Inspection on 18/01/07 for Grove Court

This inspection was carried out on 18th January 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Grove Court 06/09/07

Grove Court 05/10/05

Grove Court 19/04/05

Grove Court 17/11/04

Grove Court 16/06/04

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

CARE HOME ADULTS 18-65 Grove Court 100 Lancaster Road Newcastle Staffordshire ST5 1DS Lead Inspector Mandy Brassington Key Unannounced Inspection 18 January 2007 10:00 Grove Court DS0000004950.V317332.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 Grove Court DS0000004950.V317332.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. Grove Court DS0000004950.V317332.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grove Court Address 100 Lancaster Road Newcastle Staffordshire ST5 1DS 01782 628983 01782 714982 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.rethink.org Rethink Mr Karl Michael Bullock Care Home 14 Category(ies) of Learning disability (1), Mental disorder, registration, with number excluding learning disability or dementia (14), of places Mental Disorder, excluding learning disability or dementia - over 65 years of age (14) Grove Court DS0000004950.V317332.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 14 MD - 25 years on admission. Date of last inspection 5 October 2005 Brief Description of the Service: Grove Court is a large Victorian building located in a residential area close to Newcastle town and with good access to public transport. It was opened in 1991 and is run by the Rethink Organisation. The accommodation is on three floors, with a lift to access some bedrooms on the first floor. On the ground floor, there is a large lounge dinning room, a dining room, which is also used as the smoking room, kitchen two bedrooms and toilet facilities. The laundry is located in the basement. The first and second floors have bedrooms and toilet facilities, in total there are six single and four double bedrooms some have en-suite facilities. One bedroom is in the annex within the garden of the home; it has good facilities including en-suite shower and for one service user who is more independent. The home accommodates up to 14 people with enduring mental health issues. This is provided in a supportive environment with support from specialist primary care and hospital health professionals. The aim is to maximise independence, promote an increased quality of life and provide individuals with an opportunity to develop living skills and have a positive community presence. The Pre-inspection questionnaire completed by Kylie Goodwin, Acting Area Service Manager reported that the weekly fee level for the home is £326 per week. Grove Court DS0000004950.V317332.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was an unannounced key inspection and therefore covered all of the core standards. The inspection took place over 6.5 hours by one inspector who used the National Minimum Standards for Younger Adults as the basis for the inspection and an Expert by experience visited the home for 3 hours, discussing the service with individuals. CSCI are trying to improve the way we engage with people who use services so we gain a real understanding of their views and experiences of social care services. We are currently testing a method of working where ‘experts by experience’ are an important part of the inspection team and help inspectors get a picture of what it is like to live in or use a social care service. The term ‘experts by experience’ used in this report describes people whose knowledge about social care services comes directly from using them. A tour of the home was undertaken. On the day of the inspection, the home was accommodating thirteen people. Prior to the inspection visit, survey information has been obtained from service users and their relatives. Five comment cards were received back from relatives. The inspection included an discussions with five service duty. Case tracking of three events took place. Three recruitment and training. examination of records, indirect observation, users, the nurse in charge, and three staff on care plans was undertaken. Observation of daily staff records were examined in relation to The inspector observed two members of staff administer medication, and inspected the storage system and medication procedures. The Expert by Experience and the inspector ate lunch with the service users in the two dining areas. Six requirements were made as a result of this visit. Grove Court DS0000004950.V317332.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The registered person needs to ensure the Commission is informed of the current management arrangements and to include timescales; the registered manager remains responsible for ensuring the home meets the National Minimum Standards. A formal application to begin the Fit person process is required to ensure the home has a registered manager employed in the home. Grove Court DS0000004950.V317332.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. Grove Court DS0000004950.V317332.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 Grove Court DS0000004950.V317332.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): 2, 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions are not made to the home until a full needs assessment has been undertaken and prospective individuals are given the opportunity to spend time in the home. EVIDENCE: There have been no new admissions to the home since the last inspection and inspection of care records demonstrated individuals had received an initial assessment and documentation was in line standard practice at the time of the admission. On the day of the inspection one service user was visiting for lunch. The individual stated that this was the second visit and an over night visit had been planned. Staff reported that individuals could be introduced to the home at a pace to suit that person. Three plans of care were inspected and each person had an up to date contract that detailed Terms and Conditions of occupancy. Grove Court DS0000004950.V317332.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, 8, 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a strong belief that it is essential to involve individuals in the planning of care. Each service user has a plan that has been agreed and is reviewed regularly involving the individual. EVIDENCE: A sample of three care records showed that care plans had been formulated based upon the known needs of the service users. The plans included information to personal care and support needs. Where an area of need had been identified, the required support was recorded and if necessary an assessment of risk. Plans of care contained information relating to health care needs, a medical history and details of appointments and any outcome. The Acting Manager Grove Court DS0000004950.V317332.R01.S.doc Version 5.2 Page 11 reported that a number of individuals have access to a Community Psychiatric Nurse (CPN) and a Consultant Psychiatrist. Care plans are reviewed monthly. The Key worker and the service user are involved in the review process and service users are able to record their own comments in the plan; this is an area of good practice. Residents meetings take place on a regular basis. Service users reported that all individuals have an opportunity to discuss their ideas or concerns. Staff reported that individuals were consulted regarding a change to the meeting format and for service users to chair and take full ownership of the meeting, and this was confirmed by service users to the expert by Experience; at present individuals requested that a member of staff conducts the meeting. The manager reported that this would be kept under review. Grove Court DS0000004950.V317332.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, 14, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals have the opportunity to develop and maintain important personal and family relationships. Staff promote individual’s rights, and support service users to make informed choices. EVIDENCE: From observation of practices and discussion with staff and service users it was evident that service users are encouraged to take the lead role in their care. A number of service users are independent in relation to personal care and accessing the community and leisure facilities and this is recorded in the plan of care. In the home individuals are able to have a flexible daily routine and are supported to maintain their rooms and personal finances. Snacks, simple Grove Court DS0000004950.V317332.R01.S.doc Version 5.2 Page 13 meals and drinks can be made independently throughout the day and night in the main kitchen. Whilst the main meal is being prepared at lunch-time the kitchen is only used by staff to ensure the safety of service users. Service users stated this had been discussed and agreed with them. Discussion with staff and service users revealed an awareness of local services and facilities, and individuals used local shops and leisure venues. Service users were able to choose their own activities. Discussion with four individuals revealed recent activities have included visits to local pubs, out for meals and attendance at a local Centre. A Local Day Service provision organises social activities, bingo and has a range of therapists and health care professionals available on a flexible basis for service users. The staff reported that the home has developed good relationships with the local Nursery and Scout group. At Christmas, the children performed a Nativity concert in the home. Service users spoke positively regarding seeing the children perform. One individual reported he had attended local courses and was considering his future options regarding education and learning to provide him with the skills for employment. One service users spoke enthusiastically regarding an outing to a Football Stadium which had been organised for a birthday. Service users stated they are able to receive visitors on a flexible basis. There are no restrictions on visiting. Many individuals visit the family home and spend time with family members. Personal relationships are supported within the home. On the day of the inspection, the main meal was served at lunch time and consisted of fish, potatoes, vegetables and parsley sauce, with apple crumble and custard for dessert. The expert by experience and the inspector ate lunch with the service users in the two dining areas. Service users spoke positively regarding the quality and choice of meals. Individuals reported that they are responsible for making their own breakfast and tea and participate in a rota for washing the dishes and clearing away after the meal. Grove Court DS0000004950.V317332.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, 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Specialist health and nursing requirements are clearly recorded in each individual’s plan to give a comprehensive overview of service users health needs. EVIDENCE: The plans of care recorded individual’s health needs, details of appointments and any outcomes. All service users are registered with a local General Practitioner. The service users have enduring mental health issues and the plans recorded any specific diagnosis and details to assist individual’s well-being. Individuals are able to access support from a named Consultant Psychiatrist, and Community Psychiatric nurse (CPN). The mental health needs of all residents are high. The complex and varied support needs are well documented in care planning information. Staff have had training in the specialist area of mental health needs. Grove Court DS0000004950.V317332.R01.S.doc Version 5.2 Page 15 Many individuals are independent in relation to personal care but require prompts to ensure care and daily tasks are carried out. Staff used appropriate forms of communication and through discussion demonstrated a positive attitude, and a good knowledge of plans of care and individual’s needs. Medication is stored in a locked trolley in the Hallway and the Monitored Dosage system (MDS) is used. Two staff were administering medication safely and competently, and staff confirmed training for safe administration of medication had been completed. Inspection of Medication Administration Records (MAR) sheets revealed that any amendments had been altered and signed by a Doctor. One bottle had ‘As directed’. The home was informed that medication is to include all prescribing information and any medication without sufficient information is to be returned to the pharmacy and re-dispensed. Grove Court DS0000004950.V317332.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, 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an open culture, which enables service users to express their views. Individuals are very satisfied with the service provision, feel very safe and well supported by an organisation. EVIDENCE: Service users were aware of how to make a complaint and had a copy of the procedure. Three service users reported that if they had any concerns the manager would address these promptly. There have been two complaints since the last inspection and a record of the investigation and outcomes was maintained in the home. Service users reported that they keep a small amount of personal money and other monies and valuables are kept securely in the home. Individuals have a personal bank account. Staff have access to the Vulnerable Adults Procedure and Whistle Blowing Procedure. Discussion with staff revealed they would be confident with the procedure for managing any disclosure. Measures are in place to protect service users from abuse including good recruitment procedures in relation to appropriate pre-employment checks. Grove Court DS0000004950.V317332.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 28, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals are encouraged to personalise their bedrooms and the shared areas provide a choice of communal space with opportunities to meet relatives and friends in privacy or in their own rooms. EVIDENCE: The home provides accommodation on three floors and the standard of furnishings and décor is generally good, with many original features of the home maintained. There is a large lounge with dining facilities, which looks out onto the large garden via French Doors. This room has retained many Victorian features and the room is comfortable and homely. There is also a dining area, which is used as a smoking room. A large number of service users smoke and this area leads onto the kitchen. Grove Court DS0000004950.V317332.R01.S.doc Version 5.2 Page 18 The home has not been subject to an Environmental Health Inspection and it is required that the home contacts the Local Environmental Health Department and requests an inspection, especially in relation to the ventilation of smoke and impact on the kitchen. Bedrooms are shared rooms and single, some with en-suite facilities and these are located on all three floors. There is a lift to access some rooms on the first floor. All Bedrooms are fitted with an Allen style Chubb Key. This was discussed with the Acting Manager as all rooms could be opened by the same Key and therefore does not provide any privacy or security. The Acting Manager stated that individuals have reported that they do not want a key to their room. It was agreed that this be kept under review and where individuals request a key, in consultation with the Fire officer a suitable lock is fitted. One en-suite bedroom is contained within the annexe in the garden, which also accommodates the staff office. There is a range of toilets and bathing facilities on all three floors. The Acting manager reported that the bathrooms are to be modernised, including the fitting of new flooring. The previous inspection reported that the home had drawn up plans to build an extension to provide four additional en-suite rooms; so double rooms would become single rooms. This work has not been carried out. The laundry equipment is housed in the basement. There was professional equipment that staff reported met the needs of the service users. The home has installed a new Central heating system. There remains exposed hot water pipes. These are to be covered. The home was clean and tidy and maintained to a good standard and there was suitable hand washing equipment around the home to meet infection control standards. On the day of the inspection, for safety reasons, part of the home was unable to be used in the afternoon. A tree in the grounds next door was unsafe due to extreme weather conditions. The staff are to be commended on making necessary arrangements to ensure service users were not anxious and were safe. Grove Court DS0000004950.V317332.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team that have the knowledge and experience to meet the needs of service users and demonstrate a thorough understanding of the particular needs of the service users. EVIDENCE: On the day of the inspection, there were two senior Community Health Workers (CHW) on duty in the morning, 7.00am – 3.00pm and 8.00am 4.00pm, and on senior member of staff and one Community Health Worker in the afternoon from 1.00pm – 9.00pm and 2.00pm – 10.00pm. This roster provides up to four members of staff in the afternoon to provide additional support for individuals. At night two waking night staff work from 9.00pm – 7.00am and 10.00pm – 8.00am. The manager works across the shifts, though on the day of the inspection had planned to work an afternoon shift. The manager came to the home early to support the inspection process. Grove Court DS0000004950.V317332.R01.S.doc Version 5.2 Page 20 The home has a well-established team of staff; on the morning of the inspection, the two members of staff had both worked at the home for over 11 years. There has been a change within the staffing provided, and the home no longer employs a cook. The main meal is prepared at night and staff cook and serve the meal. This has an impact on the staffing provided in the home, leaving one care staff to support all individuals. Discussion with staff and service users revealed that this has been suitably managed and staff are available if needed. The Commission was not consulted or informed of the reduction in staffing as required. A review of the current staffing is required and the home must demonstrate how it is able to continue to meet the needs of the service users. Staff have a range of knowledge regarding supporting individuals with mental health issues. All staff have either obtained or are enrolled to complete a National Vocational Qualification (NVQ). Inspection of three Staff records demonstrated that training in moving and handling, Food hygiene, Medication and Mental health Awareness had been completed. Inspection of three care staff files demonstrated that suitable pre-employment checks have been carried out to ensure the health and welfare of service users. The Acting Managers file was not kept in the home. It is required that this be available in the home for inspection. Discussion with individuals revealed staff are able to provide flexible support and are available to talk to at any time. Comments from service users regarding the support from staff included: ‘You’re always able to talk to the staff, they’re very good.’ ‘If anything is bothering you, even in the night you can talk to the staff.’ ‘The staff are lovely.’ Discussion with staff revealed the team are extremely committed to the home and how to support individuals. The staff team have undergone a significant management changes over recent months but all staff commented that this had supported them to work closer as a team and they were pleased with the progress the new team had made. A number of staff were now working in a more senior role. Supervision was completed monthly and a record maintained. Staff reported that they were able to identify training needs and areas for personal development. Key workers discuss plans of care in supervision. Staff spoke positively regarding the supervision process. There is a Staff and Care meeting monthly in the home and a record of minutes are maintained. Grove Court DS0000004950.V317332.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Acting Manager has ensured that the staff and service users in the home have continued to be supported during the changes within the management structure. Details of the future management need to be confirmed with the Commission. EVIDENCE: The manager of the home is currently working in another establishment owned by Rethink and an Acting Manager currently manages the home. The Registered Provider must notify the Commission of the future management of the home including a date for the return of the manager, or submit an application for a new registered manager. Grove Court DS0000004950.V317332.R01.S.doc Version 5.2 Page 22 The Acting Manager has developed new systems in the home to ensure all records required by regulation are in place. The Acting manager demonstrated a good approach to the over-all management of the home, including demonstrating a good knowledge of individuals needs. Staff reported that the manager is, ‘very supportive and has specific ideas on good practice’, and ‘she always makes sure the care is good and makes staff feel valued.’ The Acting Manager reported that she has completed NVQ III, which is to be externally verified during this month. The Acting Manager stated she is to enrol for Level 4. Fire records were examined and suitable checks have been completed. The home has completed a Fire Risk assessment and this includes an emergency contingency plan. The home has conducted suitable testing of equipment and the property to ensure the health and safety of service users including; Portable Appliance Testing in October 2006. Gas Safety Inspection in February 2006. The Lift has a suitable contract and serviced throughout the year. Legionella test was conducted in November 2006. The home has assessed the buildings and there is an Asbestos Plan in place. Grove Court DS0000004950.V317332.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 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 X 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 2 34 2 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 3 3 X X 3 X Grove Court DS0000004950.V317332.R01.S.doc Version 5.2 Page 24 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 YA20 Regulation 13 (2) Requirement All medication labels need to give clear details for administration. ‘As directed’ bottles are to be returned to the pharmacy To contact Environmental Health Department for an Inspection of the property in relation to the Kitchen and ventilation. A copy of this correspondence is to be forwarded to the Commission All Hot water pipes are to be covered A review of staffing is to be completed and to include details of the new staffing hours provided and how the home is able to meet the needs of the individuals The Acting Manager’s file is to be available in the home for inspection The Registered Provider must ensure that the home has a Registered Manager in the home. A report detail the arrangements or an application for a new manager is to be submitted. Timescale for action 25/01/07 2 YA24 23 (5) 28/02/07 3 4 YA24 YA33 13 (4)(a)(c) 24 (1)(2) 18 (1) 18/04/07 28/02/07 5 6 YA34 YA37 19 (1)(b)(i) 8 (1)(2) 28/02/07 18/02/07 Grove Court DS0000004950.V317332.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Grove Court DS0000004950.V317332.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Grove Court DS0000004950.V317332.R01.S.doc Version 5.2 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!