Inspection on 17/02/09 for Grosvenor Terrace, 100

This inspection was carried out on 17th February 2009.

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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Grosvenor Terrace, 100 29/01/08

Grosvenor Terrace, 100 18/12/06

Grosvenor Terrace, 100 10/05/06

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 19/06/2009.

CARE HOME ADULTS 18-65 Grosvenor Terrace, 100 London SE5 0NL Lead Inspector Emma Dove Unannounced Inspection 17th February 2009 02:00 Grosvenor Terrace, 100 DS0000060231.V374297.R01.S.doc Version 5.2 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.V374297.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V374297.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grosvenor Terrace, 100 Address London SE5 0NL 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 0207 703 8395 catalina@odyssey-csft.org www.odyssey-csft.org Odyssey Care Solutions for Today Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Grosvenor Terrace, 100 DS0000060231.V374297.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 4 29th January 2008 Date of last inspection Brief Description of the Service: 100, Grosvenor Terrace is a registered care for up to four adults with learning disabilities. Four women currently live there. The service is managed by Odyssey Care Solutions for Today, who have other similar homes in South London. The home is a two storey house in a residential road in Southwark. People have access to a lounge, kitchen/dining room, laundry room, toilet and bathroom on the ground floor with one single bedroom. Three single bedrooms, a bathroom and toilet are on the first floor. People have good access to local shops, leisure facilities, churches of different denominations, pubs, restaurants and public transport systems. The weekly fees vary depending on the individuals needs. Information about the CSCI is available at the service and in the Statement of Purpose and Service Users Guide. Grosvenor Terrace, 100 DS0000060231.V374297.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means people who use this service experience adequate quality outcomes. This unannounced inspection was carried out over four hours on the 17th February 2009 by one regulation inspector. We spoke with people who use the service, staff, the deputy manager, staff and looked at records. We also spoke with the manager from one of the organisations other homes, who is providing support one or two days a week while the manager is on leave. Surveys were sent to relatives of people who use the service, social workers and health professionals. We have received two completed surveys and comments from these are included throughout this report. We received an annual quality assurance assessment (AQAA) from the manager in July 2008. This gave us good information about the service, what it does well and the plans for improvement over the next year. We also looked at other information received from the service since the last inspection in January 2008. What the service does well: What has improved since the last inspection? What they could do better: The Statement of Purpose and Service Users Guide should be updated with details of the current manager and include the correct address of the CSCI. This will ensure people who use the service and their representatives have up Grosvenor Terrace, 100 DS0000060231.V374297.R01.S.doc Version 5.2 Page 6 to date information about the service. Both documents should have the date, so it is clear when they were written and reviewed. Old care plans should be archived to ensure staff have easy access to people’s current needs. The daily recording should be more detailed to show what people did and the support they are given. A challenge for the service is to develop more opportunities for people to participate in community activities and outings and to have more activities available to them at the home. This will ensure people have more opportunities to go out and do different activities. The records of controlled medication must be checked and the missing medication found, to comply with regulations. The central heating must be repaired, so that all radiators are working and the home is at a comfortable temperature. This would remove the need for electric plug in heaters which are currently in use. Risk assessments should be completed where electric plug in heaters are used, to keep the people who use the service, staff and visitors safe. The kitchen units are looking tired and need replacing to keep the home at a good standard for the people who live there. The worn and stained carpets in the lounge, hallway and some bedrooms should be cleaned and or replaced, to keep the environment at a good standard for the people who live there. Staff recruitment information must be available at the home for inspection, to comply with regulations. Staff must receive supervision six times a year, with clear records of sessions, to see at a glance that staff are receiving the appropriate support to do their job. The manager must register with the CSCI, to provide the service with consistent management. Systems should be developed to show actions taken following the monthly visits by the registered person. This will evidence that the manager and staff are acting appropriately to improve the services provided. The gas safety must be checked every year and the hoist must be checked every six months, to ensure people who use the service are protected from harm. Grosvenor Terrace, 100 DS0000060231.V374297.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Grosvenor Terrace, 100 DS0000060231.V374297.R01.S.doc Version 5.2 Page 8 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.V374297.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 People who use this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The service understands the importance of having information, to help people decide if the home is right for them. Assessments are completed before someone moves in, ensuring the service can meet their needs. EVIDENCE: We saw a Statement of Purpose dated 2007 and a Service Users Guide with no date. These documents include information about the home, care planning, reviews, and the service provided. The Service Users Guide is in pictorial format, making it more accessible to the people who use the service. Both these documents need updating to include details of the current manager, contact details of the CSCI and to include a more recent business plan than 2006/2007. We saw assessments in case files and the manager told us that the people who use the service are having their needs re-assessed through the local authority social services department. Grosvenor Terrace, 100 DS0000060231.V374297.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 People who use this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The service knows and records the preferred communication style of the individual and uses appropriate methods to support people to communicate. Care plans are person centred and need to be developed further to make goals more realistic for individuals. Risk assessments are completed and kept under review. EVIDENCE: We saw care plans have been developed and include the care and support individuals need. Case files detail peoples needs, including a communication profile, including what they say or gestures they make and what they mean. This is a good tool for staff to ensure everyone who works with the individuals can communicate with them. The deputy manager told us they are in the process of completing new care plans, from assessments. These new forms include a profile of the individual, Grosvenor Terrace, 100 DS0000060231.V374297.R01.S.doc Version 5.2 Page 11 their personal identity and short and long term goals. The goals seen for one person were unrealistic around finances and household tasks. The areas to develop around personal care were more achievable. Daily recording could be improved to include more detail, not just ‘good night, slept well’ but to note the time the person went to sleep and when they woke up and any support given. One person involved in the service told us, in a survey, that they have not had any concerns about the standard of care provided. Case files contained a lot of information, which could be sorted through and old reviews, assessments and care plans could be stored in another area, ensuring staff access the most current information when preparing to provide support to people. We saw reviews had taken place for people during the last six months, with evidence that some actions have been completed. Risk assessments are in place and kept under review. Staff demonstrated awareness of the risks to individuals and how to minimise them. Grosvenor Terrace, 100 DS0000060231.V374297.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 People who use this service receive adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. People have access to day centres and some regular activities, more opportunities should be developed for people to do things at the home and in the local community. People are supported to maintain contact with relatives and friends. People are offered a varied menu. EVIDENCE: We saw individuals have a weekly plan of activities including leisure and free time. This was seen to be followed during our visit, with three people at day centres and one person went on a shopping trip including eating lunch while they were out. Records are kept of activities people participate in and we saw some people have been to a social club, out on the bus, shopping, out for lunch, out for a walk, to the cinema and to another home managed by the organisation for a party and for a music therapy session in recent weeks. Grosvenor Terrace, 100 DS0000060231.V374297.R01.S.doc Version 5.2 Page 13 Staff told us ‘it can be difficult to take people out on an individual basis when there is only two members of staff on duty during the day’. The deputy manager said they are working with the local authority to get more staff, to enable people who use the service to be involved in more outings and community activities. We saw people spend time in the lounge with the television and music on, in their rooms listening to music and in the kitchen having drinks and an evening meal during our visit. Later in our visit, we saw people in the lounge, at some times asleep, without staff interaction for periods over twenty minutes during the afternoon. Staff could spend more time with individuals, engaging them in sensory activities or just talking with them. The deputy manager told us they aim for staff to spend five minutes every morning and afternoon with individuals, to improve the level of interaction. The manager told us in the annual assessment that they have worked at supporting people who use the service to maintain contact with family and friends over the last year. The manager told us that ‘people are supported to choose food items from photos’. The menu we saw displayed did not reflect the meal being prepared and we did not see staff offering the individuals the photographs to see the meal before it was served. This was a missed opportunity for staff to interact with people individually. The menu is varied and staff said it reflects the likes, dislikes and preferences of people who use the service and takes into account any medical or religious dietary needs. Grosvenor Terrace, 100 DS0000060231.V374297.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People who use this service receive adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. People who use the service have access to health care services both within the home and in the local community. Health needs are monitored and appropriate action taken. Medication records are up to date, although we found some issues with recording controlled drugs. EVIDENCE: The manager told us in the annual assessment that people are supported by staff in the way they choose. People’s health needs are met by regular appointments with health professionals, ‘Best interest’ meetings are held where people who use the service are not able to give consent to treatment. We saw records confirming best interest meetings have been held. Staff told us that they attend health appointments and record any actions to be taken. We saw records of any actions staff should take following health appointments. We received one survey from a health care professional which indicated that the service seeks appropriate medical advice and acts upon it, that peoples Grosvenor Terrace, 100 DS0000060231.V374297.R01.S.doc Version 5.2 Page 15 health care needs are met by the service, that the service respects peoples privacy and dignity. One case file contained information about when the doctor should be contacted, although the reason for doing this was not clear. Appropriate policies and procedures are in place for the administration of medication. Medication is securely stored. Staff told us they monitor the temperature of the room, to ensure the temperature is at an acceptable level. Medication Administration Record Sheets are up to date and signed by staff. A book for recording controlled medicines was started in September 2008 although most records were dated 18th April 2008, the deputy manager said this was when medication had been received at the home. Records for three controlled medications were up to date and correct. Records for one medication were not clear and a count of doses given and the medication received showed six tablets were missing. The deputy manager and staff were not clear where the tablets were and were not able to find records of medication returned to the pharmacist. The deputy manager informed us after our visit that the record of medications returned to the pharmacist had been found and showed the missing medication had been returned. Better systems need to be in place to monitor the storage and administration of controlled drugs, to ensure that the people who use the service are safe. Grosvenor Terrace, 100 DS0000060231.V374297.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The service has an accessible complaints procedure and appropriate policy for safeguarding vulnerable adults. EVIDENCE: We saw the complaints procedure in pictorial format, displayed at the service. The manager told us in the annual assessment that they intend to improve the accessibility of the complaints procedure so it is more suitable for the people who currently live there. The complaints procedure is included in the Statement of Purpose, Service Users Guide and displayed at the service so relatives, representatives and other stakeholders are able to raise issues if and when required. The manager told us they had not received any complaints. No complaints were recorded. No issues have been received by the CSCI since the last inspection in January 2008. Staff told us they completed training in the protection of vulnerable adults as a part of their induction and through the organisation and were aware of their responsibility to report concerns or issues. Grosvenor Terrace, 100 DS0000060231.V374297.R01.S.doc Version 5.2 Page 17 The service holds some money for people. All monies are securely stored. The balance and receipts for one person were checked and found to be correct and up to date. Grosvenor Terrace, 100 DS0000060231.V374297.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30 People who use this service receive adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that meets the needs of the people who live there. The service needs to work through the redecoration and refurbishment schedule to bring the home to a good standard for the people who live there. EVIDENCE: People have access to a lounge, kitchen/dining room, toilet and bathroom on the ground floor. Three single bedrooms and a bathroom with toilet are on the first floor with one single bedroom on the ground floor. Some communal areas of the home are in need of redecoration, some carpets need cleaning or replacing and the kitchen units look worn. The completion of this work will bring the environment to a good standard. We saw a number of electric heaters around the home, mainly in hallways and the lounge. Staff told us that the heating system had not been working Grosvenor Terrace, 100 DS0000060231.V374297.R01.S.doc Version 5.2 Page 19 properly and they need the extra heaters to keep the house warm. The heating system must be repaired so it heats the home adequately without the use of electric heaters. Bedrooms are single and have been decorated and personalised to the individuals taste with pictures, photographs and articles that reflect peoples religious and cultural identity. We saw people to be comfortable and have the things they want and need in their rooms. Staff told us they have a hoist, which enables them to offer appropriate support to people who use the service. We saw people using wheelchairs and armchairs that meet their assessed needs. With the exception of carpets in the entrance, hallways and lounge and the paintwork in the lounge, all areas of the home were clean and fresh. Staff told us they have domestic staff for two hours every day. This keeps the environment clean and enables care staff to spend more time with the people who use the service. Two completed surveys indicated the home is ‘always’ clean and fresh. Grosvenor Terrace, 100 DS0000060231.V374297.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 People who use this service receive adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Staff rota shows there are sometimes enough staff to meet peoples needs. The staff recruitment process meets statutory requirements although not all records are in place confirming checks happened. EVIDENCE: The staff rota showed two members of staff working during the day with one member of staff awake and one member of staff asleep but on call at the home at night. We saw these staffing levels to be less than required to fully meet the needs of the people who use the service. Staff told us there are not enough staff to support people attending appointments and participate in community activities. This issue has been ongoing for the last three years. The deputy manager told us that the people who use the service have had their needs re-assessed by the local authority and they are awaiting a response about additional resources, to be able to meet peoples needs better. Grosvenor Terrace, 100 DS0000060231.V374297.R01.S.doc Version 5.2 Page 21 The staff rota did not include details of the manager’s hours and did not reflect that she is on extended leave, although it did show the hours the manager from another of the organisation’s homes is at the service. The deputy manager told us there are two vacant posts at the service, which are currently filled by locum staff employed by the organisation, who know the people who use the service well. The last visit by the registered person identified the need to fill four vacant posts. The organisation has a training programme which is available to all staff. Staff told us they have opportunities for training. The manager told us in the annual assessment that they plan to offer staff in house training in all areas of care, support and systems in place at the service. We looked at staff files for one member of staff, this had a list of the preemployment checks completed by the organisation, with dates and the number of the Criminal Records Bureau check. Staff files were not available for the two newest members of staff, one has been in post for two years and the other member of staff has been at the home for six years. The deputy manager wrote to us after our visit and told us the recruitment information for these two newest members of staff is now at the home. Records of staff supervision were not easy to access and did not show that people are having supervision at monthly intervals. Grosvenor Terrace, 100 DS0000060231.V374297.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 People who use this service receive adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. There is no registered manager, although arrangements have been in place to cover the management position for the last four years, this does not provide consistency of care or support and direction for staff. EVIDENCE: The manager is currently on leave and the deputy is covering, with support from a manager from another of the organisations services. This situation is not ideal and does not provide stable management for a service that has not had a registered manager for the last four years. The manager told us in the annual assessment that they plan to use management to ensure regular monitoring of staff working practices and direct Grosvenor Terrace, 100 DS0000060231.V374297.R01.S.doc Version 5.2 Page 23 supervision, for staff to attend Understanding Autism training, after completion of annual surveys, the management will develop an action plan to improve the quality of the service, for medication audits to be implemented on monthly basis and for staff to attend manual handling training in the next twelve months. We did not see evidence that these have taken place and are aware that the manager has been on leave for the last three months and has not been able to see these are completed. A representative from the organisation visits the service every month to look at the quality of care and support provided and write a report with some actions required. A system to show that any of these actions have been checked and completed would be of benefit and would demonstrate that the service constantly works to improve. We saw some of these visits were announced, with details of the date and time entered in the diary. The National Minimum Standards suggest these visits are made unannounced. We saw records for health and safety checks to be generally up to date and at the appropriate time. The fire alarm system is checked weekly by staff and serviced every three months. The portable electrical appliances were tested in November 2008. The gas safety was checked in February 2008, this should be done every year, to ensure people who use the service, visitors and staff are safe. The hoists were serviced in July 2007, this should be done every six months, to ensure that the people who use the service are kept safe. Grosvenor Terrace, 100 DS0000060231.V374297.R01.S.doc Version 5.2 Page 24 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 2 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 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 2 29 3 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 2 2 X X 2 X Grosvenor Terrace, 100 DS0000060231.V374297.R01.S.doc Version 5.2 Page 25 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 YA20 Regulation 13 (2) Requirement Records of controlled medication must be checked and missing medication accounted for with better systems to check the records on a regular basis. The central heating system must be fixed so it keeps all areas of the home warm. While plug in electric heaters are being used, risk assessments must be completed to ensure people who use the service, visitors and staff are kept safe. The stained carpets in the lounge, entrance and hallway must be replaced to provide a good environment for the people who live there. There must be sufficient staff on duty at weekends and evenings to meet people’s social needs. (previous timescale of 10/07/08 not met) Information about staff recruitment including the checks completed before staff started DS0000060231.V374297.R01.S.doc Timescale for action 27/03/09 2. YA24 23 (2) p 10/04/09 3. YA24 23 (2) d 24/07/09 4. YA33 18 10/04/09 5. YA34 17 (2), 19 (1) Sch 4 10/04/09 Grosvenor Terrace, 100 Version 5.2 Page 26 work at the home must be available at the home, to show that people who use the service are protected from harm. 6. YA36 18 (2) All staff must receive regular supervision to help them carry out their job. Checks must be carried out to ensure that equipment (hoists)and utilities (gas safety check) are in good working order and are safe for use. (previous timescale of 12/06/08 not met) 13/03/09 7. YA42 23 (2) c 10/04/09 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 YA1 Good Practice Recommendations The Statement of Purpose and Service Users Guide should be updated to include details of the current manager and the correct address of the CSCI, to ensure people who use the service and their representatives have up to date information about the service. Case files should be sorted to ensure current information is easily accessible to staff. Daily recording should be more detailed and factual, so the information can be used to review and update peoples needs in their care plans. Staff should provide more opportunities for people to participate in a variety of activities in the home, to ensure their social and leisure needs are fully met. Consideration should be given to replacing the kitchen units which are looking worn, to provide a good environment for the people who use the service. DS0000060231.V374297.R01.S.doc Version 5.2 Page 27 2. 3. YA6 YA6 4. YA14 5. YA24 Grosvenor Terrace, 100 6. YA39 After the monthly monitoring visit, any actions to improve the services provided should be monitored and progress checked at the next visit. Grosvenor Terrace, 100 DS0000060231.V374297.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Grosvenor Terrace, 100 DS0000060231.V374297.R01.S.doc Version 5.2 Page 29 - 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. 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