basement, ground, first and second floor with access to the first floor and second floors via stairs or shaft lifts. Resident’s accommodation consists of twenty-seven single and two shared bedrooms, with all rooms providing en-suite facilities. Shared facilities include two lounges, dining room, hairdressing room, conservatory and rear garden. The front garden is mainly paved to provide off road parking. The homes literature states that the home is committed to offer a highly professional care service for the elderly with a personal touch. The fees vary from £441 to £480 a week depending on the room occupied. These fees include all services and facilities apart from hairdressing, chiropody and newspapers/magazines and toiletries, which are itemised separately on the monthly invoices or paid from residents monies held by the home. Grosvenor Lodge DS0000014201.V292900.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Grosvenor Lodge Care Home will be referred to as ‘residents’. This was a key inspection that included an unannounced visit to the home and follow up contact with resident’s representatives and visiting health and social care professionals. The unannounced visit included a meeting with the registered manager who facilitated the inspection and received the inspector’s feedback at the end of the inspection. The regional manager was also available for part of the inspection. On the day of the home visit the inspector spent most of her time meeting with residents and their visitors, and observing practice in the home. A tour of the premises was undertaken and a range of documentation was reviewed including the homes statement f purpose and service users guide, care plans, duty rotas, medication records, training records and recruitment files. The care documentation pertaining to four residents was reviewed in depth along with a number of policies and procedures and records relating to health and safety. The inspector was able to eat a mid-day meal with the residents during the unannounced visit. In addition service users surveys were given to 10 residents or their representatives and 4 staff surveys were left in the home for identified staff to return. The information contained in the returned surveys has been incorporated into this report. What the service does well: The home provides both prospective and existing residents, with a good level of information about what services are provided and what to expect when living at the home. The home works closely with health care professionals including GP’s, district and specialist nurses, chiropodists, opticians and dentists to ensure residents receive the necessary health care intervention. Grosvenor Lodge DS0000014201.V292900.R01.S.doc Version 5.1 Page 6 Communal areas of the home are attractive and allow different activities and space for walking and wandering. All staff were found to have a good rapport with residents and visitors and promoted a relaxed atmosphere in the home. Staff contribute positively to the quality of life of residents. The organisation is committed to providing training opportunities for its staff, which promotes staff competence. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Grosvenor Lodge DS0000014201.V292900.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Grosvenor Lodge DS0000014201.V292900.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides both prospective and existing residents, with a good level of information about the home and its facilities and services. The admission procedures allow for the needs of prospective residents to be fully assessed by a competent person who ensures that the home admits only those residents who’s needs can be met by the home. EVIDENCE: A statement of purpose and service user guide sets out the homes aims, objectives, facilities and the terms and conditions of the home. A copy of the service users guide is made available to residents and other interested parties and is displayed within the home along with a copy of the last inspection report. The homes statement of purpose is available at request. Grosvenor Lodge DS0000014201.V292900.R01.S.doc Version 5.1 Page 9 Contact with relatives both during and after the inspection confirmed that the admission procedure was clear and thorough with a visit to the home being encouraged and facilitated, including the prospective resident whenever possible. A relative confirmed that the first six weeks of occupancy is looked upon as a trail period. Following this placements that are funded by social services are review, to establish whether the home is meeting a residents needs. A formal process is also in place for privately funded residents to have a say whether they wish to remain at the home and become a permanent resident. A review of the care documentation confirmed that pre-admission assessments are always completed by the home manager prior to an admission being agreed and a copy of a care management assessment from the placing authority is obtained when pertinent. The quality of these assessments, which include input from relatives and other professionals, enabled the manager to make informed judgements about the suitability of any admission to the home, bearing in mind the homes registration environment, facilities and skills of staff. Intermediate or rehabilitative care is not provided at Grosvenor Lodge Care Home. Grosvenor Lodge DS0000014201.V292900.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health care needs of all the residents are not clearly recorded although there is evidence of regular input from health care professionals to ensure the needs of residents are met. Procedures and practice in the home allow for the safe administration of medicines and for the privacy of residents to be promoted. EVIDENCE: The care documentation pertaining to 4 residents was reviewed as part of the inspection process. A resident that had been admitted to the home 2 weeks prior to the inspection visit did not have a plan of care. Therefore there was no clear guidance for staff on how to meet this residents needs. A relative spoken to earlier had also raised concerns that not all the care staff had a clear understanding of her mother’s needs resulting in a lack of continuity and appropriate care provision. Grosvenor Lodge DS0000014201.V292900.R01.S.doc Version 5.1 Page 11 This shortfall was not identified within the other care documentation reviewed, which recorded the key areas of care with evidence of regular monthly review by the key workers. Guidance for staff relating to challenging behaviour however was minimal and this was discussed with the home manager. There was written evidence that residents or their relatives are involved with the planning of care and two relatives contacted following the inspection confirmed that they were kept fully informed of the care provided and any changes planned. When the home wanted to move a resident to another room they discussed this with the family and resident before this was progressed. There was evidence in the records that confirmed that risk assessments are completed and responded to. Health and social care professionals spoken to felt that the home responded appropriately to the health and welfare needs of residents consulting with them regularly. Staff observed during the inspection visit had a good understanding of residents needs and were seen to be caring for residents appropriately. The home manager confirmed that a verbal handover is to be provided in the future to improve information sharing across the whole staff group. Visitors and relatives spoken to were satisfied with the care provided in the home and made the following comments ‘my mother is safe and comfortable here and she is much better than she was’ ‘I am very happy with the care and the staff are lovely’ None of the residents accommodated are assessed as safe to administer their own medication. Medication is stored in a clinic room, which was clean and well ordered. The medicine administration practice observed was seen to be safe and the records demonstrated that systems have been established to ensure staff are appropriately trained and records are accurate and provide a history of what was given by who and when. The contents of the controlled drug cupboard was checked and found to be in order along with a tablet counting devise. Observation in the home confirmed that resident’s privacy and dignity is being respected, staff knock on doors and speak to residents in a courteous manner. Residents were found to be dressed in well-laundered clothing and residents enjoyed the regular input from the visiting hairdresser. Grosvenor Lodge DS0000014201.V292900.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social activities in the home provide a varied provision and social links are well maintained. The provision of meals ensures residents have a well balanced diet that they enjoy and resident’s choices are respected. EVIDENCE: During the inspection visit the home was busy and vibrant with staff engaging with residents. In the afternoon staff were playing Bingo with some residents in one area of the home while residents were watching a video in another. Many of the residents were having their hair attended to by a visiting hairdresser who promoted an environment that created a social activity within a designated hairdressing area in the home. Residents said how much they liked this and one residents spoke to the inspector about how important the hairdressers visits were to her. A programme of activities is arranged and feedback from relatives said the activities were good although their relatives did not always join in. The home manager confirmed it was difficult to engage with all the residents as they often lost interest and the need to ensure input Grosvenor Lodge DS0000014201.V292900.R01.S.doc Version 5.1 Page 13 from staff with specific training on activities and entertainment provision for this client group was discussed. On arrival to the home it was noted that ‘Southern Sound’ was on the radio and that although staff were enjoying the music it was not appropriate for the residents. A survey received also identified that the radio in the home was often set on Southern sounds this concern was discussed with the home manager. Discussion with the homes manager and relatives confirmed that activity outside the home is not provided and the provision of outings and trips was also discussed with the home manager. Visitors commented upon how welcomed they are made to feel during their stay, this included being offered beverages and staff being ‘friendly and approachable’. Visiting is not restricted and is encouraged. Residents were moving around the home as they wished and were able to spend time where they wanted. Staff were seen to ask residents what they wanted to do and offered choices around every day activities. The meal eaten by the inspector was found to be well presented and to have a very good taste. Most residents chose to have their meal in the attractive dining room and it was noted that all residents had a choice of meal. It was noted that resident independence was encouraged with the use of adapted utensils and staff assisting as necessary. All feedback received regarding the food were positive and included ‘my mum eats well and enjoys her food’ ‘he really enjoys his food, which is surprising as he used to live off take always’. An Environmental Health inspection was completed in November with no requirements being made however it was confirmed that the kitchen floor is to be replaced by the end of June 2006. The inspector was told that the cook has completed training on catering for people with dementia and Alzheimer’s disease in accordance with a requirement made at the last inspection. Records demonstrating the food actually eaten by residents were not full and needed to be clearer especially when residents are reluctant to eat. Grosvenor Lodge DS0000014201.V292900.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures in the home ensure that complaints and any allegation or suspicion of abuse made would be managed appropriately. EVIDENCE: The home has a clear complaints procedure and a system for recording these. The complaints procedure is displayed in the front entrance area along with complaint forms and a suggestions box. The manager also added a comments form during the inspection to encourage people to make suggestions. Although there have been no complaints recorded and investigated by the home since the last inspection, all visitors and residents spoken to said that they would be happy to raise any concern with the staff and most knew who the manager was and were confident that any issues would be responded to. There are clear procedures in place for staff to follow to report suspected abuse. Staff have also received formal training in adult protection and prevention of abuse and the manager demonstrated a good understanding of her role and responsibilities under adult protection. Grosvenor Lodge DS0000014201.V292900.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. On the whole the facilities provide a comfortable environment, which meets the needs of residents, although maintenance issues need to be addressed to ensure residents safety. EVIDENCE: The home is located in a residential area in Hove with access to transport links to Brighton, it is a converted premises and accommodation is found over three floors. The ground floor has two lounges, dining area, panelled hallway, hairdressing room and large conservatory. The conservatory overlooks a small, attractive, secure garden. Grosvenor Lodge DS0000014201.V292900.R01.S.doc Version 5.1 Page 16 The good provision of communal space allows for residents to engage in different activities and to be with people that they want to be with, and to move freely around the home. The tour of the home identified a number of areas that needed maintenance attention including a broken window in a bedroom, ill-fitting lino in en-suite toilets, extractor fans not working, an emergency bell hanging, broken tiles in washing areas and the wooden flooring in the hallway and one of lounges having been sanded not being surfaced appropriately. An immediate feed back form was left with the manager at the end of the inspection and she confirmed as agreed the following week that the window had been repaired and the extractor fans had been repaired. A programme of routine maintenance and renewal is not maintained and the need for this was discussed with the home manager. The home was found to be warm and comfortable, with good levels of light and ventilation. The home is not registered to admit residents with physical disabilities and the stairs and other access arrangements would make it unsuitable for people with significantly restricted mobility. There was a range of individual aids and adaptations to assist resident’s mobility and independence, including raised toilet seats, walking aids, hoist, ramps and grab rails. Resident’s bedrooms are decorated and furnished to a satisfactory standard with appropriate furniture and fixtures. Individual rooms were found to be personalised and clean. It was however noted that all rooms have vinyl flooring and the soft furnishings are rather plain this presents a rather institutional feel to the home. During the inspection it was noted that the small smoking room for residents is used as a treatment room for visiting professionals including nurses and the chiropodist. This is a useful facility where the visiting nurses also store their records. These records need to be stored securely and the home need to ensure that the cleaning of this room is maintained to a very high standard to prevent any cross infection and should discuss this with the relevant health care professionals. A separate staff room is not provided and staff use a room that is part of the kitchen area for storage and changing. This practice needs to be reviewed with the Environmental Health Officer. Grosvenor Lodge DS0000014201.V292900.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is sufficient numbers of staff on duty to meet needs of resident’s although the skill mix when the manager is not on duty is not always appropriate. Staff are provided with suitable training and development opportunities although induction training needs to be evidenced. Residents are not fully protected by the home’s recruitment practices. EVIDENCE: At the time of this visit 31 residents were living in the home. On the day of inspection there was sufficient care staff on duty to meet the needs of residents. In addition there were domestic staff and a cook. Rotas indicated that staffing levels were being consistently maintained. Staff confirmed that the staffing numbers were ‘enough’ visiting relatives and health care professional also confirmed the staffing was suitable. A review of the duty rota identified that the weekend and evenings when the manager is not on duty tends to staffed by less experienced carers and ones without the appropriate qualifications, albeit that the manager remains on call at all times. Training continues to be accessed and discussion took place around more flexible staffing arrangements to provide on going supervision. Grosvenor Lodge DS0000014201.V292900.R01.S.doc Version 5.1 Page 18 Staff and relative satisfaction with the staff is high and their comments included ‘Staff care for Mum and they are all nice and polite to her’ ‘the staff are lovely’ ‘all staff are appropriate and helpful’ ‘ I have found the care workers sympathetic very helpful and easy to communicate with at all times and have complete confidence in them’. Three recruitment files were selected for review. These included one recently recruited member of staff. The records demonstrated that references are obtained and applications forms are completed. However it was noted that one carer was working in the home unsupervised without a CRB being completed albeit that a POVA check had been completed. The manager was reminded that all staff working in the home without a CRB must be supervised until this is received. Evidence of induction training for new staff was not available to the inspector and evidence of appropriate training must be retained in the home. The organisation continues to show commitment towards obtaining NVQ training for staff. An NVQ training plan has been developed to ensure that the vast majority of staff have an opportunity to undertake this training. A yearly training and development plan is in operation, which identifies what training is available. This includes core-training topics of manual handling, first aid, adult protection and fire safety. In addition specialist training is also offered in Alzheimer’s and dementia care. Grosvenor Lodge DS0000014201.V292900.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The homes management is well established but needs to ensure clear supervision throughout the week along with effective quality monitoring systems are introduced and maintained. Resident’s financial interests are safeguarded along with resident’s safety through the homes procedures. EVIDENCE: The manager has been in post since 2001, prior to this she worked at the home for many years in a senior care position. She confirmed that she has now Grosvenor Lodge DS0000014201.V292900.R01.S.doc Version 5.1 Page 20 completed an NVQ level 4 in care and is aware that she needs to complete an equivalent qualification in management. During the visit to the home it was clear that the manager has a high profile in the home and positive interaction was noted between her residents and staff. Contact with relatives confirmed that they knew who the manager was and that she communicated regularly with them. Staff meetings and staff appraisals are completed and recorded. Some quality monitoring has been established in the past and this included the use of resident/representative satisfaction questionnaires, which were completed last year, however there has been no audit of these or concluding report. The regional manager advised that the Quality assurance procedures in the home are currently being reviewed. Where the home acts as corporate appointee regarding resident’s personal monies, clear records were maintained of any expenditure, with receipts. Two amounts and records were fully checked and found to be accurate. Records relating to Health and safety in the home were reviewed and on the whole were found to be full and extensive. Windows are restricted by chains and the manager said that these are checked regularly to ensure they are working and secure. During the inspection it was identified that the lock on the laundry room door is not working and residents are still able to access this area and that there was an un-guarded radiator in a communal bathing room. The regional manager said that the radiator is not used and would be guarded in the near future and that the lock would be repaired. At the last inspection the fire escape leading from the top floor onto a flat roof and the need for a risk assessment was discussed to ensure that it provides a safe fire exit route. This still needs to be addressed and remains a requirement. Grosvenor Lodge DS0000014201.V292900.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X 3 2 X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Grosvenor Lodge DS0000014201.V292900.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(2)(c) Requirement That clear guidance on how to care for all residents is clearly documented within a care plan and includes the care required to meet the challenging behaviour and social needs of residents. That a full maintenance programme is implemented to ensure the home is well maintained and safe. That the suitability of the top floor fire escape, leading from the top floor onto a flat roof be risk assessed to ensure that it provides a safe fire exit route. That persons in charge in the absence of the manager are suitably qualified. (First made at inspection of 19/1/04) That any staff working in the home with a POVA check and awaiting a CRB is fully supervised. That a full quality assurance system is established and used to maintain and improve the provision of care and services in DS0000014201.V292900.R01.S.doc Timescale for action 01/07/06 2. OP19 23 (2) 01/07/06 3. OP19 23(4) 01/07/06 4. OP28 18(1)(c)(i ) 01/09/06 5. OP29 19 (1) 01/06/06 6. OP33 24(1) 01/09/06 Grosvenor Lodge Version 5.1 Page 23 the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. Refer to Standard OP12 OP12 OP14 OP15 OP15 OP26 OP27 Good Practice Recommendations That the activities in the home are further improved with outings and trips. Staff ensure that appropriate music is used in the home for the benefit of residents. That the nursing records held in the home are stored securely. That clear records are maintained to identify what is actually eaten by each resident. That the certificate demonstrating that the cook has completed specialist food training on catering for people with dementia and Alzheimer’s it provided to the CSCI. That the lock to the laundry room is repaired and used to restrict resident’s access. That the staffing arrangements are reviewed to ensure adequate supervision of care staff over the whole week. Grosvenor Lodge DS0000014201.V292900.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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. 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