Inspection on 29/01/08 for Grosvenor Terrace, 100

This inspection was carried out on 29th January 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 12 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 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 27/09/2008.

CARE HOME ADULTS 18-65 Grosvenor Terrace, 100 100 Grosvenor Terrace London SE5 0NL Lead Inspector Maria Kinson Unannounced Inspection 29th January 2008 10:45 Grosvenor Terrace, 100 DS0000060231.V341891.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.V341891.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.V341891.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grosvenor Terrace, 100 Address 100 Grosvenor Terrace 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 www.odyssey-csft.org Odyssey Care Solutions for Today Vacant Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Grosvenor Terrace, 100 DS0000060231.V341891.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th December 2006 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 inspector was not able to obtain information about the fees charged by this home but the manager said that each person contributes £63.95 a week. People also contribute towards the cost of the homes vehicle. The contribution is dependent on the amount of benefits people receive. This information was obtained on 29/01/08. Grosvenor Terrace, 100 DS0000060231.V341891.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 the people who use this service experience adequate quality outcomes. This inspection took place on the 29th January 2008, and was unannounced. The inspector spent six and a half hours in the home. During this period all of the communal areas and three bedrooms were viewed. Two relatives and one health care professional provided written feedback about the service and the inspector spoke with two members of staff during the inspection. Some of the records that were kept in the home were sampled and medication records and supplies were assessed. There were four people living in the home at the time of this inspection. An immediate requirement was issued as the laundry door was wedged open with a fire extinguisher and staff were observed moving and handling people in an inappropriate manner. The Registered Person was asked to advise the commission in writing by 12/02/08 about the action they would take to address these concerns. The manager provided a written response on 13/03/08. What the service does well: The information included in care plans and guidelines was detailed and described what people liked and disliked and how they wanted to be supported. Relatives were consulted when people were not able to make decisions for themselves. People were supported to attend health care appointments and to take their medicines. Relatives said their family members physical needs were well met and staff usually told them if their family member was unwell. The food provided in the home was varied. The home was clean, tidy and comfortable. People could organise and arrange their personal things how they liked. Staff attended relevant training sessions and could discuss their development needs and work with senior staff. Grosvenor Terrace, 100 DS0000060231.V341891.R01.S.doc Version 5.2 Page 6 Records showed that thorough checks were carried out before new staff were allowed to work in the home. What has improved since the last inspection? What they could do better: Service users received a copy of the terms and conditions for the service. This document was difficult to understand and did not include adequate information about the service. Care plans and guidelines were not always followed and staff did not always take adequate care to maintain peoples privacy. People were supported to undertake activities in the home and community but the range of activities provided was limited. There were not enough staff to support people to go out during weekends and evenings. One relative said their family member needed “more social contact”. The management of medicines was good overall but staff did not always amend the records when medicines changed and did not carry out regular checks to ensure that medicines were stored at a suitable temperature. Complaints were recorded and investigated but the records did not show if the complainant was told about the findings or the action the home had taken to address their concerns. The manager had not submitted an application to register with the commission and was now spending less time in the home. Some quality assurance work was taking place but it was not always clear if the findings were used to improve the service. Grosvenor Terrace, 100 DS0000060231.V341891.R01.S.doc Version 5.2 Page 7 The manager did not always notify the commission about significant events that occurred in the home. Fire safety arrangements were good overall but the laundry room door was wedged open with a fire extinguisher. This will stop the door from closing if there is a fire and could result in the fire spreading to other parts of the home. It was not possible to establish if health and safety checks and assessments were always carried out, as some records could not be located. Some of the homes policies and procedures were old. It is essential that staff have access to up to date information. Staff held some people around the upper arm when they were leading them around the home. This practice gives the person very little control over where they are going and could result in bruising. 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.V341891.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.V341891.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): 5. (Standard 2 could not be assessed). Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The terms and conditions did not include adequate information about fees or people’s rights and responsibilities. This information must be provided so that people know what they can expect from the service. EVIDENCE: The registration and public liability insurance certificates were displayed in the hallway. This included the registration certificate for the previous manager, who staff said left some years ago. Old certificates should be removed so that people visiting the service know who is responsible for managing the service. It was not possible to assess the arrangements and procedure followed by staff when admitting new people into the home, as all of the current service users had lived in the home for many years. People received a copy of the terms and conditions for the home. Some of the information in this document was incomplete or difficult to understand due to the language used. The section on fees was blank and it was not clear how much notice people had to give if they wanted to move out. See Grosvenor Terrace, 100 DS0000060231.V341891.R01.S.doc Version 5.2 Page 10 recommendation 1. The terms and conditions were agreed and signed by service users representatives. Grosvenor Terrace, 100 DS0000060231.V341891.R01.S.doc Version 5.2 Page 11 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, 8 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans reflected people’s individual needs and preferences but were not always followed by staff. People were able to make staff aware of their likes and dislikes but relied on other people such as relatives to help them make decisions about other issues. EVIDENCE: All of the people that lived in the home had complex needs and difficulty communicating. Two sets of records were examined. The records provide specific information about peoples health and social care needs and detailed guidance about peoples likes and dislikes. Information was provided for staff about how they should support people to eat and drink and what help people required to move around the home. Each person had a communication passport. This showed how each person communicates and how staff should interpret specific sounds Grosvenor Terrace, 100 DS0000060231.V341891.R01.S.doc Version 5.2 Page 12 or movements. This helps staff and other professionals to judge if the person was happy, comfortable or in pain. Plans were reviewed and updated in May 2007. The National Minimum Standards for Young Adults states that care plans should be reviewed every six months or more frequently if the person’s needs change. See recommendation 2. Care plans indicated that people would be supported to undertake small tasks around the home such as tidying their room. This did not occur during the inspection and one relative said, “there is little evidence of anyone trying to involve people in activities either in house or outside”. See recommendation 3. Risks were identified and information was provided about the action that staff should take to maintain peoples safety. Risk assessments were seen for activities such as bus travel and specific behaviours. Risk assessments were easy to follow and understand and were reviewed regularly. Staff tried where possible to involve service users in decisions about their care and future. People such as key workers and relatives were invited to attend meetings about the person’s needs and interests. Although most of the people that live in the home have difficulty communicating they were able to show staff through their movements or facial expressions that they were tired or disliked something. Grosvenor Terrace, 100 DS0000060231.V341891.R01.S.doc Version 5.2 Page 13 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, 14, 15, 16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People did not have adequate opportunities to go out of a weekend or evening. The menu was varied but people’s individual dietary needs were not always met. EVIDENCE: The people that live in the home attend day care services for part of the week. During the inspection two people were supported to attend dental appointments and one person spent most of the day in the lounge. Records indicated that people were supported to undertake regular activities but the range of activities offered was limited and there were few opportunities to go out during the weekends and evenings. In recent weeks some people were supported to attend the day centre, complete walking exercises, listen to music, visit the hairdresser or have a massage. See requirement 1. Grosvenor Terrace, 100 DS0000060231.V341891.R01.S.doc Version 5.2 Page 14 As all of the service users require support from one member of staff. The current staffing levels do not enable staff to take people out during the evenings or on weekends. See standard 33. The homes bus was not suitable for people in wheelchairs. One service user spent several hours in the lounge with the television switched on. During the afternoon one person fell asleep in the lounge whilst the other service user showed very little interest in the television. One relative said their family member had little stimulation on the days when they did not attend the centre. Staff interacted with service users when they were undertaking tasks such as bathing and feeding people but spent little time engaging them in activities in the home. Some people received regular visitors. Staff prepared the menu on a Sunday. There was no evidence of any input from service users but staff said they took into account peoples likes and dislikes and included people’s favourite dishes. There were adequate supplies of fresh and frozen food in the home. One person required a special diet. The records showed that a separate menu was usually developed for this person but this could not be located for the week of the inspection. Staff were not certain why the person required a low salt/ fat diet but the manager was able to clarify this issue when she arrived in the home. See requirement 2. Staff were observed supporting people to eat. On one occasion a staff member was seen feeding a service user whilst standing above the person. It is essential that staff sit at the same level as the service user so that they can be seen and the person knows what is happening. The guidelines for the person that was eating indicated that they could lift the spoon to their mouth if staff put food on the spoon. There was no evidence that staff followed the guidance or promoted the persons independence. See requirement 3. Grosvenor Terrace, 100 DS0000060231.V341891.R01.S.doc Version 5.2 Page 15 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Support was provided to meet people’s individual personal and health care needs but staff did not always take adequate care to maintain people’s privacy and dignity. The management of medication was mostly good. EVIDENCE: Records included information about health and personal care issues and about peoples preferred routines. All of the people that live in the home require support with personal care. People were supported to bathe and dress when they were ready and were able to take their time getting up. Staff did not always ensure that doors were fully closed when they were assisting people with personal care. See requirement 4. One health care professional provided written feedback about the service. The person said that staff requested medical advice if they needed it and were able to meet people’s individual health care needs. Relatives confirmed that staff were usually able to meet their family members “physical needs” and said they Grosvenor Terrace, 100 DS0000060231.V341891.R01.S.doc Version 5.2 Page 16 were usually informed about important issues such as hospital visits and accidents. Medication was stored in the kitchen. This is not an ideal area to store medication, as kitchens can get very hot. The room temperature was not monitored so it was not possible to assess if medicines were stored at an appropriate temperature. Information about allergies was recorded and there was a photograph to help identify people. Guidance was provided about the circumstances when staff should give medication for seizures. Records of receipt and administration of medicines were good overall but one person did not receive one of their medicines for an eight-day period. Staff said the pharmacist could not obtain a supply of the medicine so an alternative medicine was prescribed. The original medicine was not crossed off. See requirement 5. Grosvenor Terrace, 100 DS0000060231.V341891.R01.S.doc Version 5.2 Page 17 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were procedures in place to protect the people using the service and to ensure that concerns were listened to and addressed. Work was in progress to improve the staff teams understanding of safeguarding procedures. EVIDENCE: The complaints procedure was displayed in the hallway. The contact address for CSCI was incorrect. The office listed closed in December 2006. The manager should ensure that information provided for service users and visitors is up to date. The company had recently introduced a new complaints leaflet for service users. The leaflet included pictures to help people to understand whom they should speak to if they were unhappy. The home had received one complaint in the period since the last inspection. The complainant raised concerns about staff attitude and approach. The manager arranged to meet the complainant to obtain more information about their concerns and an action plan was developed to address the issues raised. The plan included additional training for staff. It was not clear from the records if the complainant was advised about the outcome of the investigation or about the action that the manager took to address their concerns. See requirement 6. The money records for two people were examined. The records included information about money received in the home or paid out for items that were Grosvenor Terrace, 100 DS0000060231.V341891.R01.S.doc Version 5.2 Page 18 purchased by the service user. Receipts were kept, where possible and an explanation of what the money was spent on, was recorded. Recent expenditure included massage, personal toiletries, hairdresser, plants, music therapy, clothing, photographs and snacks. Each person had a personal bank account. The manager carried out regular checks to ensure that people had adequate money and that records and bank statements were correct. Staff said they would report concerns or allegations to senior staff and were confident that the management team would refer concerns to social services for investigation. The manager had requested safeguarding training updates for staff. Grosvenor Terrace, 100 DS0000060231.V341891.R01.S.doc Version 5.2 Page 19 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean, tidy and comfortable. People had their own room and there were shared areas where they could spend time with their friends and family. EVIDENCE: All areas were clean, tidy and free from unpleasant odours. The building was decorated to a satisfactory standard and some work had been undertaken since the last inspection to repair and repaint some of the doors and windows. Hand-washing facilities were satisfactory and waste was stored appropriately. All of the people that lived in the home had their own bedroom. Bedrooms were personalised with family photographs and items that reflected the person’s cultural history and background. Grosvenor Terrace, 100 DS0000060231.V341891.R01.S.doc Version 5.2 Page 20 The lounge and dining room were comfortable and warm and there was adequate seating for service users and their visitors. Grosvenor Terrace, 100 DS0000060231.V341891.R01.S.doc Version 5.2 Page 21 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, 33, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Weekend and evening staffing levels do not enable people to attend or undertake activities and social events in the community. Staff recruitment procedures had improved. This helps to ensure that people receive safe and suitable care. Staff had access to relevant training and support. EVIDENCE: 50 of staff had a vocational or equivalent qualification in care. See standard 8. Three staff had left since the last inspection and two new members of staff were appointed. This included a deputy manager and a support worker. Two bank staff were now undertaking regular shifts in the home to improve continuity of care. There was one member of staff on duty when the inspector arrived and the second carer was out of the home for a brief period escorting a service user to the day centre. Staffing levels were satisfactory during the day but do not Grosvenor Terrace, 100 DS0000060231.V341891.R01.S.doc Version 5.2 Page 22 provide adequate support for people to go out during the evening or at weekends. The manager said she had advised the funding authority about this issue and they were currently reassessing people’s needs. See requirement 7. A CSCI inspector visited the company’s head office in June 2007 to check staff recruitment records. Systems and procedures were robust and effective and all of the records required were obtained and kept on staff files. Staff had access to a comprehensive programme of internal and external training sessions. During the past year some members of staff had attended first aid, health and safety, moving and handling, food hygiene, COSHH, mental health, person centred approach, makaton, leadership, hoist, mental capacity act, end of life care, protection of vulnerable adults (POVA), epilepsy, report writing, service user participation, stress management, managing sickness, challenging behaviour, medication, learning disability award framework (LDAF), induction and equality and diversity training sessions. Staff were satisfied with training arrangements and said induction training covered everything that they needed to know. Staff confirmed that they had regular opportunities to discuss their development and work with senior staff. Records confirmed that staff received regular supervision. Grosvenor Terrace, 100 DS0000060231.V341891.R01.S.doc Version 5.2 Page 23 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, 39, 41 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The current management arrangement did not provide adequate time for regular monitoring of staff and work practices. People’s physical needs were well met but there was a lack of understanding amongst some staff about people’s emotional needs. Health and safety records and practices were difficult to evidence. The home had a quality assurance system but it was difficult to establish if this work led to improvements, as some of the findings and action plans could not be located. EVIDENCE: The current manager has been in post since September 2006 but had not submitted an application to register with the commission. The Manager is committing an offence under Section 11(1) of the Care Standards Act 2000. Grosvenor Terrace, 100 DS0000060231.V341891.R01.S.doc Version 5.2 Page 24 This could result in a conviction under section 11(5). The current manager was appointed to another job in the company in November 2007 and is now working in the home for two days a week. The commission were not notified about this change and one relative said that they heard about it from “a third party”. A new manager has been appointed and pre employment checks were being processed. The home must advise the commission in writing about the change of management and ensure that the new manager submits an application to register with the commission. A number of the concerns that were identified during this inspection do not pose a significant risk to people’s health and safety but could affect people’s quality of life and wellbeing. More frequent monitoring and direct supervision of staff is required to address some of the issues highlighted in this report. The management arrangements were discussed with the area manager following the inspection and it was agreed that the roster would be reorganised so that the deputy manager and manager would work different days and bank staff would work alongside permanent staff. The home had developed some systems to monitor and assess the quality of care provided in the home and to obtain feedback from the people using the service or their representatives. The manager completes a quarterly performance indicator form. This form provides information about specific issues such as staffing, training, finances, complaints and health and safety and progress about issues highlighted in previous reports. A health and safety audit was completed in December 2007 and an external medication audit was completed in 2007. The report for the medication audit could not be located. Satisfaction surveys were used to obtain peoples views about the service but the findings from the most recent survey was not available to view. The manager said the results were included in the homes business plan. A copy of the plan was requested. The commission did not receive this information. See requirement 8. The company is required to undertake monthly, unannounced visits to the home to assess the conduct of the service. The reports from two recent visits were seen. The self-assessment form that was completed by the manager showed that a number of policies and procedures had not been reviewed or updated for many years. See recommendation 4. Accident and incident records were examined. Staff had recorded issues of concern such as unexplained bruising and problems with an external taxi company. Discussion with the manager indicated that appropriate action was taken to investigate these issues and to prevent a reoccurrence but the commission were not notified about theses events. See requirement 9. Grosvenor Terrace, 100 DS0000060231.V341891.R01.S.doc Version 5.2 Page 25 A fire risk assessment was completed and kept in the home. Fire safety equipment was serviced at regular intervals and ‘in house checks’, tests and drills were taking place regularly. The laundry door was wedged open with a fire extinguisher. An immediate requirement notice was issued. The response from the manager said that the staff team were made aware of the health and safety implications of using fire extinguishers inappropriately and would receive a health and safety training update. See requirement 10. It was difficult to assess the management of health and safety issues as some records could not be found. Records showed that portable electrical appliances and hoists were serviced regularly but reports for the main electricity installation and the Legionella risk assessment could not be located. Gas appliances were last serviced in December 2006. Radiators were uncovered and felt hot. There was no risk assessment for hot surface temperatures. The manager agreed to send the inspector a copy of the documents that could not be located during the inspection. The commission did not receive this information. See requirement 11. Staff were seen guiding some people around the home by holding them around their upper arm. This could cause bruising. An immediate requirement notice was issued. The manager advised the commission that work would be undertaken with the staff team to improve moving and handling practices. See requirement 12. Grosvenor Terrace, 100 DS0000060231.V341891.R01.S.doc Version 5.2 Page 26 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 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 2 X 2 2 X 2 X Grosvenor Terrace, 100 DS0000060231.V341891.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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 YA14 Regulation 16 Requirement The Registered Person must make arrangements for people to have access to a varied programme of activities in the home and community. The Registered Person must ensure that staff are aware and follow guidance about people’s dietary needs. The Registered Person must ensure that eating and drinking guidelines are followed. The Registered Person must ensure that the home is conducted in a manner that respects people’s privacy and dignity. The Registered Person must ensure that: • Medicines are stored at an appropriate temperature • If the prescription changes the medication administration record is amended The Registered Person must ensure that adequate records are maintained in the home about complaints. This includes a copy of the response to the DS0000060231.V341891.R01.S.doc Timescale for action 12/06/08 2. YA17 12 15/05/08 3. 4. YA17 YA18 12 12 15/05/08 15/05/08 5. YA20 13 15/05/08 6. YA22 22 15/05/08 Grosvenor Terrace, 100 Version 5.2 Page 28 complainant. 7. YA33 18 The Registered Person must ensure that there are sufficient staff on duty at weekends/ evenings to meet people’s social needs. The Registered Person must forward a copy of the recent satisfaction survey to the commission. The Registered Person must ensure that the commission is notified about significant events. The Registered Person must ensure that fire doors are not wedged open with fie extinguishers. An immediate requirement was issued in respect of this issue. The response received by the commission indicates that action was taken to address this requirement. The Registered Person must ensure that adequate checks are carried out to ensure that equipment and utilities are in good working order and are safe for use. A copy of the gas safety inspection report, mains electricity installation report, hot surface temperature (radiator) risk assessment and Legionella risk assessment must be supplied to the commission. The Registered Person must ensure that staff move and handle people correctly. An immediate requirement was issued in respect of this issue. The response received by the commission indicates that action was taken to address this requirement. 10/07/08 8. YA39 24 12/06/08 9. 10. YA37 YA42 37 23 15/05/08 13/03/08 11. YA42 23 12/06/08 12. YA42 13 13/03/08 Grosvenor Terrace, 100 DS0000060231.V341891.R01.S.doc Version 5.2 Page 29 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 YA5 Good Practice Recommendations The Registered Person should ensure that terms and conditions include information about fees, the period of notice and are presented in a clear and easy to understand format. The Registered Person should ensure that care plans are reviewed and updated every six months or more frequently if the person’s needs change. The Registered Person should ensure that people are supported to participate in the day- to- day running of the home where possible. The Registered Person should ensure that policies and procedures are reviewed and updated regularly. 2. 3. 4. YA6 YA8 YA40 Grosvenor Terrace, 100 DS0000060231.V341891.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup Kent DA14 5RH 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.V341891.R01.S.doc Version 5.2 Page 31 - 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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