Inspection on 24/05/07 for Grove Road (107-109)

This inspection was carried out on 24th May 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Grove Road (107-109) 08/12/06

Grove Road (107-109) 25/04/06

Grove Road (107-109) 18/10/05

Grove Road (107-109) 05/05/05

Grove Road (107-109) 05/01/05

Grove Road (107-109) 04/08/04

Grove Road (107-109) 16/02/04

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

CARE HOME ADULTS 18-65 Grove Road (107-109) 107- 109 Grove Road Walthamstow London E17 9BU Lead Inspector Rob Cole Unannounced Inspection 24th May 2007 10:00 Grove Road (107-109) DS0000007245.V341139.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 Road (107-109) DS0000007245.V341139.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 Road (107-109) DS0000007245.V341139.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grove Road (107-109) Address 107- 109 Grove Road Walthamstow London E17 9BU 020 8520 6435 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) bagano98@aol.com Mrs Conchita Damaguen Pooten Mrs Conchita Damaguen Pooten Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places Grove Road (107-109) DS0000007245.V341139.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th December 2006 Brief Description of the Service: The home is registered to provide accommodation and support to nine service users with mental health needs. It consists of three homes that have been converted into one. The home is situated in a residential area of Walthamstow in the London Borough of Waltham Forest, and is close to shops and other local amenities, including transport networks. The home is indistinguishable from other homes in the area. The home is privately run. Grove Road (107-109) DS0000007245.V341139.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 24/5/07 and was unannounced. The inspector had the opportunity of speaking with service users, staff from the home, and the homes manager was present throughout the course of the inspection. The inspection also included a tour of the premises, and an examination of documents and other records, and observation of the support provided. Overall, the inspector was satisfied that this is a well run home, and considerable improvements have been made since the previous inspection. Service users spoken to informed the inspector that they were satisfied with the level of care and support provided, one commented, “I am very happy living here, staff are excellent.” While another informed the inspector “I am able to do the things that I want to do here.” There are however some issues that must be addressed, as highlighted within the report. What the service does well: What has improved since the last inspection? What they could do better: Of the seven requirements made in this report, one is a repeat requirement from the previous inspection, and that is that all staff must receive regular formal one to one supervision. Other issues that must be addressed include the training of all staff in adult protection issues and ensuring that risk assessments are comprehensive. Grove Road (107-109) DS0000007245.V341139.R01.S.doc Version 5.2 Page 6 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 Road (107-109) DS0000007245.V341139.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 Grove Road (107-109) DS0000007245.V341139.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that prospective service users are provided with sufficient information about the home to make an informed choice as to move in or not. This information is provided through written documentation, and the opportunity of visiting the home. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place. The Statement says that “We are committed to providing a secure, happy and comfortable home, promoting a good standard of care that meets individual needs …… that help to maintain personal dignity and independence.” Both documents are written in plain English, and all service users are provided with their own copy of both documents. They have been dated and are subject to review. The Statement includes details of the organisational structure, the aims and objectives and the services and facilities provided by the home. The Service User Guide includes details of the homes physical environment and its complaints procedure. The Guide also includes information on what fees cover and what is not included, but do not state what the actual fees are, and this must be addressed. Grove Road (107-109) DS0000007245.V341139.R01.S.doc Version 5.2 Page 9 There has been one new admission to the home since the previous inspection. A pre admission assessment was carried out by the homes manager prior to them moving into the home. This was of a satisfactory standard, and included needs associated with mental health needs and personal care. The service user initially moved into the home on a trial basis, after which a placement review meeting was held, attended by the service user, their social worker and the homes manager. The service users next of kin was also invited. All service users have a written contract/statement of terms and conditions in place. These have been signed by the service user and the homes manager, and service users have their own copy of the contract. Contracts include details of services provided and the rights and responsibilities of both parties. Grove Road (107-109) DS0000007245.V341139.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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that service users have control over their daily lives, and that they are involved in the day to day running of the home. EVIDENCE: Care plans are in place for all service users. These are of a satisfactory standard. They are drawn up with the involvement of the service user and the homes manager, and are subject to regular review. Plans include needs associated with mental health and social and cultural needs. Risk assessments are also in place for all service users, and since the previous inspection these are now subject to regular review. They cover risks associated with smoking and accessing the community, and include strategies to manage and reduce any risks. However, assessments are not comprehensive, for Grove Road (107-109) DS0000007245.V341139.R01.S.doc Version 5.2 Page 11 example, the most recent service user to move into the home has a recent history of alcohol abuse, yet there was no risk assessment in place around this. It is required that comprehensive risk assessments are in place for all service users, covering all areas of potential risk to themselves and others. The home presented as having a homely and relaxed atmosphere, and through observation and discussion there was evidence that service users have a large measure of control over their daily lives. Subject to the completion of a risk assessment, service users are able to come and go from the home as they choose, and have been offered keys to both the front door and their bedrooms. Service users get up and go to bed at a time of their choice, although staff will prompt service users to get up if they have an appointment. Service users plan their own individual menus, and are involved in buying and cooking their food. The manager informed the inspector that service users are regularly consulted over the running of the home on an ad hoc basis, for example over menus. More formal arrangements are also in place to provide service users with the opportunity of been involved in the running of the home, such as regular service user meetings. The agenda for these meetings is set jointly by service users and staff, and minutes are maintained. These minutes evidenced discussions on activities, and a discussion on an upcoming holiday, which service users have been able to help choose and plan. The home has recently had some decoration work carried out, and service users were involved in choosing the new décor. Confidential records within the home are stored securely, staff and service users can access their records as appropriate. The home has a confidentiality policy in place. This states that a confidence can be broken on occasions in the health, safety and welfare interests of service users and others. However, it states that on such occasions confidences may only be ever shared with the homes manager. There may be occasions when a confidence should be broken, but it would be inappropriate to share the information with the manager, and the policy must reflect this. Grove Road (107-109) DS0000007245.V341139.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): 11,12,13,14,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that service users are supported to live valued and fulfilling lives, and that the home is able to meet their cultural needs. EVIDENCE: One service user at the home has employment working in a café at a day service. Service users are involved in various educational opportunities, one service user attends English classes at a local mosque, while another attends IT and numeracy classes at an adult education centre. Service users also attend yoga classes and guitar lessons. The inspector was impressed by the homes ability to meet the social, cultural, racial and religious needs of service users. Service users attend various places of worship, including a mosque, a Greek Orthodox church, a Catholic church Grove Road (107-109) DS0000007245.V341139.R01.S.doc Version 5.2 Page 13 and a Baptist church. A church group also visits the home weekly for singing sessions, service users spoken to said they very much enjoyed this. Service users attend a day service for adults with mental health issues, where they have the opportunity of socialising and developing friendships, while one service user attends a Greek social club. Service users regularly access public transport, including buses and trains. There was evidence that service users have access to a variety of social and leisure activities, both in house and in the community. In house service users have access to TV, video, music, board games and the home organises occasional parties. For example, on the day of the inspection, it was the birthday of one service user, and a party was held to celebrate this, in line with their wishes. The home has a pet cat, and it is the responsibility of service users to look after it. Service users visit local pubs, cafes, and shops, and go to the cinema and the greyhound races. The home arranges various day trips, such as to Southend. All service users are entitled to a weeks holiday away from the home each year as part of their basic contract price. It is planned that service users will be going to Kent for a weeks holiday later this year. Service users spoken to informed the inspector that they had been involved in choosing this holiday, and that they were very much looking forward to it. Service users are supported to maintain contact with family and friends, and are able to visit them, including for overnight says. At the time of the inspection one service user was away from the home, as they were staying with their farther. Another service user has recently been to Glasgow to visit their uncle. Service users are able to maintain contact by phone, which they can use in private if they so wish. A service user informed the inspector that they are able to phone their family in Pakistan on a regular bass. Service users are given their own mail to open. Food was of a good standard within the home. The inspector was impressed by the amount of choice service users are offered. On the day of inspection some service users had beef casserole for lunch, others had chicken curry and rice, while one had fish fingers, in line with their preference. Menus are maintained, these evidenced that service users are offered a varied, balanced and nutritious diet, and that the diet helped to meet service users cultural needs. For instance, the menu indicated that Caribbean and Greek food were regularly provided. Service users are involved in food preparation, and are able to buy their own food. One service user is on a Halal diet, and there is appropriate provision for the storage and preparation of this food. There was fresh fruit available on the day of inspection, and evidence that fresh produce is routinely used in cooking. The kitchen was clean and tidy, and food was stored appropriately. The home keeps records of fridge and freezer temperatures, and since the previous inspection all staff have now had training in food hygiene. Service users were observed to help themselves to drinks and snacks throughout the course of the inspection. Grove Road (107-109) DS0000007245.V341139.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 and 21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that the home is generally able to meet the health and personal care needs of service users. Service users have access to health care professionals as appropriate, and the recording and administration of medications has improved considerably since the previous inspection. EVIDENCE: Service users are able to manage their own personal care, although the home will give encouragement and advice on clothing appropriate for the weather. The manager informed the inspector that service users would be able to remain in the home with a terminal illness, so long as the home could meet their medical needs. Service users wishes in the event of their death have been sought and are recorded on their care plans. All service users are registered with a GP. Records are maintained of medical appointments, including of any follow up action necessary. Records indicate Grove Road (107-109) DS0000007245.V341139.R01.S.doc Version 5.2 Page 15 that service users have access to health care professionals as appropriate, including CPN’s, psychiatrists and opticians. Appointments have been made for all service users to see a dentist in June of this year. One service user has burns on their legs, there was evidence that they receive appropriate treatment, a district nurse routinely visits the home to change the dressing, and they regularly attend the burns unit of a local hospital. The inspector was pleased to note that the recording and administration of medications has much improved since the previous inspection. The home has a medication policy in place, and all staff undertake training before they administer any medications. Medications are stored securely in locked cabinets inside individual bedrooms. Records are maintained of medications leaving the home, and of those that are returned to the pharmacist. Medication Administration Records (MAR) are maintained, and all medications recently administered have been recorded appropriately. There was however one issue with the MAR charts. They indicated that one service user was on PARACETAMOL tablets on a PRN basis, but the medication that they had in their cabinet was CO-CODAMOL. The manager informed the inspector that they had originally been on PARACETAMOL, but the GP had subsequently changed the prescription, but the MAR chart had not been altered. It is required that MAR charts accurately record the current medication service users are prescribed. Grove Road (107-109) DS0000007245.V341139.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home has taken reasonable steps, and has appropriate policies and procedures in place, to help ensure that service users are protected from the risk of abuse. EVIDENCE: The home had a complaints log, although the manager informed the inspector that they have not received any complaints since the previous inspection. There is also a complaints procedure, all service users have been given their own copy of this, and it is on display within the home. The procedure makes appropriate reference to the CSCI, and includes timescales for responding to any complaints. Service users spoken to demonstrated a good understanding of who they could complain to if they so wished. The home has a copy of the Local Authorities adult protection procedure, and also its own policy on adult protection. This appeared to be in line with current legislation. Since the previous inspection several staff at the home have undertaken training in adult protection issues, and those staff spoken to demonstrated a god understanding of their roles and responsibilities with regard to adult protection. The inspector was informed that it is planned that all staff will undertake adult protection training, and this is required. Grove Road (107-109) DS0000007245.V341139.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): 24,25,26,27,28,29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home is suitable to meet its sated purpose with regard to the physical environment. Service users are provided with adequate communal and private space, and the home was generally well maintained. EVIDENCE: The home consists of three houses converted into one, and is situated in a quiet residential area of Walthamstow in the London Borough of Waltham Forest. The home is in keeping with other homes in the vicinity, and is close to shops, transport links and other local amenities. All service users have their own bedrooms, five of these are ensuite and the others all have hand basins fitted. All bedrooms had adequate natural light and ventilation, and bedding, carpets and curtains were well maintained. Service Grove Road (107-109) DS0000007245.V341139.R01.S.doc Version 5.2 Page 18 users have been able to personalise their rooms, for example with family photographs, and bedrooms meet National Minimum Standards on size requirements. In addition to the five ensuite bedrooms, the home has one toilet/shower room, one toilet/bathroom and one toilet on its own. Bathrooms were clean, tidy and free from offensive odours. All bathrooms have working locks fitted, including an emergency override device. The communal areas of the home consists of three lounges, (one a designated smoking room), two kitchen/dining areas and a garden with appropriate garden furniture. Furniture and fittings around the home were generally well maintained and domestic in character. The home has recently had some of its communal areas decorated, which service users helped to choose. The home has suitable measures in place to help prevent the spread of infection, for example protective clothing is available to staff, and hand washing facilities were situated around the home. The home contracts out service users laundry, service users informed the inspector they were happy with this situation. However, although the home has a designated and locked COSHH cupboard, COSHH products were found to be stored in an unlocked kitchen cupboard on the day of inspection, and it is required that all COSHH products are stored securely. Grove Road (107-109) DS0000007245.V341139.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): 31,32,33,34,35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that the home is staffed in sufficient numbers to meet the needs of service users, and that staff have a good understanding of their roles and responsibilities. EVIDENCE: The home provides 24-hour support, including waking night staff. There was a staffing rota on display within the home, this accurately reflected the staffing situation on the day of inspection. All staff are provided with a copy of their job description, and staff spoken to by the inspector demonstrated a good understanding of their roles and responsibilities. Through observation and discussion there was evidence that staff have built up good relations with individual service users, and were seen to interact with them in a friendly and respectful manner. Service users spoken to informed the inspector that they were very happy with the staff. Grove Road (107-109) DS0000007245.V341139.R01.S.doc Version 5.2 Page 20 All staff undertake a structured induction programme on commencing working at the home, this includes the environment and health and safety issues. Recent staff training has included first aid, fire safety and manual handling. Of the eight care staff employed at the home, the inspector was informed that five have an appropriate care qualification, and that a further two staff were currently working towards such a qualification. Staff supervision has only been sporadic since the previous inspection. Several staff have not had at least six supervisions a year, and records indicated that supervision did not adequately address all relevant issues. For example, one set of supervision notes only covered the subject of food hygiene, and this was the only formal one to one supervision that this staff member has received in the past year. It is required that all staff have regular formal one to one supervision at last six times a year. The home has various employment polices in place as appropriate, including on recruitment and selection and equal opportunities. The inspector checked staff employment files, these were found to contain all necessary documentation, including references, proof of ID and CRB checks. Grove Road (107-109) DS0000007245.V341139.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): 37,38,39,40,41,42 and 43. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that appropriate systems are in place to ensure the smooth running of the home. The home has various quality assurance systems in place, and the management of health and safety issued was of a satisfactory standard. EVIDENCE: The homes manager is a Registered Mental Health Nurse with over thirty years experience of working with adults with mental health issues, including twenty five years experience of working in a managerial capacity. The manager informed the inspector that they are now working towards the Registered Managers Award. Staff and service users informed the inspector that they Grove Road (107-109) DS0000007245.V341139.R01.S.doc Version 5.2 Page 22 found the manager to be approachable and accessible, and on the day of inspection staff were observed to interact with the manager in a relaxed manner. Staff and service user meetings are regularly held, and these contribute to the quality assurance within the home. Copies of previous inspection reports were available to view in the home. Since the last inspection, the home has introduced a system of questionnaires for service users and their relatives, to gain their feedback on the running of the home. Feedback seen by the inspector was generally positive. The home has a set of policies and procedures in place, in line with National Minimum Standards. Those checked by the inspector appeared to be satisfactory, with the exception of the confidentiality policy as already mentioned in this report. Other polices checked included adult protection and admissions. Record keeping in the home was generally of a satisfactory standard, records are stored securely, and staff and service users can access their records as appropriate. Fire extinguishers were situated around the home, these were last serviced on the 27/3/07. Fire alarms are tested weekly, and the home was able to evidence that it had arranged for them to be serviced the day after this inspection. It was positively noted that since the last inspection the home now holds regular fire drills. Fridge/freezer and hot water temperatures are checked regularly. The home had in date safety certificates for electrical installation, and PAT testing. The home had in date employer’s liability insurance cover in place. Grove Road (107-109) DS0000007245.V341139.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 2 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 2 LIFESTYLES Standard No Score 11 3 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 3 3 3 3 3 3 3 3 Grove Road (107-109) DS0000007245.V341139.R01.S.doc Version 5.2 Page 24 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 YA36 Regulation 18 Requirement The registered person must ensure that all staff receive regular formal supervision at least six times a year, and that records are kept of supervisions, and staff receive a copy of the minutes. (Timescale 28/02/07 not met) The registered person must ensure that the Service User Guide contains all information listed in National Minimum Standard 1, including details of fees charged by the home. The registered person must ensure that comprehensive risk assessments are in place for all service users, covering all areas of potential risk to service users and others, and that these assessments are subject to regular review. The registered person must ensure that the homes confidentiality policy makes clear that on occasions a confidence may need to be breached to persons other then the homes registered manager. Timescale for action 31/07/07 2. YA1 5 31/07/07 3. YA9 13 31/07/07 4. YA10 13 31/07/07 Grove Road (107-109) DS0000007245.V341139.R01.S.doc Version 5.2 Page 25 5. YA20 13 6. YA23 13 and 18 7. YA30 13 and 23 The registered person must ensure that Medication Administration Record charts accurately record the actual medication prescribed for the service user. The registered person must ensure that all staff who work at the home undertake appropriate training in adult protection issues. The registered person must ensure that all COSHH products in the home are stored securely. 30/06/07 31/08/07 30/06/07 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 Road (107-109) DS0000007245.V341139.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 Road (107-109) DS0000007245.V341139.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. 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