Inspection on 10/05/06 for Grosvenor Terrace, 100

This inspection was carried out on 10th May 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 25 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Grosvenor Terrace, 100 17/02/09

Grosvenor Terrace, 100 29/01/08

Grosvenor Terrace, 100 18/12/06

Grosvenor Terrace, 100 18/10/05

Grosvenor Terrace, 100 15/06/05

Grosvenor Terrace, 100 19/10/04

Grosvenor Terrace, 100 28/06/04

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 Grosvenor Terrace, 100 London SE5 ONL Lead Inspector Lisa Wilde Unannounced Inspection 10th May 2006 10:00 Grosvenor Terrace, 100 DS0000060231.V294557.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 Grosvenor Terrace, 100 DS0000060231.V294557.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. Grosvenor Terrace, 100 DS0000060231.V294557.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Grosvenor Terrace, 100 Address London SE5 ONL 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 7701 5622 www.odyssey-csft.org Odyssey Care Solutions for Today Ms Celia Denise Bownass Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Grosvenor Terrace, 100 DS0000060231.V294557.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th October 2005 Brief Description of the Service: The home provides care for four women who have learning disabilities and additional needs that arise from physical disability and sensory impairment. It is equipped to provide care for one service user who is a wheel-chair user. All four service users have lived together for many years at this home and view this home as their home for life. The home is in a residential street close to Walworth Road where there are a range of facilities including public transport routes, shops, pubs and restaurants nearby. The organisation that runs this home is Odyssey Care Solutions for Today. The home makes the reports of the Commission’s inspections available in the hallway of the home. The fees for a place at this home were not available at the time the draft report was written but will be in the final draft. Grosvenor Terrace, 100 DS0000060231.V294557.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day in May 2006. The acting-manager was not at the home so the inspection took place with staff and the new deputy manager. The deputy had only been at the home for around a week but had been with the organisation for several years at another home. The service users at this home are not able to speak and communicate in different ways other than talking and so the inspector was not able to find out from them directly how they feel about living here. The inspector could only get in touch with the family of one of the service users following the day at the home. That relative said that the place was perfect, that the staff are very caring and look after them very well. They said their relative was always spotlessly clean and their room was always clean as well. They said their relative goes out to the cinema and cafes and that they can visit them at the home whenever they choose. They said they had no problems. What the service does well: The standards looked at during this inspection showed that the home makes sure that: • • service users are offered high levels of personal support as they are not able to do many things for themselves. service users are offered support to go for regular appointments with the GP, dentist, optician and chiropodist so that health problems can be avoided where possible. They are offered specialist advice from other professionals when necessary. service users are supported to stay in touch with their families as far as possible. service users are offered a healthy diet and as far as is possible to judge, they enjoy their food. the home is clean, homely and attractive. the home was clean and hygienic throughout. the home is reaching the target of 50 of its staff holding the NVQ in Care the health, safety and welfare of service users is protected. • • • • • • What has improved since the last inspection? The home has had a review of one service users specific healthcare needs in addition to the general reviews that take place regularly. Staff said that there have been some slight improvements in how things get fixed in the home. Grosvenor Terrace, 100 DS0000060231.V294557.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. Grosvenor Terrace, 100 DS0000060231.V294557.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 Grosvenor Terrace, 100 DS0000060231.V294557.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&5 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users do not have documents that describe all their rights at this home. Not all service users’ families or advocates have been asked to read the document and sign them on the service user’s behalf. This means that even though service users at this home would not be able to understand all of this information, their families and representatives have not been made aware of their rights so do not have all the information they may need to take decisions. EVIDENCE: These four service users all moved into the home at the same time and no one new has moved in since. It would not be useful to assess the home’s assessment of prospective service users until this happens. The inspector checked two files and found two different contracts or terms and conditions being used. Neither of these documents covered all the areas required by the standards and neither of them described that service users have an assured tenancy at this home and told them what rights they have. One of the service users or their representative had signed the documents but the other one hadn’t. (See Requirement 1) Grosvenor Terrace, 100 DS0000060231.V294557.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 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a lot of information in the files and staff understand the needs of the service users, but the support guidelines and risk assessments are not being regularly reviewed which means that the service may not be adapting to the needs of the service users or they may be being put at some risk. It also may mean that service users are not being supported to take reasonable risks in order to develop their skills and try out new things. Service users find it hard to understand some information and they communicate in different ways other than talking so it is harder to ask them what they want and allow them to make decisions. Staff try to find out what they want by getting to know them and understanding how they react to things and has brought in a woman to help advocate for them in review meetings. They have not brought in peer support or found out about people who may have more things in common with service users to help them with decisions and make sure their views are heard by staff, which means that staff are not doing all it can to make sure that they are finding out about how service users may think and feel about things. EVIDENCE: Grosvenor Terrace, 100 DS0000060231.V294557.R01.S.doc Version 5.1 Page 10 Although there was evidence of good planning around how to support service users in their day-to-day lives many of these documents had not been reviewed for several years. The new manager had been through some of the support guidelines and risk assessments and signed and dated them in November 2005, which could look like a review but without any comments made of this review it is not possible to say that they have been usefully reviewed. Staff felt that most of the care needs are reviewed in the sixmonthly meetings that take place with social services. These reviews showed that goals are stated at these meetings and there are then reviews of how things are going but files showed that targets that are set are not always met and one example of a review in November 2005 showed that little of the required work had been done when much of it could have been sorted out very quickly. The organisation has been working on Person Centred Planning over the past year and this inspector has seen this in operation at other Odyssey homes as well. Staff talked about how there are plans in place to begin this work setting goals with service users that are reviewed every quarter but that this point it is not in place. (See Requirements 2 & 3) Service users at this home have very limited verbal communication and their understanding of things is also limited so it is harder for the staff team to find ways to let them make their own decisions. When the home realises that something may have to be done that the service user may not like such as having an operation, a Best Interest Meeting is called where all interested parties are invited along to discuss the issue and make the decision. Staff talked about how they try to find out what service users want by understanding their body language and other communication. The organisation is starting work on Communication Passports as part of their Person Centred Planning work, which will describe in detail how a service user communicates and tells staff what they want but these are not in place and have not been tried out yet. (See Requirement 4) All service users have the same advocate, a woman from a local agency but they do not have advocates who share some of the same disabilities or, in some cases their ethnic and cultural background. (See Requirement 5) There was a lot of information in the files that did not need to be there and was quite old which meant that current information was more difficult to find. (See Recommendation 1.) Grosvenor Terrace, 100 DS0000060231.V294557.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, 15, 16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally service users are supported to access the community and undertake an activities programme throughout the week. There is an ongoing unresolved issue about increasing staffing to enable service users to be supported out of the house more often and do more individual things. Service users are supported to stay in touch with their families as far as possible. Service users are offered a healthy diet and as far as is possible to judge, they enjoy their food. EVIDENCE: Service users attend day centres and sometimes go out in the local area if this can be planned in advance. Grosvenor Terrace, 100 DS0000060231.V294557.R01.S.doc Version 5.1 Page 12 There is a current problems in that the vehicle that this home uses is out of action and one member of staff has to use their own car to drive service users to day centres and appointments. (See Requirement 6) There has been an ongoing issue at this home about whether there are enough staff available to allow service users to do the activities that they need to do. This has now being mentioned in the service users’ six-monthly reviews with social services. There was a previous requirement (mentioned under Standard 33) that there must be enough staff on duty to allow service users to do enough in and outside of the home and that a copy of the outcome of the staffing review must be sent to the Commission. Nothing had been sent to he Commission. Staff said that the rota has changed and shifts have been shortened to allow them to do more shifts in a week. This has just meant that they can cover sickness and annual leave and they now can use less agency staff, it had not freed up any extra time to do things with service users. Reviews now talk about how the limited staffing also mean that service users cannot undertake personal development programmes in the home around daily living skills. (See Requirement 7) Service users are supported to maintain contact with their family and have made efforts to help service users re-establish contact with family members they have lost touch with. There is a repeating menu for service users, which has been decided from meals that staff have seen service users eat and enjoy. Staff said that they will offer alternatives when service users don’t want to eat something. The menus showed that some Caribbean meals are made sometimes but less African meals (one service use is Guyanese and one African/Irish). Although there is some choice available there is scope for more variety as weekly menus showed generally the same things being cooked each week. (See Recommendation 2) Grosvenor Terrace, 100 DS0000060231.V294557.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are offered high levels of personal support as they are not able to do many things for themselves. Staff try to find out how service users want things done. Service users are offered support to go for regular appointments with the GP, dentist, optician and chiropodist so that health problems can be avoided where possible. They are offered specialist advice from other professionals when necessary. Given the different abilities of people at this home it is not possible for service users to self-medicate. There are some problems with the way medication is recorded which means that there is the risk that there may be some mistakes made with giving medication which may not be found out. EVIDENCE: There was a previous requirement that the Registered Manager must ensure that a review takes place of the use of the helmet for one service user, involving all members of the care team with an additional Epilepsy Nurse or Grosvenor Terrace, 100 DS0000060231.V294557.R01.S.doc Version 5.1 Page 14 epilepsy specialist. This has occurred and has come to the decision that the use of the helmet should continue. Service users have a variety of different medical conditions and staff support them all to attend for regular and specialist appointments There was a previous requirement that the Registered Manager must ensure that all staff attend training in the administration of rectal diazepam. This had not been done but staff believed that they do not now administer rectal drugs but would call a doctor to do this. The written guidance in the file still says that staff will administer this drug and it is being held in the home, which could lead to confusion about correct procedures. The diazepam in the home was counted and although the record stated there should have been 13 tablets, there were only 12. The diazepam was not recorded on the current medication administration chart. Staff were unclear about whether one service user had been taken off another medication or was on a break from it. It was still on the medication administration chart just saying that none had been prescribed for the month. There was a previous requirement that the Registered Manager must ensure that all p.r.n. medication is recorded on the same type of medication administration charts as regular medication. This had not been done and there was evidence that prn medications were being prescribed but were rarely used and would be more appropriately taken off the prescription. There was a previous requirement that the Registered Manager must ensure that all medication is received into the home in correctly labelled packaging. This had now been done. (See Requirements 8 - 12) There was no medication counter in the home (See Recommendation 3) Grosvenor Terrace, 100 DS0000060231.V294557.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 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints policy does not have the correct contact details for CSCI so anyone wishing to complain to someone other than staff would not be able to do so. Not all complaints and concerns raised by service users or their families are recorded which means that the home is not able to show that it is responding to the views of service users and making things better in the ways that they want. Staff are not trained or aware enough of the policies, procedures and current best practice in protecting service users from abuse which means that service users may be being put at some risk. EVIDENCE: There was a previous requirement that the Registered Manager must ensure that the correct contact details for CSCI, along with a brief explanation of their purpose, is included in the Complaints Policy and Procedure and Service User Guide. These documents have not been altered by the organisation although the contact details have been handwritten on the complaint procedure in the hallway of the home. (See Requirement 13) There is a complaints book in the home and it appeared that complaints are being recorded more regularly since the last inspection. However there have been recent complaints or concerns raised by service users about a particular staff issue and these were not recorded. (See Requirement 14) Grosvenor Terrace, 100 DS0000060231.V294557.R01.S.doc Version 5.1 Page 16 Staff stated that they have not had training around abuse and protection of vulnerable adults for many years and staff were not fully aware of the borough of Southwark’s adult protection procedures; they had not all signed that they had read and understood the policy. (See Requirements 15 & 16) Grosvenor Terrace, 100 DS0000060231.V294557.R01.S.doc Version 5.1 Page 17 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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, homely and attractive. Service users have individualised bedrooms that are decorated to meet their own tastes and the numbers of toilets and bathrooms mean that they have sufficient privacy. On the day of the inspection the home was clean and hygienic throughout. EVIDENCE: There was a previous requirement that the Registered Individual must ensure that the home is issued with clear guidance about who is responsible for repairs and maintenance in the home and that all necessary repairs are carried out in a timely manner. Staff reported that this issue has got better but that they still do not know exactly who to call is they need minor repairs made and when they do it seems to take a long time of things to get fixed. The tour of the building showed that the home is clean and comfortable throughout. Service users’ rooms have been decorated in the way they like and one of them had extra pictures that represented their cultural heritage, as requested by their family recently. Grosvenor Terrace, 100 DS0000060231.V294557.R01.S.doc Version 5.1 Page 18 Grosvenor Terrace, 100 DS0000060231.V294557.R01.S.doc Version 5.1 Page 19 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, 33, 34, 35 & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is reaching the target of 50 of its staff holding the NVQ in Care but there is no training and development plan in place which looks at what training staff need to meet the particular needs of service users and the aims of the home. This means that service user may not be being offered support from staff who fully understand what they need to do. Service users are not supported by a fully effective staff team as there are not currently enough staff to ensue that service users can go out and undertake activities on an individual basis or ‘as they choose’. Events have to be booked well in advance and cannot be spontaneous. Staff are not being fully supervised by management which means that service users are not being offered support from staff who are being given the right amount of advice and guidance. EVIDENCE: Staff stated that three staff hold the NVQ Level 3 with three staff not holding it, therefore the home is just meeting the requirement of 50 of staff holding the NVQ. Grosvenor Terrace, 100 DS0000060231.V294557.R01.S.doc Version 5.1 Page 20 There was a previous requirement that the Registered Individuals must ensure that the staffing levels at the home are sufficient to fully met the needs of the service users. The Commission must be informed of the outcome of the current staffing review. The Commission had not been sent any information about this issue and as discussed earlier in this report there are still concerns that the staffing levels are not enough to meet service users’ needs. (See Requirement 7 made earlier in the report) The organisations’ recruitment records are not held in the homes and the inspector will be going to their head office to assess the records for all the homes at a later date. The Commission now has a form that has to be held on file for all staff which is a form of checklist for recruitment records and which is signed by one of the Registered Individuals. (See Requirement 17) Some staff files had records of training that they had undertaken but some didn’t and there was no training plan for the home that shows what training had been identified for staff following their annual appraisals. (See Requirements 18 & 19) Some staff have not been supervised since August 05 and not all staff have full annual appraisals of their work on file although staff did believe that they had all been done as dates had been set up to meet with the acting manager about this. (See Requirements 20 & 21) Grosvenor Terrace, 100 DS0000060231.V294557.R01.S.doc Version 5.1 Page 21 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 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The deputy manager is now acting-manager and as she is new to the post it is not possible to say yet whether she is effective in her role. Although the organisation does undertake reviews of care and aims to include the goals of service users in their development plans for the home, the home does not make sure that service users views (or the views of their families) are part of all development at the home. There is not a complete system in place that makes sure that all areas of work at the home are assessed regularly and then plans put in place to make things better for service users. The health, safety and welfare of service users are being protected by the effective use of procedures and regular monitoring at the home. EVIDENCE: Grosvenor Terrace, 100 DS0000060231.V294557.R01.S.doc Version 5.1 Page 22 The previous deputy manager is not the acting manager and she must now put in an application to be registered with the Commission (See Requirement 22). A deputy manager from another home had just been moved over to support her. Staff described the acting manager as open and said that she discusses things with the team to make sure everyone is involved in decision making. There was a previous requirement that the Registered Manager must ensure that an annual survey (or other form of annual audit) of service users families and other stakeholders takes place that then feeds into the annual review of the service and the local business plan with a previous recommendation that the Responsible Individuals should consider investigating and employing a professionally recognised quality assurance tool within the home. The home does not currently have in place a system that makes sure the home can monitor and develop all areas of the work. The organisation does have a system in operation at its other homes that this inspector has seen that looks at service users goals and feeds those into a quarterly action plan but that is not working at this home. The organisation does conduct the monthly visits to the service by an external manager or service manager and send these through to the Commission as required. A survey about what people think of the home is about to be sent out to service users’ families and other professionals who work with the home. (See Requirements 23 & 24 and Recommendation 4) The inspector checked all the health and safety records and documents and found them all to be in order except that the weekly fire system tests are not occurring every week, or are not being recorded every week. (See Requirement 25) Grosvenor Terrace, 100 DS0000060231.V294557.R01.S.doc Version 5.1 Page 23 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 X 3 X 4 X 5 1 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 2 34 X 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 2 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 2 X Grosvenor Terrace, 100 DS0000060231.V294557.R01.S.doc Version 5.1 Page 24 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 YA5 Regulation 5 Requirement The Registered Individuals must ensure that there are terms and conditions for all service users which describe all the areas required by the standards and state the rights service users have under an assured tenancy. These terms and conditions must be signed by service users or their representatives. The Registered Manager must ensure that all support guidelines and risk assessments are effectively reviewed at least every six months following the meeting with social services and other interested parties. The Registered Manager must ensure that ongoing monitoring tools are in place to make sure that action identified in the sixmonthly reviews is carried out as soon as possible. The Registered Manager must ensure that the service users’ Communication Passports are completed as a priority. The Registered manager must ensure that staff research DS0000060231.V294557.R01.S.doc Timescale for action 31/08/06 2. YA6 15 (2) (b) 31/07/06 3. YA6 15 (2) (b) 31/07/06 4. YA6 12 (b) & 15 31/07/06 5. YA7 12 (b) 31/08/06 Grosvenor Terrace, 100 Version 5.1 Page 25 6. 7. YA13 YA14 8. YA20 agencies and individuals who can advocate or offer peer support for service users and who share some of the same culture, heritage and disabilities. 12 (1) The Registered Individual must 31/05/06 ensure that both vehicles in use at the home are operational. 16(2)(m)(n) The Registered Individuals 31/08/06 18(1)(a) must ensure that the staffing levels at the home are sufficient to fully meet the needs of the service users. The Commission must be informed of the outcome of the current staffing review. Previous requirement: Unmet timescales 30/09/05 & 31/03/06 30/06/06 13 (2) The Registered Manager must ensure that all staff attend training in the administration of rectal diazepam. Previous requirement: Unmet timescales 30/09/05 & 31/01/06(now extended to): The Registered Manager must ensure that the guidelines for the administration of rectal drugs are clear and if staff are to continue to administer it all staff must attend training in how to administer. The Registered Manager must ensure that all current medications are recorded on the current medication administration chart. The Registered Manager must ensure that the medication stock checking systems are effective. The Registered Manager must ensure that all p.r.n. medication is recorded on the same type of medication administration charts as regular DS0000060231.V294557.R01.S.doc 9. YA20 13 (2) 31/05/06 10. YA20 13 (2) 31/05/06 11. YA20 13 (2) 31/05/06 Grosvenor Terrace, 100 Version 5.1 Page 26 12. YA20 13 (2) 13. YA22 22 (7) 14. YA22 22 15 YA23 13(6) 18(1)(c)(i) 16 YA23 13(6) 18(1)(c)(i) 19(1)(b) 17. YA34 18. YA35 18(1)(c)(i) 19. YA35 18(1)(c)(i) medication. Previous requirement: Unmet timescale 21/11/05 The Registered Manager must ensure that the use of all p.r.n. medications is reviewed to make sure that any medication not being used is taken off the regular prescription. The Registered Manager must ensure that the correct contact details for CSCI, along with a brief explanation of their purpose, is included in the Complaints Policy and Procedure and Service User Guide. Previous requirement: Unmet timescale 30/09/05 & 31/01/04 The Registered Manager must ensure that all concerns and complaints from service users, their families and other stakeholders are recorded in the complaints book along with action taken, timescales and whether the complainant was satisfied with the outcome. The Registered Individuals must ensure that all staff attend training around abuse and protection of vulnerable adults. The Registered Manager must ensure that all staff are familiar with the borough’s adult protection procedures. The Registered Individuals must ensure that the Commission’s recruitment form is completed for all staff and held on file at the home. The Registered Manager must ensure that records are held for all staff of all training that they have undertaken. The Registered Individuals must ensure that at there is an DS0000060231.V294557.R01.S.doc 31/05/06 30/06/06 30/06/06 31/08/06 30/06/06 31/08/06 31/08/06 31/08/06 Page 27 Grosvenor Terrace, 100 Version 5.1 20. YA36 18 (2) 21. 22. YA36 YA37 18 (2) S11 CSA 23. YA39 12 (3) 24. YA39 24 25. YA42 23 (c) annual training an development plan in place for the home that is based on individual staff’s annual appraisals and assessment of training needs. The Registered Manager must ensure that all staff are supervised regularly by a line manager who has been trained to offer such supervision. The Registered Manager must ensure that all staff have an annual appraisal of their work. The Responsible Individual must ensure that the acting manager puts in an application to be registered with the commission. The Registered Manager must ensure that an annual survey (or other form of annual audit) of service users families and other stakeholders takes place that then feeds into the annual review of the service and the local business plan. Previous requirement: Unmet timescale 31/03/06 The Registered Individuals must ensure that an effective quality assurance system, based on seeking the views of service users, their families and others is in place in the home. The Registered Manager must ensure that the weekly fire system tests are carried out as required. 30/06/06 30/06/06 31/05/06 31/08/06 31/08/06 31/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000060231.V294557.R01.S.doc Version 5.1 Page 28 Grosvenor Terrace, 100 1. 2. 3. 4. Standard YA6 YA17 YA20 YA39 The Registered Manager should consider archiving information from service users files so that only current, useful information is kept in them. The Registered Manager should consider researching and trying out more frequent and more varied cultural options of meals for service users. The Registered Manager should consider buying a medication counter for the home. The Responsible Individuals should consider investigating and employing a professionally recognised quality assurance tool within the home. Previous Requirement. Grosvenor Terrace, 100 DS0000060231.V294557.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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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