Inspection on 18/05/06 for Grosvenor Terrace, 52-60

This inspection was carried out on 18th 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, 52-60 16/02/09

Grosvenor Terrace, 52-60 05/02/08

Grosvenor Terrace, 52-60 18/12/06

Grosvenor Terrace, 52-60 18/10/05

Grosvenor Terrace, 52-60 02/06/05

Grosvenor Terrace, 52-60 11/11/04

Grosvenor Terrace, 52-60 23/08/04

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, 52/60 52/60 Grosvenor Terrace Camberwell London SE5 0NP Lead Inspector -Lisa Wilde Unannounced Inspection 18th May 2006 10:00 Grosvenor Terrace, 52/60 DS0000060236.V295777.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, 52/60 DS0000060236.V295777.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, 52/60 DS0000060236.V295777.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grosvenor Terrace, 52/60 Address 52/60 Grosvenor Terrace Camberwell London SE5 0NP 020 7277 1619 020 7277 1619 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) www.odyssey-csft.org Odyssey Care Solutions for Today Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Grosvenor Terrace, 52/60 DS0000060236.V295777.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th October 2005 Brief Description of the Service: 52-60 Grosvenor Terrace is a home that has rooms for eight service users with learning disabilities. It is in a residential street just a short distance from the shopping area of Walworth Road. The home is made up of two large Victorian terraced houses that are connected with a garden and patio at the back. There is a disabled parking bay outside the home that is used for the home’s minibus. On the ground floor are 2 bedrooms that are wheelchair accessible. No 60 has a specially adapted kitchen for wheelchair users. The home is close to local shops, entertainment and public amenities. There is no lift in the home. There were no vacancies at the time of this inspection and all the current service users have been at the home for a number of years. The service user part of the fees for a place at this home are £62.35. There are contributions towards transport of £4.25 if on the lower rate of Disability Living allowance or £11.06 if on the higher rate of Disability Living Allowance. The home makes the report of the Commission’s inspections available in the staff office. Grosvenor Terrace, 52/60 DS0000060236.V295777.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day in mid May 2006 when the inspector spoke with staff and some of the service users. The new acting-manager of the service was not at the home. Most of the service users at this home cannot speak or communicate in different ways other than language so the inspector spent the two week following the inspection at the home trying to phone all the service users’ relatives to find out what they thought of the home. The inspector managed to speak to three of the seven sets of relatives before the draft report had to be written. One service user told the inspector they were happy and liked living at the home. They said they liked staff. Relatives were generally happy with the service and said they had no major problems. One said that their relative “always seems happy” another said staff “get on well with (their relative)”. They did have some concerns and these are discussed in the main part of this report. The registered manager and one of the deputies of this service have recently been moved to another service in the organisation, which has been difficult for staff. A senior member of staff is now acting up as manager. It appears from the record and from what staff said that it has been hard to keep things going in the same way with the lack of managers and the home must now make sure that things do not slip too far as the new manager settles in over the next few months. What the service does well: Areas that were loked at during this inspection shows that the home makes sure that: • • • • • • • • • staff work with service users to find out what they want and write down things that they will do and get better at over the next few months. service users are supported to make decisions as far as possible and most of them have family who are involved to help them make those decisions. someone is brought in from a local agency to offer more support for service users when they make decisions and tell staff what they want service users have individual weekly programmes that include doing things in and outside of the home. staff support service users to keep in touch with their families. service users are offered varied and healthy meals. service users are supported by staff in the way that they choose and their health need are met by going for regular appointment at the GP. medication is given to service users safely and recorded properly. complaints are taken seriously and investigated DS0000060236.V295777.R01.S.doc Version 5.2 Page 6 Grosvenor Terrace, 52/60 • • the home is clean and hygienic generally service users’ health and welfare are protected. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Grosvenor Terrace, 52/60 DS0000060236.V295777.R01.S.doc Version 5.2 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, 52/60 DS0000060236.V295777.R01.S.doc Version 5.2 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): 1, 2 & 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Service Users’ Guide is now in a language that could be understood by the service user group at this home and it does not include some of the areas required by the standard. This means that service users and their families are provided with all the information they need to make an informed choice about where to live or about what they can expect from the home once they are there. 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: There were previous requirements that the Registered Individuals must ensure that the Service User Guide must be drawn up in a format that can be understood by more people from the service user groups for which the home is registered i.e. learning disabilities and that the Registered Individuals must ensure that the Service User Guide must cover all areas required by Regulation 5 and Standard 1. This has been done. Grosvenor Terrace, 52/60 DS0000060236.V295777.R01.S.doc Version 5.2 Page 9 No new service users have moved to this home for many years so it is not possible or useful to try and assess what happens when someone wants to move to the home. There was a previous requirement that the Registered Manager must ensure that service user contracts must be signed by the service user or their representative e.g. family member of advocate and dated. Some relatives had signed the contracts but not all the contracts had been signed. The previous manager had stated that this was due to the current advocates for service users not wishing to sign contracts on their behalf. This issue links to the general issue about advocates discussed under Standard 7. (See Requirement 1) Grosvenor Terrace, 52/60 DS0000060236.V295777.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 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. Staff work with service users to find out what they want and write down things that they will do and get better at over the next few months. This means that service users lives do not just stay the same but they are trying new things and improving. This work has not been as good over the last few months because two managers of the service have left. Work that is identified in the annual review of the service users lives is not always done quickly enough which means that service users do not always get what they want or need when they need it. Service users are supported to make decisions as far as possible and most of them have family who are involved to help them make those decisions. Someone is brought in from a local agency to offer more support when making decisions and telling staff what they want but staff could do more to make sure that this type of help is from someone who has more experience of the type of thing that service users have been through. If this was done them staff could be more certain that they were finding out what the service users really want and feel. Grosvenor Terrace, 52/60 DS0000060236.V295777.R01.S.doc Version 5.2 Page 11 Staff work with service users to find out what may harm them and what help they may need but there are not always plans drawn up afterwards to get rid of this harm or make sure that the risk is as small as possible. This means that service users may be put at risk or they may not be supported to do things that would make them more independent. EVIDENCE: There was a previous requirement that the Registered Manager must ensure that the new care planning and goal setting systems in operation are incorporated into the care plan documents. Files showed that staff are now regularly finding out what service users want and setting goals with them. Staff said that they really like this way of working because it means that they feel that they are doing something with service users and they can see the difference it makes to their lives. The files showed that the recording of these issues has not been as good recently and it is possible that this is due to the home losing its manager and one of its deputy managers. Staff said that they have found it hard to keep recording their work recently. (See Requirement 2) The home has annual reviews of care plan with social services and the service users with their families and then six monthly reviews with staff at the home. The last reviews on some files showed that targets that had been set and action that had been identified had not been carried out in some cases although there had been enough time to carry out the work. (See Requirement 3) One file stated in some areas that cultural and religious requirements were not applicable to one service user. The inspector discussed this with their key worker. There are African and Caribbean service users at the home as well as a mix of religions and gender but staff have not thought as a team about the issues that this may raise for the service users. (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) Files showed that in some cases risk is identified for service users but there are no plans out in place to manage or minimise those risks. (See Requirement 6) Grosvenor Terrace, 52/60 DS0000060236.V295777.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 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. Service users have individual weekly programmes that include doing things in and outside of the home. Staff support service users to keep in touch with their families. Service users are offered varied and healthy meals. EVIDENCE: There was a previous requirement that the Registered Individual must ensure that the home’s transport is repaired or that effective alternatives are accessed in the interim. There have been ongoing problems with this and it has affected service user activity programmes. On the day of this inspection one service user was waiting to go to the day centre but they did not come to pick them up and the service had no transport to take them in so the service user had to stay at home. The service manager later told the inspector that the problems Grosvenor Terrace, 52/60 DS0000060236.V295777.R01.S.doc Version 5.2 Page 13 are now but fixed staff still need to be trained and insured to drive the vehicle. (See Requirement 7) Each service user has a weekly plan of activities that included things to do in and outside of the home. One service user talked about how he visits his dad and is planning to go on a day trip soon. One service user’s last review in December 2005 said the service should buy sensory equipment for them and this had not been done by this inspection. Staff said this was because the day centre’s sensory room had been out of action so the staff at the home had not been able to watch the service user in that room. However work had been done with this service user around painting and drawing which staff said had been interesting for them. The issue of meeting goals set in reviews is addressed under Standard 6. One member of staff talked in detail about the needs of the service user they key work and what they do and don’t like to do. Service users’ relatives told the inspector that staff bring people from the home to visit them regularly. The kitchen is currently locked at night even though there is a member of staff awake during the night to make sure that service users are all right. (See Requirement 8) There are weekly menus for the home, which show that service users are offered different sorts of meals. Some of the service users have seen the dietician and are on healthy diets. 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. The weekly shopping was being done during this inspection and different sorts of food were bought. 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 1) Grosvenor Terrace, 52/60 DS0000060236.V295777.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 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 good. This judgement has been made using available evidence including a visit to this service. Service users are supported by staff in the way that they choose and their health need are met by going for regular appointment at the GP. When service users needs special help, meetings are held with all people involved in their care to make sure that decisions are made in their best interests. Medication is given to service users safely and recorded properly. EVIDENCE: Files showed that there is work done with service users to make sure that their health care needs are met but some areas still need further work. The last set of reviews with social services state that Health Action Plans are needed for all service users. The notes of the meetings show that the organisation has said that they are being drawn up in line with recent government guidance. This issue will be further assessed at the next inspection. One service users’ last review in December 2005 had stated that they should be weighed fortnightly and their target weight established with the dietician and this had not been fully completed although a lot of work had been done Grosvenor Terrace, 52/60 DS0000060236.V295777.R01.S.doc Version 5.2 Page 15 with them around necessary dental work and a teeth cleaning training programme. The organisation has been doing a lot of work around communicating with service users and making sure that staff work with them as individuals not treating them all the same. Staff said that this has made things better for service users in lots of ways. The inspector examined the medication stocks and the records and found no problems with the systems that staff are following to make sure that medication is given to service users safely. Service users at this home would not be able to take their own medication without staff support. There was a previous requirement that the Registered Manager must ensure that photos of service users are held in the medication files. This has now been done. Grosvenor Terrace, 52/60 DS0000060236.V295777.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 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. Complaints are taken seriously and investigated but staff need to get better at recording when investigations are finished and whether the person who complained is happy with the decision. It is not clear from the records whether staff have been fully trained to protect service users from abuse. The home is not doing enough to investigate and inform people about unexplained bruises, which is very important for these service users who cannot speak and tell staff if they are being hurt. EVIDENCE: There was a previous requirement that the Registered Individuals must ensure that the Complaints Procedure must be updated to include current contact details of the Commission and a brief explanation of what the Commission do so that people understand why they may need to complain directly to them. This had been done. The complaints book showed that action is taken in response to complaints but dates are not recorded in the book to show that complaints are being investigated quickly enough. (See Requirement 9) Training records weren’t complete at this inspection so it was not possible to assess when all staff last had training around vulnerable adults. Two staff on duty said they had had it in February and last year. (See Requirement 10) Grosvenor Terrace, 52/60 DS0000060236.V295777.R01.S.doc Version 5.2 Page 17 One relative said that they had to call staff at the home recently when they noticed bruises on one of the service users, which they hadn’t been told about. They said they didn’t get much information about this. The home does not have an unexplained bruising policy that includes telling service users’ family as soon as possible. (See Requirement 11) Grosvenor Terrace, 52/60 DS0000060236.V295777.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The building is in need of some decoration as it is beginning to look a little tatty in the corridors, kitchens and lounges. The bathrooms are bare and institutional. The home is clean and hygienic although there is a washing machine and dryer in one of the kitchen that should be moved to the laundry room to make sure that soiled laundry is not cleaned in areas where food is prepared and eaten. EVIDENCE: There was a previous requirement that the Registered Individuals must ensure that work must be done on all the bathrooms and toilets, particularly the upstairs bathroom in No 60, to ensure they are homely rather than institutional with regard to decoration and fittings. Some minor work had been done and some cabinets had been bought but the bathrooms, particularly one on the first floor are still very bare and institutional. The hallways, particularly upstairs are the same. (See Requirement 12) Grosvenor Terrace, 52/60 DS0000060236.V295777.R01.S.doc Version 5.2 Page 19 The general decoration of the home is starting to need some work and certain areas of the home are starting to look a little tatty such as areas where wheelchairs hit the wall and doors and the corridors. There was a previous requirement that the Registered Provider must supply a copy of any further planned maintenance and renewal for the fabric and decoration of the premises to the C.S.C.I. which has not been done and is repeated. This had not been done and the lack of a plan to regularly decorate all areas of the home is part of the reason why the home is starting to need work. (See Requirements 13 & 14) The pictures and decoration throughout the home do not reflect the different ethnicities and cultures of the service users in the home. This means that the home is not doing enough to make sure that all service users feel equally welcome in the home. (See Recommendation 2) 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. This had not been done and staff reported that it still takes some time to get maintenance work done. One service user’s bathroom had tiles that were coming away from the wall and there had been no agreement yet as to who would fix it. Staff said that they were willing to do this work. (See Requirement 15) There was a previous requirement that the Registered Individual must ensure that the first floor bathroom is made operational. This had been done. On the day of the inspection all areas of the home were clean and hygienic. There is a washing machine and dryer in one of the kitchens which should be moved to the laundry room (This is also the kitchen that is used by the people in wheelchairs and these machines restrict the access to the dining table). (See Requirement 16) Grosvenor Terrace, 52/60 DS0000060236.V295777.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Most staff hold or have nearly finished the NVQ in Care which means they should understand what they need to do at the home. There isn’t a training plan in place for the home, which means that service users may not be being supported by staff who know exactly what to do to meet their needs. Staff have not all had annual appraisals, which means that they have not had their work performance assessed regularly enough and service users may not be fully supported by staff who are as good as they could be. EVIDENCE: There was a previous requirement that the Registered Individuals must ensure that the current staff vacancies are recruited to as a priority. Due to one of the deputy managers acting up there is a now a deputy manager vacancy. One relative said that staff seem to change a lot. Staff were not clear about other vacancies and so again this requirement is carried over. (See Requirement 17) There was a previous requirement that the Registered Individuals must ensure that the home meets the required target if 50 of care being provided by staff Grosvenor Terrace, 52/60 DS0000060236.V295777.R01.S.doc Version 5.2 Page 21 holding the NVQ Level 2 in Care or equivalent. All staff either hold or are due to start the NVQ soon and the home is meeting the 50 target. 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 18) As mentioned earlier, training records were not complete and there is no training and development plan in place at this home that shows what is expected from each role and what training is necessary for the forthcoming year to make sure that all staff can meet the needs of service users. (See Requirement 19) Minutes from the April staff team showed that appraisals were due for all staff but they reported that they have not all had these appraisals. Again this is possibly due to the fact that there is new management in place at the home. (See Requirement 20) Grosvenor Terrace, 52/60 DS0000060236.V295777.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 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 number of repeated requirements in this report and the fact that the registered manager and one of the deputies have been moved to another service means that this home is starting to look as if it is not as well run as it could be. It is too soon to say whether the new manager can run the home well but he must put in an application to the Commission as a priority so that the Commission can assess his application. 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. Grosvenor Terrace, 52/60 DS0000060236.V295777.R01.S.doc Version 5.2 Page 23 The home is not fully protecting service users from harm by making sure that the fire and electrical systems are regularly checked. Apart from this the service users’ health and welfare are protected. EVIDENCE: The previous registered manager and one of the deputies have moved to another home in the organisation. One of the previous deputy managers is now acting-up as the manager. (See Requirement 21) There was a previous requirement that the Registered Individuals must ensure that the home must develop an annual development plan that reflects aims and outcomes for service users. Views of family, friends, advocates and other stakeholders (e.g. GPs, local community) must be sought annually to feed into this development plan. There was a previous recommendation that the Responsible Individuals should consider investigating and employing a professionally recognised quality assurance tool within the home. The home does do quarterly surveys of people involved in service users’ lives but doesn’t draw up an annual plan based on these audits and their checks of the service. 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 Requirement 22) Relatives said they were not told about the Commission’s inspections and had not seen any of these reports. (See Requirement 23) There was a previous requirement that the Registered Individuals must ensure that refresher training must be offered to staff in the areas of Food Hygiene and Fire Safety. This has not occurred. (See Requirement 24) Records showed that some weekly fire test have been missed on the past few months. (See Requirement 25) Grosvenor Terrace, 52/60 DS0000060236.V295777.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 X 2 3 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 2 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 2 36 X 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 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 2 X Grosvenor Terrace, 52/60 DS0000060236.V295777.R01.S.doc Version 5.2 Page 25 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 (3) Requirement The Registered Manager must ensure that service user contracts must be signed by the service user or their representative e.g. family member or advocate and dated. Previous requirement: Unmet timescales 30/09/05 & 31/01/06 The Registered Manager must ensure that the care planning and goal setting systems are regularly recorded and monitored. The Registered Manager must ensure that all action identified in the service user reviews is carried out in a timely manner. The Registered Manager must ensure that all service users needs, including needs around culture, ethnicity, religion and gender are considered and addressed in the care plan. The Registered Manager must ensure that staff research agencies and individuals who can advocate or offer peer support for service users and who share some of the same culture, heritage and disabilities. DS0000060236.V295777.R01.S.doc Timescale for action 31/08/06 2. YA6 15 31/08/06 3. YA6 15 31/08/06 4. YA6 15 31/08/06 5. YA7 12 (b) 30/09/06 Grosvenor Terrace, 52/60 Version 5.2 Page 26 6. YA9 13 (4) (a) & (c) 7. YA13 16 (2) (m) & (n) 8. 9. YA16 YA22 16 (1) 22 10. YA23 13 (6) & 18 (1) (c) (i) 13 (6) 11. YA23 12. YA27 23 (2) (b) & (d) 13. YA24 23 (2) (b) The Registered Manager must ensure that plans to manage and minimise risk are drawn up whenever a risk is identified in an assessment. The Registered Individual must ensure that the home’s transport is repaired or that effective alternatives are accessed in the interim. Previous requirement: Unmet timescale 30/11/05 The Registered Manager must ensure that the kitchen is not locked at night. The Registered Manager must ensure that the timescales for all investigations of complaints are recorded in the complaints book. The Registered Manager must ensure that records are complete and show that all staff have had recent training around protection of vulnerable adults. The Registered Manager must ensure that there is an unexplained bruising procedure that includes calling the GP to investigate unexplained bruises and informing relatives as soon as possible and other agencies when necessary. The Registered Individuals must ensure that work must be done on all the bathrooms and toilets, particularly the upstairs bathroom in No 60, to ensure they are homely rather than institutional with regard to decoration and fittings. Previous requirement: Unmet timescales 30/09/05 & 31/12/05 The Registered Provider must supply a copy of any further planned maintenance and renewal for the fabric and decoration of the premises to the C.S.C.I. Previous requirement: Unmet timescales 31/08/04, DS0000060236.V295777.R01.S.doc 31/08/06 31/07/06 14/06/06 30/06/06 31/08/06 30/06/06 31/08/06 31/08/06 Grosvenor Terrace, 52/60 Version 5.2 Page 27 31/08/05 & 31/01/06 14. YA24 23 (2) (b) The Registered Individuals must ensure that the corridors and lounges are reasonably decorated i.e. paint and wallpaper that is dirty, has been scuffed or taken off is made good. 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. Previous requirement: Unmet timescale 31/08/05 & 31/01/06 The Registered Individuals must ensure that the washing machine and dryer are moved out of the kitchen. The Registered Individuals must ensure that the current staff vacancies are recruited to as a priority. Previous requirement: Unmet timescale 28/02/06 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 Individuals must ensure that the staff training records are complete and that there is a training and development plan in the home that assesses what training is necessary for each role to meet the needs of service users and identifies the required training for the year ahead. The Registered Manager must ensure that all staff receive at least annual appraisals of their work that include identifying any training and development they need to meet the needs of service users and the aims and DS0000060236.V295777.R01.S.doc 31/08/06 15. YA24 23 (2) (b) & (d) 31/08/06 16. YA30 16 (2) (j) 30/09/06 17. YA32 18 (1) (a) 30/09/06 18. YA34 19 (1) (b) 31/08/06 19. YA35 18 (1) (c) (i) 31/08/06 20. YA36 18 (1) (c) (i) & (2) 31/08/06 Grosvenor Terrace, 52/60 Version 5.2 Page 28 objectives of the home. 21. YA39 24 The Registered Individual must ensure that there is a manager in post who submits and application to be registered to the Commission and who holds or begins the NVQ Level 4 Registered Manager Award (followed by the NVQ Level 4 in Care) The Registered Individuals must ensure that the home must develop an annual development plan that reflects aims and outcomes for service users. Views of family, friends, advocates and other stakeholders (e.g. G.Ps, local community) must be sought annually to feed into this development plan. Previous requirement: Unmet timescales 31/10/05 31/03/06 The Registered Manager must ensure that relatives are told about the Commission’s inspections and copies of the reports are made available to them. The Registered Individuals must ensure that refresher training must be offered to staff in the areas of Food Hygiene and Fire Safety. Previous requirement: Unmet timescales 31/10/05 & 31/01/06 The Registered Manager must ensure that weekly tests of the fire system are conducted as required. 31/07/06 22. YA37 12 (2) & 24 31/08/06 23. YA39 24 30/06/06 24. YA42 18 (1) (c) (i) 31/08/06 25. YA42 23 (4) (c) 14/06/06 Grosvenor Terrace, 52/60 DS0000060236.V295777.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. 2. Refer to Standard YA17 YA24 Good Practice Recommendations 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 make sure that the pictures and decoration throughout the home reflects the different cultures and ethnicities of the service users in the home. The Responsible Individuals should consider investigating and employing a professionally recognised quality assurance tool within the home. Previous recommendation. 3. YA39 Grosvenor Terrace, 52/60 DS0000060236.V295777.R01.S.doc Version 5.2 Page 30 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. Extracts may not be used or reproduced without the express permission of CSCI Grosvenor Terrace, 52/60 DS0000060236.V295777.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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