Inspection on 20/06/06 for Grove House

This inspection was carried out on 20th June 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 but made no statutory requirements on the home.

Other inspections for this house

Grove House 08/09/08

Grove House 20/08/07

Grove House 06/12/05

Grove House 11/08/05

Grove House 21/10/04

Grove House 27/04/04

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

CARE HOMES FOR OLDER PEOPLE Grove House 7 South Hill Grove Harrow Middlesex HA1 3PR Lead Inspector Clive Heidrich Key Unannounced Inspection 20th June 2006 10:00 X10015.doc Version 1.40 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 House DS0000017573.V300505.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 Older People. 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 House DS0000017573.V300505.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grove House Address 7 South Hill Grove Harrow Middlesex HA1 3PR 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 8864 5216 020 8864 5216 Mrs Dympna Kritikos Mr N Kritikos Mrs Dympna Kritikos Care Home 5 Category(ies) of Old age, not falling within any other category registration, with number (5) of places Grove House DS0000017573.V300505.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons who can manage the stairs without physical assistance may reside on the first floor. You may only accommodate service users in the bedrooms located on the second storey When they have been subject to an assessment by a competent person representing the service user and nominated by the placing agency. In the case of a service user who is self funding, the assessment must be undertaken by a competent person who is independent of the home - Occupational Therapist, CPN or Care Manager. This assessment must clearly state that the service user is able to ascend and descend the stairs to the ground floor without the assistance of staff. A copy of this assessment must be retained in the home and be available for inspection. Any such assessments held at the home, must be subject to regular external review in accordance with the changing needs, abilities or condition of the service user. 6th December 2005 Date of last inspection Brief Description of the Service: Grove House is a care home that provides personal care and accommodation for up to 5 older people. The service can meet Greek-language needs. Mr and Mrs Kritikos own the home. The registered manager is Mrs Kritikos. Grove House is a family owned and run care home. Mr and Mrs Kritikos live on the premises with their family. The home is located in Sudbury, Harrow, on a quiet residential road. It is within a few minutes walk from local shops and other amenities. There are local public transport facilities in the vicinity, which include a public bus and train service. Sudbury Town underground train station is within a few minutes walk from the care home. The home was opened in 1995, and consists of a semi-detached house, with parking for approximately four cars at the front drive area of the house. There are two single bedrooms for service user accommodation on the first floor, and one on the ground floor. There is also a shared bedroom on the ground floor. The home has an enclosed, well-maintained garden with a seating area, that is accessible to service users. The current scale of fees is £450 to £465. A service user guide is available on request. Grove House DS0000017573.V300505.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home successfully applied for a variation of their registration since the last inspection, allowing for a fifth service user to live in the home. This variation took place on 27/4/06. This inspection took place across a warm day in June. The site visit lasted six hours in total. The purpose of the inspection was to assess all of the key standards, and to check on compliance with the small amount of requirements from the last inspection. The inspector met with most of the five service users during the visit, to discuss about how the home operates and meets their needs. The inspector also discussed aspects of the service with the staff who were working during the visit, and with the owners (including the manager) who were present across the visit. Additionally, care practices were observed, records were read, and aspects of the environment were checked on. A few months prior to the inspection, the manager was requested to send out comment cards to involved people, and to complete an inspection questionnaire. Consequently information from four service users’, one friend/relative/visitor’s, and one health & social care professional’s comment cards, along with the completed inspection questionnaire, has been included in this report. Feedback was almost entirely positive. What the service does well: The care home generally meets the needs of people wishing to live in a family atmosphere and environment. Staff and management provide individual and needs-led care. All feedback from service users, relatives, and health professionals, was generally positive. Service users made such comments as “I have always felt like one of the family. I am very happy living here.” Service users are supported to acquire appropriate healthcare professional input. Service users are given some support to access the community, for such things as local walks and day trips out. A professional standard of home cooking is provided, tailored to meet dietary requirements. Grove House DS0000017573.V300505.R01.S.doc Version 5.2 Page 6 There are generally good and efficient standards of record-keeping about service users’ lives and well-being. Good standards of training are generally provided to staff. 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. Grove House DS0000017573.V300505.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Grove House DS0000017573.V300505.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (standard 6 is not applicable) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. An assessment procedure is followed in practice, showing that prospective service users’ needs are considered before offering admission. Records of the process need improvement, to help show that appropriate consideration is made by management of how the home will meet the service user’s needs. EVIDENCE: The manager provided good verbal evidence of following appropriate assessment procedures in respect of admitting new service users. She explained that for the most-recently admitted person, she had assessed their needs through two visits to a day centre placement. The person had then visited the home with family for a few hours, before agreement was made for them to move in on a trial basis. There were a few records in support of initial assessments, including a brief needs assessment dating from a few days after the start of the placement. Improvement is needed with the recording the key findings of the manager’s Grove House DS0000017573.V300505.R01.S.doc Version 5.2 Page 9 pre-admission assessments, to openly evidence what the service user’s needs are and whether the home can meet them. One part of the new registration agreement for a fifth service user, was that a new placement was not to happen unless an independent occupation therapy assessment for that service user, to use the stairs, had taken place, as the bedroom for this person is upstairs. The assessment was not in place at the time of the visit. The manager said that she would address this when the therapist visits another service user shortly. She must ensure that a copy of the assessment is forwarded to the CSCI promptly, in support of the admission of the fifth service user. Grove House DS0000017573.V300505.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users benefit from good support to access appropriate healthcare professionals. They are generally treated respectfully in terms of staff and management support. Care planning is generally up-to-date and needs-led. Improvements were mainly needed with the safe storage and recording of medication, as a number of shortfalls were found both during this visit and at a follow-up visit from the pharmacy inspector. The shortfalls had the potential to put service users at risk of receiving incorrect medications. A further visit has shown that the majority of issues have been consequently addressed. EVIDENCE: Service users were seen to be appropriately dressed from the start of the inspection, in clean, well-maintained and well-fitting clothing. Service users reported no concerns with clothing. Hair and nail care was seen to be suitably upheld, with some service users receiving hairdresser visits frequently according to records. Grove House DS0000017573.V300505.R01.S.doc Version 5.2 Page 11 Service users spoke positively about the support provided to them in the home by the manager, her family, and the care staff. Observations confirmed this, through such things as people knocking on doors and personal care being carried out behind closed doors. The check of one service user’s file found a suitable care plan to be in place relative to the person’s presenting needs. It contained guidance about their needs and how staff would address these, including in respect of typical daily routines and in key areas of risk. Manual handling guidance was consequently recorded in good detail, for instance, and there was guidance about individual risks such as for ensuring the swallowing of medication. Most of these documents were signed by the service user and the manager, and were suitably up-to-date. The check of the newest service user’s file found no care plan or risk assessments in place. The manager explained that this would shortly be set-up with the help of the service user and their family. As the service user had been in the home for over three weeks, a simple care plan and baseline risk assessments should have been in place. These could then have been reviewed and adjusted as the ongoing needs of the service user became more apparent. The manager must ensure that this is addressed. It was however positively noted that staff and the manager spoke clearly about what the service user’s needs are. The manager keeps a daily record about each service user’s day, in terms of such things as activities, meals, and health, along with making general comments about how the home operated that day. This was seen as a useful tool to map and review service users’ daily lifestyles in the home. Feedback and records showed that many service users had recently received dentist and optician support. The manager spoke positively of how this had made a difference to some service users, such as with enabling them to read again. Service users stated that they can access their GP when they want to, and spoke positively about how often they receive chiropody visits. The manager also explained about how individual service users are supported to receive specialist health professional advice relative to their conditions. Consequently, for instance, a diabetic menu is in place in the home in conjunction with the standard menu. Weight records were in place and showed regular checks, including for the newest service user. Feedback from one GP was received, and was positive about how the home works in conjunction with them. No service users self-medicate. Medication is provided through an established pharmacist in weekly dosette boxes. Medication is stored in a designated cupboard that was not locked when checked on during the visit. Further supplies of medication for the month were found to be stored elsewhere without being secure. Storage needs to be secure, to ensure that medication is not used by anyone inappropriately. Service user and the manager’s family Grove House DS0000017573.V300505.R01.S.doc Version 5.2 Page 12 medication should additionally be stored on different shelves, to help prevent any mistakes. Checks of medication administration sheets found that they are kept up-todate. Sheets were signed in the morning on administration, but not again at any other time that day if there are for instance evening medications. Dosette packs were found not to be dispensed according to the daily compartments. The manager explained that this was agreed with the pharmacist to prevent waste of medication. The recording and dispensing arrangements however put service users at risk of receiving their medication incorrectly, as there would be no way of checking administration in the evening except by memory. This was discussed with the manager, who agreed to change methods of recording to make sure that medications are signed for at each administration. The manager noted that those people who dispense medication have had training in this respect. Refresher training was being lined-up. Due to these concerns about the safe handling and recording of medications, the local pharmacy inspector was requested to undertake an unannounced visit of the home. Two visits consequently followed, with the second visit showing that most issues identified from the first visit had been addressed. Reports of these visits have been sent to the manager separately, and are available on request. Grove House DS0000017573.V300505.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All of them. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are supported to pursue lifestyles of their choice within the home, and to use the community through support from the home. Dietary needs are catered for through home-cooked meals. EVIDENCE: Most service users spoke positively about their lifestyles in the home, saying that there is enough to do. One service user said that they go out for walks, to the library, and for days out. Another service user kindly showed the inspector around the garden, including the plants that she is growing. Most others spent the inspection watching television, sleeping, or going to their rooms. The manager explained that she usually takes people out when going shopping or running errands, and that exercise and reading is encouraged. They also undertake occasional day trips out, to such places as national parks in the wider vicinity. Additionally, the manager takes two service users to a local church service on Sundays. Records included daily focus on the activities that service users are involved in. One service user continues to attend a day service as part of helping them to Grove House DS0000017573.V300505.R01.S.doc Version 5.2 Page 14 cope with the changes involved in moving into this home, which is good practice. Service users all confirmed that they can receive visitors at anytime. One stated that they also receive phone calls from the manager’s mobile phone. Record confirmed the regular visits of family members to some service users. Service users were seen to have reasonable freedom of the home, with support to get upstairs or into the garden where needed. Service users confirmed that support is quickly provided when they use the call-alarm, including at night. A prompt response was received when the alarm was tested during the inspection. The manager explained where restrictions on freedom apply, noting that it is documented about within care files. Care plans were seen to place value on service users’ choice in matters affecting them. Records showed some evidence of individualised care, such as for bedroom furniture being moved around to help the newest service user to settle in. Service users, including one vegetarian, fedback positively about the food provided. Menus showed that it is home-cooked, often by the manager’s husband who reported previously being a chef by trade. The lunch during the visit was seen to be a pasta and mince dish with broccoli, with a desert being provided afterwards. Most service users ate it and reported being happy with it. The home had a plentiful supply of food. Management provided reasonable feedback about providing nutritional food including for those with restricted diets. The manager also emphasised and ensured that service users were provided with enough liquids during the visit. The manager and her husband were seen to have certificates in food hygiene at foundation level, which is very suitable to their cooking roles in the home. Grove House DS0000017573.V300505.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are protected by a suitable complaints procedure. They stated that they have confidence that issues would be addressed by the home. Staff have had suitable training in the prevention of abuse. The only improvement needed is in updating and making available suitable policies and procedures in respect of abuse prevention. EVIDENCE: The home has a simple but suitable complaints procedure. It enables service users to make verbal complaints, and aims to ensure that complaints are dealt with quickly. Copies of the procedure on care files were signed by the respective service user. Service users generally confirmed confidence that any issues would be listened to and addressed, although most said that they never have complaints about the service. There were no entries in the complaints book, and there have been no complaints to the CSCI since the last inspection. The manager could not find an abuse-prevention policy for the home. They have a copy of Harrow’s adult protection procedure, although the version had recently become out-of-date. The manager agreed to write a short policy relevant to the home, and to acquire the most up-to-date local borough Grove House DS0000017573.V300505.R01.S.doc Version 5.2 Page 16 procedures, so that appropriate guidance about abuse prevention is readily available in the home. Records and certificates confirmed that everyone working in the home has attended a recent training course on abuse-prevention, with some having attended more than one course. Staff were able to provide reasonable evidence of knowledge of appropriate responses to allegations of abuse. An upto-date Criminal Record Bureau checks was in place for a sampled staff member. The manager confirmed that such checks are acquired before employment. This is all appropriate. Grove House DS0000017573.V300505.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. This is a family-run home in which the owners’ family also live. Service users reported having suitable bedrooms, and they were seen to have freedom of the communal areas of the home. Suitable equipment is provided in this respect. The home is kept clean and pleasant. EVIDENCE: The care home is a family-run home, in which the owners live with their family and the service users. Service users commented that their rooms are nice and cosy, and warm enough. One reported that their room is hoovered each day, another that they have a lovely, clean room. There are locks on bedroom cupboards, available for service users to use if requested. There were no concerns with facilities in the service users’ bedrooms. Two bedrooms are upstairs, and one downstairs Grove House DS0000017573.V300505.R01.S.doc Version 5.2 Page 18 is a shared room. The owners noted that service users’ rooms have been redecorated since the last inspection. Suitable equipment was available to each service user depending on need. For instance, one service user had their walking stick close by and was hence seen to get around independently. The home has mobile staff-call systems which were seen to work, and plentiful hand-rails for getting around toilets, showers and stairs. All radiators in the service users’ areas of the home were seen to be covered to prevent scalding. The home is warm, well lit, and airy. The premises was clean and free from offensive odours during the inspection. There are hand-washing facilities sited in the laundry/shower room area, to help uphold infection-control. The laundry area has a domestic washer and a domestic drier. The washer was seen to have sluice and disinfection options, as is appropriate. The garden is accessible via a few steps, and is much used to grow plants. There is a covered seating/decking area (with appropriate furniture) leading to the garden. It is accessible from the sitting room and the kitchen. The owners noted that this area has had a new roof. Previous maintenance requirements have been partly addressed. The maintenance necessary for the roof of the front porch of the house has been structurally addressed, but remains to have surface attention to improve appearance. The fire-release device needed for a door in the home was seen to have been acquired and was awaiting to be fitted. The manager noted that the fire authority has approved of the device. Grove House DS0000017573.V300505.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All of them. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The people working in the home have a suitable understanding of service users’ needs, and everyone fedback positively about staff. Staffing levels are upheld, although documentation about this needs improvement. A range of suitable training is provided to the people working in the home. Improvements are needed to ensure that this includes relevant NVQ courses, which is being planned for. EVIDENCE: The manager, her husband, and their two adult children provide the majority of staffing in this home. Two other people are employed as carers and domestics. The manager noted that she is actively searching for further suitable employees. Service users reported that the staff are fine and nice, and treat them well. One service user said that they like the kindness and generosity of these people. Discussions with staff found them to be knowledgeable about the individual needs of the service users. GP feedback also reflected this. There were always at least two competent people, sometimes including the manager, available to work with service users during the visit. The manager explained that this is her minimum expectation. She provides cover during the Grove House DS0000017573.V300505.R01.S.doc Version 5.2 Page 20 night, undertaking a documented check of all service users once during the night and otherwise attending as needed. Feedback from relatives found that staffing levels are seen as sufficient. The roster for June did not uphold staffing levels, nor was it fully accurate compared to people present during the visit. The manager clarified how levels are maintained in practice. It was agreed that the times of people actually working would be documented in the house diary, to show how staffing levels are maintained. The manager has qualified at NVQ level 4. The manager’s husband is currently undertaking the relevant NVQ course. They plan for two other people to enrol on a course in September. These plans will fully address the NVQ qualification standard, as required. Training records showed a good standard of enabling people who work in the home to attend relevant training courses. There has for instance been attendance at emergency first aid courses and abuse prevention courses recently. Attendance at a dementia care course in shortly to take place for everyone. Additionally, the manager oversees the training and assessment of people through video training, for such things as manual handling. Care staff are provided with detailed induction packages based around national training standards, and there was documentation of assessment of ability in respect of key areas of training. Training plans were documented. The manager stated that she has not employed anyone since the last inspection. Brief checks of recruitment records for the most recently-employed staff member raised no concerns. Grove House DS0000017573.V300505.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The manager has suitable experience and qualifications for the role. There are systems in place to support the home being run in service users’ best interests. A supervision system has been implemented in the home. Service users’ financial interests are handled appropriately by the home where applicable. There are some suitable systems of health and safety in place. Improvements necessary in some other areas have been identified and must be addressed. EVIDENCE: The manager has run this care home with her husband, the other registered proprietor, for in excess of ten years. She has recently completed the relevant management qualifications, and provided a certificate in evidence. She Grove House DS0000017573.V300505.R01.S.doc Version 5.2 Page 22 explained how the course has affected her practice, and there was much documented evidence of how the course has influenced her management practice. For instance, there are now regular documented supervision records using a variety of supervision templates. This includes observation of practice, and improvement targets. Appraisal systems have also been set up. The manager and her husband have attended supervision training courses. The manager was overall seen to have a good knowledge of the individual service users, and of how to run the home to meet the standards. In terms of quality assurance, there were a number of questionnaires completed by service users, usually with support from the home, within their files. The manager does not provide an overall report on this process, but stated that she addresses any individual areas for improvement. Being a small home, there is also good liaison with service users’ families, as confirmed from feedback. Staff meetings also showed how the service aims to meet service users’ individual needs and looks to improve on inspection reports. It is recommended that management further consult with service users and their representatives, and everyone working in the home, to form opinions on the strengths of the home and where improvements could be made. A record of this could then be used to evaluate, with time, on how the service is progressing. The manager stated that they do not look after any service users’ finances. Families or social workers have this role. Personal shopping is undertaken by the service, with invoices sent to the person in charge of the service user’s finances. Receipts for purchases were in place within individual care files. This is suitable. There are documented monthly health and safety checks of a number of aspects of the home. The manager has also implemented daily, recorded checks of the kitchen in response to recent legislation changes about food hygiene. The accident book was seen to contain one entry since the last inspection, in relation to a minor injury to a service user that was additionally reported to their GP. The manager confirmed that there have been no incidents since the last inspection. Suitable professional checks of the gas and electrical wiring were in place. Monthly fire drills, and a fire risk assessment, were also in place. Improvements are needed: • To ensure that the smoke alarms are checked weekly instead of monthly, • To update the professional check of portable electrical appliances, • To address the cracks in an area of the portable hand-rail for the main downstairs toilet, and • To ensure that tripping hazards are addressed such as the mat over the threshold of the lounge to the kitchen area. Grove House DS0000017573.V300505.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 X 3 X 3 X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 Grove House DS0000017573.V300505.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 Requirement The manager must ensure that pre-admission assessments of service users fully evidence what the service user’s needs are and whether the home can meet them. The manager must ensure that a copy of a professional assessment, showing that the newly-admitted service user can use the stairs to their bedroom independently, is forwarded to the CSCI promptly. The assessment is a condition of registration. The manager must ensure that a simple care plan and baseline risk assessments are in place within a week of a new service user moving into the home. The manager must ensure that: • The medication cupboard is always kept locked when not in use; and • All medication in the home, including surplus supplies, is stored securely. Service users’ and the manager’s family medication must be DS0000017573.V300505.R01.S.doc Timescale for action 10/09/06 2 OP3 10, 14 01/09/06 3 OP7 15 10/09/06 4 OP9 13(2) 15/08/06 5 OP9 13(2) 15/08/06 Grove House Version 5.2 Page 25 6 OP9 13(2) 7 OP9 13(2) 8 OP18 10, 13(6) 9 OP19 23(2) stored on different shelves of the medication cupboard, to help prevent any mistakes in administration. Medication must be signed for straight after each administration, not just once a day. The requirements of the pharmacy inspector’s report must be addressed within the timescales provided. The manager must ensure that the home has its own policy on abuse prevention, and that they have access to the local borough’s adult protection procedures. There needs to be maintenance carried out to an area of the care home located above the front door. Previous timescale of 1/3/06 partially met. Following seeking advice from the Local authority fire service, there needs to be suitable safe mechanisms in place to enable two doors to be kept safely open at times during the day. Previous timescale of 1/2/06 partially met. The times of when anyone works in the home must be documented in the house diary, to show how staffing levels are maintained. The manager must ensure that the plans to train people in NVQs are followed through, so as to ensure that 50 of the people working in the home have NVQ qualifications as soon as possible. Improvements are needed: • To ensure that the smoke DS0000017573.V300505.R01.S.doc 15/08/06 01/10/06 20/09/06 01/10/06 10 OP19 12, 13(4), 23(4) 01/09/06 11 OP27 17(2) sched 4 part 7 10, 18(1)(c) 01/09/06 12 OP28 01/10/06 13 OP38 13(4), 23 01/09/06 Page 26 Grove House Version 5.2 • • • alarms are checked weekly instead of monthly, To update the professional check of portable electrical appliances, To address the cracks in an area of the portable hand-rail for the main downstairs toilet, and To ensure that tripping hazards are addressed such as the mat over the threshold of the lounge to the kitchen area. 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 OP9 OP33 Good Practice Recommendations Medication should be administered from the appropriate day of the medication dosette packs. It is recommended that management further consult with service users and their representatives, and everyone working in the home, to form opinions on the strengths of the home and where improvements could be made. A record of this could then be used to evaluate, with time, on how the service is progressing. Grove House DS0000017573.V300505.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Grove House DS0000017573.V300505.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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