Inspection on 26/01/07 for Grove Road (45)

This inspection was carried out on 26th 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Grove Road (45) 29/11/07

Grove Road (45) 05/08/05

Grove Road (45) 08/03/05

Grove Road (45) 01/10/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Grove Road (45) 45 Grove Road Sutton Surrey SM1 2AW Lead Inspector Ms Rin Saimbi Key Unannounced Inspection 26th January 2007 10:00 Grove Road (45) DS0000007131.V324193.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 (45) DS0000007131.V324193.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 (45) DS0000007131.V324193.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grove Road (45) Address 45 Grove Road Sutton Surrey SM1 2AW 020 8642 2899 F/P 020 8642 2899 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) The Regard Partnership Limited Anna Maria Nazareth Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Grove Road (45) DS0000007131.V324193.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow one specified service user who is in both the learning disability and dementia service user categories to be accommodated. 5th August 2005 Date of last inspection Brief Description of the Service: Grove Road is a care home that is for up to nine younger adults who have learning difficulties. The home is a large semi-detached Victorian house, which is within walking distance of Sutton town centre. There are plenty of shops, pubs and post office near by. There are good bus and rail routes into London and other shopping areas. From the outside, the home looks like any other house in the road and people would not know it was a care home. The home itself has nine single bedrooms which all have their own sink, wardrobe and bed. The service users have their own keys to their bedrooms, and service users are able to come and go as they please. On the ground floor there is a large lounge/diner, and a separate dining room, kitchen and a laundry room in the basement. There is a small garden at the back of the building, and the front is paved for car parking. The home is owned and managed by Regard Partnership Limited. The current charges for the year 2005/06 ranges from £974 to £1,398 per week dependent upon need. Placing authorities are advised to contact the home directly for details for the actual costing. Grove Road (45) DS0000007131.V324193.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first inspection for the year 2006/07; it was an unannounced inspection which started at 10.00 a.m. The inspection took approximately six hours during which time the inspector had a tour of the building, discussions with service users and staff, looking through the documentation relating to service users and to the running of the home. Information received by the Commission throughout the year was also considered. A strategy meeting was held regarding an incident, which involved two service users. The issue was resolved at this meeting, with plans in place to reduce the likelihood of such an incident occurring again. The registered manager has not been in post since July 2006. The service has instead been managed by the deputy, Ms. Tracey Murphy who will continue to act up in this role until a new manager is in post. The inspector would like to thank the service users and staff for their time and co-operation during the inspection process. What the service does well: The staff team within the home range in age and experience. They appear to work effectively together in providing the service users with a good quality of life. The staff team were observed communicating effectively with service users who had no verbal language and constantly giving choices. There remains an overall ethos within the home that all aspects of daily living should be accessible to service users. So many of the forms and policies are in a format that is easier for service users to understand, either written in plain English or in Makaton symbols. This includes a contract, which has been recently developed. All the paperwork that was seen was up to date, well written and thorough. Grove Road (45) DS0000007131.V324193.R01.S.doc Version 5.2 Page 6 The home itself is pleasant, clean and well furnished; it is maintained both internally and externally to a high standard. It was positive to note the degree of personalisation in the service users bedrooms, and the individual touches throughout the home of framed photographs of service users at particular events. What has improved since the last inspection? What they could do better: The home is running well with only a small number of requirements made at this inspection. There are two issues concerning the environment, namely the provision of a lockable space for one of the service users and a rather noisy extractor fan. The main issue at this inspection relates to the lack of regular supervision. The standards relating to younger adults under the Care Standards Act 2000 state that supervision must take place at least six times a year, that is to say, one session every second month. Records within the home indicate, that supervision for three members of staff last took place in March, May and August. There are plans in place to ensure that staff in the future are sufficiently supervised, however, these measures are not currently in place. This situation needs to be rectified urgently. Grove Road (45) DS0000007131.V324193.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 Road (45) DS0000007131.V324193.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 Road (45) DS0000007131.V324193.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): 2,3,4 and 5 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. No new service user has been admitted to the home for some considerable time. However, the process has been checked at previous inspections and remains the same. Information is gathered prior to any new service users coming into the home. Only if everyone were happy for the placement to continue, in particular the service users, that it would do so. In this way, service users feel that they are making positive choices about where they live, rather than just being slotted into vacancies. EVIDENCE: The process of a new service users being admitted to the home is that information is gathered and a personal profile is completed. This personal profile has information about the person’s general health, communication needs, what household tasks they could do and what help they needed with personal care. Grove Road (45) DS0000007131.V324193.R01.S.doc Version 5.2 Page 10 It is only at the point that the senior staff are satisfied that a new service users might fit into the home and that the home could meet their needs that the introductory visits are started. There is then a long process of visits, starting with a tea visit and culminating in weekend visits. Once a new service user has moved into the home, there is a review after six weeks, then six weeks after that and then the final meeting to confirm the placement is then after six months. It was positive to note that the home has changed its contract documents. Previously they compiled with the format as set out in the Care Standards Act, but were not in a format suitable for the service users within the home. Documentation viewed showed that the contract was now pictorial and written in plain language. It included details of which room was to be occupied, what the fees covered and the process for moving in. The service user, their advocate and a representative of the home then signed the contract. The introductory process is well thought out and considered, and the inclusion of new contracts is positive. The home has therefore been awarded excellent for this outcome group. Grove Road (45) DS0000007131.V324193.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are involved in making major life decisions as well as every day choices thereby allowing them an opportunity to feel in control of their lives. Service users are encouraged to be involved in all activities of daily life, even if this might be thought risky for them. They are supported in the choices that they make so that they have the opportunities offered to others in the community. EVIDENCE: Paperwork was checked for three of the service users currently living in the home. Each had a plan, which was based on the original assessment. The home is in the process of introducing Person Centred Planning (PCP) for all service users. Grove Road (45) DS0000007131.V324193.R01.S.doc Version 5.2 Page 12 This showed that service users were involved in the process of deciding what went into their PCP. There was information about their health needs, what they liked to be called, what they liked and what made them happy. In addition, there were notes from monthly meetings that service users had had with their key workers. This gave the home a picture of service users changing wishes, and also acted as a quality assurance monitor for the home. Activities were changing dependent upon wishes of the service users. For example, one service user was going swimming four times a week. Another enjoyed looking after her newly acquired guinea pigs. The service users plan is looked at least every six months to make sure that it is up to date, and that service users get the chance to say what they want for themselves and for the future. When the plan is looked at, this is called a review meeting and involves all the important people in the service users life. The deputy manager stated that there were no outstanding review meetings with Social Services. One service users is currently having his needs assessment reviewed on a monthly basis because of changing circumstances. Service users are encouraged to be as independent as possible and that this sometimes means taking risks. There were numerous risk assessments in place for service users within the community, within the environment of the home or specific to individuals such as ironing. The risk assessments are working documents and there was evidence that they are reviewed and updated on a regular basis. Service users are represented on the interviewing panels of the selection of staff. They also have a choice as to whether they to attend staff meetings or not. In reality the inspector was informed that only one service users attends on any regular basis, though they do often have something to contribute. Grove Road (45) DS0000007131.V324193.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported to live fulfilling lives both within the home and in the community, dependent upon their needs, interests and wishes. This opportunity to be a part of the community should enable service users to feel that they have a fulfilling and meaningful life. EVIDENCE: Birthdays are clearly an important time for the service users and treated with a sense of occasion. On the day of the inspection, one of the service users took the inspector to their bedroom and showed the banner and balloons that were still up two weeks after his birthday. Grove Road (45) DS0000007131.V324193.R01.S.doc Version 5.2 Page 14 Friends and family are welcomed into the home; on the day of the inspection a relative was visiting the home and later the plan was that the relative, service user and a member of staff would be going out together. Service users all have keys to their bedrooms and to the front door. In reality however, there is only one service user who uses her key to lock her bedroom door when she leaves the building. Staff are aware that the building is the home of the service users and as such they rarely close doors even for meetings, if they do need to close a door it is with the service users permission; before entering bedrooms, staff were observed asking permission or knocking; staff were engaged with service users and were observed giving choices. Some of the service users attend day centres dependent upon their wishes and needs. Service users use a number of different day centres, with a maximum attendance of three days per week. One particularly active service user goes swimming up to four times a week, horse riding, attends a day centre and goes to church on a regular basis. All service users are given the opportunity to fulfil their spiritual needs. The inspector was informed that most do attend church on a regular basis, with two service users attending a local Catholic church. The home is located very near Sutton town centre, and the home makes good use of it. It is used for shopping, going out for a coffee, and for two service users to use the swimming pool at a local hotel. With regards to holidays in the summer of 2006, service users went on a variety of holidays including abroad. One of the service users preferred to go on day trips with his family; this was supported by the home that provided one to one support. One service user did not have the opportunity to go away, this was for various reasons including sickness. The deputy manager reported that this particular service user would have the opportunity for two breaks this year, if he wishes. Arrangements are currently been made for holidays for 2007; these include Greece and Centre Parcs. One of the service users who is Catholic has decided that he ‘wants to go to see where the Pope lives’, and therefore the home are in the process of arranging a trip to the Vatican. The level of consultation with service users and the number of different arrangements that are made would indicate that this home is achieving higher in the area of leisure and has been scored accordingly. Grove Road (45) DS0000007131.V324193.R01.S.doc Version 5.2 Page 15 Service users decide meals on Sundays during the residents meetings. The home is developing a library of pictorial images of food that is available so that those service users without verbal communication are also able to make choices. Meals are all freshly prepared, and on Saturdays there is a choice of take-away food, which the inspector was informed is invariably fish and chips. An alternative is always available if the service users do not want what is on offer. Service users were observed moving freely around the kitchen and helping themselves to drinks and fruit. The use of pictorial images as a menu, and the quality of the food that has been presented during inspections exceed the minimum required and therefore the home has been graded as excellent in this outcome group. Grove Road (45) DS0000007131.V324193.R01.S.doc Version 5.2 Page 16 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. Service users are supported wherever possible to manage their own health care needs. They also generally have access to NHS facilities thereby ensuring that service users have good quality physical care. EVIDENCE: Each service user has a clear record of the health appointments that have been kept and, that are in the future. If the service user wants a member of staff to go with them for an appointment, they will; the member of staff then writes down what the appointment was for and how it went. Records for three service users were checked, they showed evidence of regular dentist and opticians appointments. There was also evidence that the home access specialist advice such as that from a clinical psychologist. At least once a year, a doctor will go through all the medication that someone is taking to make sure that it is still right for him or her. Grove Road (45) DS0000007131.V324193.R01.S.doc Version 5.2 Page 17 Medication is stored in a locked metal cupboard, which is secured to the wall; this cupboard is within a locked store room. No service users within the home is able to self medicate; instead staff have been trained to give medication. Medication arrives in the home delivered by Boots the Chemist, it arrives in blister packs. The home completes its own internal audit of medication on a weekly basis. The Medication Administration Records were checked and showed no omissions or errors. Staff were asked questions about providing personal care and how they would be able to ensure privacy and dignity. Staff that were asked were able to give a satisfactory response to questions. Service users weight is monitored on a weekly basis. There was some discussion about the appropriateness of this. The acting manager stated that in the near future monitoring would be completed on a monthly basis unless there was a specific reason to make it more often. It was noted that on all health files of service users there was a letter from relatives about their wishes in case of illness or death of service users. Grove Road (45) DS0000007131.V324193.R01.S.doc Version 5.2 Page 18 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. Service users should be able to feel that what they think about the home and what happens to them, is listened to. This will contribute to them feeling able to speak up if there were any issues that made them feel unsafe. EVIDENCE: The home has a complaints policy, which says what should happen when if someone is not happy about something or someone at the home. The complaints policy is written in a way that the service users would understand, and they all have a copy. The home has had one complaint in the last year, which is currently being dealt with. The home has its own internal policies and procedures regarding vulnerable adults, which was last reviewed in May 2006; in addition they have a copy of Sutton’s policy and procedures. The home has not had to make any referrals to Social Services regarding vulnerable adults. Staff are given annual training regarding vulnerable adults and certificates were available during the inspection. Some staff were given a scenario Grove Road (45) DS0000007131.V324193.R01.S.doc Version 5.2 Page 19 regarding vulnerable adults; they were able to give a suitable response as to the actions that they would take. Grove Road (45) DS0000007131.V324193.R01.S.doc Version 5.2 Page 20 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): 24,26,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is pleasant, well furnished and is maintained to a high standard. Each of the service users has their own bedroom, which is personalised showing what they are interested in. EVIDENCE: The accommodation at Grove Road is over four floors of a semi-detached Victorian house. On the ground floor there are four bedrooms, a large lounge/diner, separate dining room and small kitchen; the first floor has three bedrooms, a small office and staff sleeping in room; there are a further two bedrooms on the second floor and a laundry in the basement. Grove Road (45) DS0000007131.V324193.R01.S.doc Version 5.2 Page 21 The previous inspection made a requirement that the home must install hand washing facilities in the laundry. This has been actioned and therefore this requirement has been withdrawn. All the bedrooms are single and with a wash hand basin in them. The bedrooms all feel homely; service users have chosen how to decorate their rooms; what furniture they want; and to chosen their own pictures and photographs. One service user had models of emergency vehicles, which he showed with great pride The home is kept in good decorative order both inside and outside. It was clean and hygienic. Staff and service users are responsible for cleaning the home. The home allows for service users privacy and dignity; all the bathrooms and toilets are lockable from the inside. The toilet on the first floor had an extremely noisy extractor fan. As the toilet is situated next to a service users bedroom, a requirement has been made that the noise of the extractor fan must be reduced. Service users all have their own keys to their bedrooms and the majority have a lockable space in their bedrooms. It was noted that one service user did not have a lockable space in their bedroom; therefore a requirement is made that one must be provided. Service users are able to move around the home freely and to leave if they so wish. Grove Road (45) DS0000007131.V324193.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff team within the home have a range of experience and expertise. They are well supported in terms of training, which in turn enables them to help service users live fulfilling lives. Formal supervision appears ad hoc; this could affect the quality and calibre of care given to service users. EVIDENCE: Grove Road has an establishment of seven full time staff and nine bank staff. The establishment of nine bank staff does seem rather high. The inspector was assured however, that this was because this would allow some staff to work part-time, rather than at the convenience of the company. Of the establishment of sixteen staff, four had completed their National Vocational Qualification (NVQ) Level 3; four had completed Level 2; and a further four were in the process of completion. The Human Resources Grove Road (45) DS0000007131.V324193.R01.S.doc Version 5.2 Page 23 department had recently informed the home that this constituted 55 of the staff team. The staff team are mixed in terms of gender, age, ethnic background and experience. There are four male members of staff, and experience ranges from being employed since the home was set up to two weeks. Documentation was checked regarding the recruitment of employees within the home. In general, there was a job description, application form, two references, evidence of identity and a Criminal Records Beaux (CRB) check. A previous requirement that there was no evidence of valid Criminal Records Beaux checks has been withdrawn. The practice had previously been to destroy the original CRB’s because of Date Protection whilst keeping the original reference number. The company had not been keeping a copy of the reference number. This issue has now been rectified. Files were checked for three individual members of staff. It was noted that whilst references had been taken up, they were completed on a proforma’s with no official stamp or compliment slip attached. A requirement has therefore been made that references are followed up with a telephone call to the referee verify the information given. The home has extensive training opportunities available. There is an induction programme that new staff are expected to attend and a series of statutory training that is undertaken with regular refreshers. The home keeps a record of training undertaken by staff; the inspector was able to view the certificates of training undertaken and verify that staff do all complete the required levels. Staff were able to confirm the level of training available to them, there were some shortfalls identified although staff felt able to approach the acting managers to discuss. The duty rota was checked randomly for November and over the Christmas period. The rota indicated that there were sufficient numbers of staff on duty, that is to say, three in the morning, three in the evening and two staff on during the night. There were some occasions over the Christmas period when staffing did go down to two staff, however, this was because of a parallel reduction in service users who were staying with relatives over this period. Supervision records were checked for three members of staff. It indicated that supervision was held on an ad hoc basis. Last recorded supervision, were in March, May and August 2006. The acting manager explained that previously she and one senior had been responsible for supervising all staff. This has recently changed as two seniors had undertaken the supervision training. Therefore a new structure was in place, whereby the manager supervised the seniors, and the three seniors supervised support staff. Grove Road (45) DS0000007131.V324193.R01.S.doc Version 5.2 Page 24 However, until such time as this new structure is in place, supervision for staff was outstanding. Therefore a requirement has been made that supervision must take place within the required time frames. Grove Road (45) DS0000007131.V324193.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40,41 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Whilst acknowledging that usually the calibre of the manager is crucial to the running of the home; it is to the credit of this home that it has continued running to a high standard with an acting manager on a part-time basis. EVIDENCE: The registered manager of the home left in July 2006 for a sabbatical period and is subsequently not returning. In the interim, the deputy, Ms Tracey Murphy, has managed the home. It is a credit to the previous manager, staff team and Ms Murphy in particular, that the home has continued to run with the interests of the service users as paramount. Grove Road (45) DS0000007131.V324193.R01.S.doc Version 5.2 Page 26 The inspector was informed that the company have recruited a new manager pending all appropriate checks. However, until such time that a manager is in post and becomes registered, a requirement is made in this matter. As Regard Partnership Limited runs the home, all the policies and procedures about how to run the home are written and agreed centrally. These policies and procedures are looked at and reviewed on an ongoing basis to make sure that they keep up to date with new legislation and research. At previous inspections a random selection of policies and procedures from Appendix 3 of the National Minimum Standards for Care Homes for Adults (18-65) seemed to indicate that all were available and appropriate. The home keeps all its records up to date and in good order. Service users are encouraged to add to the information that is held about them. Service users files are stored confidentially. With regard to quality assurance, the home completes very thorough Regulation 26 visits, copies of which are made available to the Commission. A previous requirement that the company must complete annual questionnaires with service users and other stakeholders has been actioned and therefore this requirement is withdrawn. At the weekly residents meetings it was noted that an action book is maintained, which identifies follow up for key workers to complete. This process further enhances the quality assurance and feed-back from service users. Documentation relating to health and safety checks was viewed. PAT was completed on the 15.8.06; electrical installation on 15.9.06; gas certificate on 16.5.06; employers liability runs until 31.3.07. Weekly fire testes have been completed and the last fire drill was on 22.11.06 A current Legionella test could not be found on the day of the inspection. However, the home did supply a valid certificate within a few days of the inspection. Grove Road (45) DS0000007131.V324193.R01.S.doc Version 5.2 Page 27 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 3 4 4 5 4 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 2 27 X 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 2 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 3 12 3 13 3 14 4 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 2 X 3 3 3 3 X Grove Road (45) DS0000007131.V324193.R01.S.doc Version 5.2 Page 28 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. 2. 3. Standard Regulation 23(2)(b) 23(2)(m) 19(1)(a) Requirement The extractor fan on the first floor toilet must be repaired All service users must have a lockable space provided for them in their bedrooms All references must be followed with a telephone call to the referee verifying the information given. A record must be maintained of this Supervision must take place on a regular basis The home must recruit a manager Timescale for action 26/02/07 26/03/07 26/01/07 4. 5 18(2) 8(1)(a) 26/03/07 26/03/07 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 (45) DS0000007131.V324193.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 (45) DS0000007131.V324193.R01.S.doc Version 5.2 Page 30 - 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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