Inspection on 29/11/07 for Grove Road (45)

This inspection was carried out on 29th November 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 (45) 26/01/07

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 29th November 2007 09:30 Grove Road (45) DS0000007131.V354570.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.V354570.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.V354570.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 Ltd Vacant Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Grove Road (45) DS0000007131.V354570.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. 26th January 2007 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 people who use the service have their own keys to their bedrooms, and people 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 2007/08 ranges from £1,037 per week upwards, dependent upon need. Placing authorities are advised to contact the home directly for details for the actual costing. Grove Road (45) DS0000007131.V354570.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 2007/08; it was an unannounced inspection which started at 9.30 a.m. The inspection took approximately six hours during which time the inspector had a tour of the building; discussions with people who use the service and staff; looking through the documentation relating to people who use the service and to the running of the home. Information received by the Commission throughout the year was also considered. An ‘expert by experience’ had been booked to assist the inspector during the inspection process. It was regrettable that an administrative error had meant that no one was available for the inspection. Some people who use the service have little verbal communication, the inspector observed people’s non-verbal communication and did speak to some individuals about the service, and all said that they liked the service when asked. A member of staff had recently been suspended for a short period whilst vulnerable adults procedures had been initiated. The home and organisation had taken all appropriate steps; the outcome of the investigation was that the allegation had been unfounded. The home has not had a registered manager in post since July 2006. The deputy manager who had been in an acting up position is currently on maternity leave. Mr. Paul Bennett, who is currently in an acting position, has managed the home for the last two months. The organisation has confirmed that they are seeking to appoint a permanent manager in the near future. The home has been granted a variation for one person who uses the service to have dementia; the inspector was informed was other people who use the service may also fall into this category. This issue needs further discussion with the Commission and the providers of the service. 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: Grove Road (45) DS0000007131.V354570.R01.S.doc Version 5.2 Page 6 There is an ethos within the home that all aspects of daily living should be accessible to people who use the service. Many of the forms and policies are in a format that is easier for people to understand, either written in plain English or in Makaton symbols. In addition, the home has started writing the minutes of residents meetings in a format that is accessible. The home is constantly reviewing its processes, most notably the pictorial menu, which was in existence, did not make sense to many of the people who use the service and so therefore it has been changed. It no longer is photographs of packets of food, rather the food itself. The files that have been reviewed by the acting manager are exemplary; they are thorough, well thought out, comprehensive working documents 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 people’s bedrooms, and the individual touches throughout the home of framed photographs of people who use the service at particular events. The staff team are well trained to meet the needs of the people who use the service. They have a range of experience and are from differing cultural backgrounds. It is very positive to note that the home has four male members of staff. People who use the service enjoy a range of activities, which are based on their needs and wishes, some attend day centres, volunteer at various projects or enjoy leisure activities. What has improved since the last inspection? For some time, supervision has been rather an ad hoc arrangement in this home. In general, it has improved dramatically with staff now receiving regular supervision sessions and yearly appraisals. Grove Road (45) DS0000007131.V354570.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Grove Road (45) DS0000007131.V354570.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.V354570.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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. No new person 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 person coming into the home. Only if everyone were happy for the placement to continue, that it would do so. In this way, people feel that they are making positive choices about where they live, rather than just being slotted into vacancies. EVIDENCE: The process of a person 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. It is only at the point that the senior staff are satisfied that a new person might fit into the home and that the home could meet their needs that the introductory visits are started. Grove Road (45) DS0000007131.V354570.R01.S.doc Version 5.2 Page 10 There is then a long process of visits, starting with a tea visit and culminating in weekend visits. Once a new person 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. Documentation viewed showed that the contract is in a pictorial format 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 people who use the service, their advocate and a representative of the home then have signed the contract. The introductory process is well thought out and considered, the contracts are in a suitable format for the people who use the service. The home has therefore been awarded excellent for this outcome group. Grove Road (45) DS0000007131.V354570.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. People who use the service 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. People who use the service are encouraged to be involved in all activities of daily life, even if this might be thought risky for them. In general it appears that 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 people who use the service. Each had a plan, which was based on the original assessment and covered aspects of personal and social support, and healthcare needs. There was evidence that Grove Road (45) DS0000007131.V354570.R01.S.doc Version 5.2 Page 12 each of these plans had been reviewed within the last year by the home, the person using the service and their representatives. One of the files viewed was exemplary; it had a care plan updated in August 2007, just prior to the annual statutory review; It contained a one page summary which profiled the person using the service; it had support plans which identified the persons issue or need, how this would be attained and the intervention required to attain the goal; risk assessments were all up to date; and there were notes of meetings between the key worker and the person using the service. This provided evidence that people within the service are consulted and given choices, and that their changing needs and aspirations are reviewed regularly. The acting manager stated that he is systematically going through all the documentation relating to people who use the service and updating it. Not all files had been updated as yet. A number of requirements have been made in this outcome group, however, the overall rating remains good. Evidence from files that had not been updated showed that one file was not constructed or maintained in an appropriate manner. Key worker meetings with the people who use the service had not been recorded on a monthly basis; on one file it was noted that the last written evidence of the meeting was in early September. Two requirements are therefore made relating to the above issues. Firstly that all files must be maintained in accordance with the Data Protection Act 1998, and secondly that key worker meetings must be recorded as a way of indicating that people who use the service have been consulted on a regular basis. The home is in the process of introducing Person Centred Planning (PCP) for all people who use the service. It was noted that one person had completed their PCP, which was displayed on their bedroom wall; it contained information about what made them happy and what they wanted for the future. For this particular individual it had included a trip to the Vatican to see the Pope, which had been achieved. Currently, there are only two members of staff who have completed their PCP training. A recommendation is therefore made that additional staff undertake PCP training before any further PCP’s are developed for people who use the service. Each person who uses the service has a weekly activity schedule, although the inspector was informed, this varies dependent upon the wishes of the individual. From observation of the schedule, everyone has an activity in the Grove Road (45) DS0000007131.V354570.R01.S.doc Version 5.2 Page 13 morning and one in the afternoon. This may not always be an outside activity, and could for example, help in preparing brunch or tidy bedroom People who use the service are encouraged to be as independent as possible and that this sometimes means taking risks. There were numerous risk assessments in place for people within the community, within the environment of the home or specific to individuals such as ironing. There was some evidence that not all the risk assessments are been reviewed on an annual basis. Therefore a requirement has been made in this regard. People who use the service meet all prospective candidates for jobs. They also have a choice as to whether they to attend staff meetings or not. In reality the inspector was informed that people do attend, but rarely contribute. Grove Road (45) DS0000007131.V354570.R01.S.doc Version 5.2 Page 14 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. People who use the service 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 people to feel that they have a fulfilling and meaningful life. EVIDENCE: Staff are aware that the building is the home of the people who live there and as such they rarely close doors even for meetings, if they do need to close a door it is with permission; staff were observed asking permission or knocking before entering someone’s bedroom. Grove Road (45) DS0000007131.V354570.R01.S.doc Version 5.2 Page 15 Activities are determined by the person using the service, although there is a weekly schedule, it is flexible. Some people who use the service are very busy, one person volunteers at a City farm because she loves animals; she can no longer ride horses because of a hip replacement and so instead visits a stable so that she can groom them. Hallmead, the large day centre in the borough is due to close and therefore alternatives are being sought. It is likely that two people who use the service will start volunteering at a local furniture project. The inspector was informed that activities are reviewed on a termly basis. People who use the service are given the opportunity to fulfil their spiritual needs, and many do in fact attend church. One person identified on their PCP that they wanted to go to the Vatican to see the Pope, which was fulfilled this year. The home is located within walking distance of Sutton town centre. It is used for shopping, going out for a coffee, and for two people, to use the swimming pool at a local hotel. One the day of inspection, there was a German market in the town centre and a number went out to visit it. People who use the service have all had a summer holiday, this year there have been trips to Spain, Centre Parks and the Vatican. The level of consultation with people who use the service 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. People who use the service decide upon meals on Sundays during the residents meetings. The home has a library of pictorial images of food that is available; however, the manager stated that many of pictorial images of food packets have little meaning, so instead photographs of actual food were being taken. The homes continued attempts to give people with little verbal communication, choices, is to be commended. Meals are all freshly prepared, and on Fridays there is a choice of take-away food, which the inspector was informed is invariably fish and chips. An alternative is always available if people do not want what is on offer. People who use the service were observed moving freely around the kitchen and helping themselves to drinks and fruit. People who use the service all have keys to their bedrooms and to the front door. In reality however, there is only one person who uses her key to lock her bedroom door when she leaves the building. Grove Road (45) DS0000007131.V354570.R01.S.doc Version 5.2 Page 16 Grove Road (45) DS0000007131.V354570.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are supported wherever possible to manage their own health care needs. They also generally have access to NHS facilities thereby ensuring that people who use the service have good quality physical care. EVIDENCE: Documentation relating to three people who use the service was examined. One file had a personal health care, which summarised all medical needs, and what intervention if any was required. The aim is that all files will have this information in the future. Other files had a clear record of the health appointments that have been kept; this appeared to be up to date and accurate. There was evidence of regular dentists and opticians appointments; There was also evidence that the home access specialist advice such as that from a clinical psychologist. Grove Road (45) DS0000007131.V354570.R01.S.doc Version 5.2 Page 18 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. Medication is stored in a locked metal cupboard, which is secured to the wall; this cupboard is within a locked storeroom. No one 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. In addition, there is an external audit of medication completed by Boots the Chemist, the last being on the 3.8.07, some recommendations were made, all of which according to the manager have been actioned. 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. People who use the service should have their weight monitored on a monthly basis. It was noted however that this is not always occurring; with one person their weight was taken in May, June and November. A requirement has therefore been made, that everyone in the home must have his or her weight monitored monthly, unless there was a specific reason to make it more often. It was noted that on all health files of people who use the service there was a letter from relatives about their wishes in case of illness or death of the person. Grove Road (45) DS0000007131.V354570.R01.S.doc Version 5.2 Page 19 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. People who use the service 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 people who use the service would understand, and they all have a copy. The home has a complaints log, but none have been recorded within the last year. 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. Staff are given annual training regarding vulnerable adults and certificates were available during the inspection. Some staff were given a scenario regarding vulnerable adults; they were able to give a suitable response as to Grove Road (45) DS0000007131.V354570.R01.S.doc Version 5.2 Page 20 the actions that they would take. Staff were also aware of the whistle blowing policy. Grove Road (45) DS0000007131.V354570.R01.S.doc Version 5.2 Page 21 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 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 people who use the service 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. All the bedrooms are single and with a wash hand basin in them. The bedrooms all feel homely; people who use the service have chosen how to Grove Road (45) DS0000007131.V354570.R01.S.doc Version 5.2 Page 22 decorate their rooms; what furniture they want; and chosen their own pictures and photographs. The home is kept in good decorative order both inside and outside. It was clean and hygienic. Staff and people who use the service are responsible for cleaning the home. The home allows for privacy and dignity; all the bathrooms and toilets are lockable from the inside. A previous requirement that the extremely noisy extractor fan must be repaired has been completed and therefore this requirement has been withdrawn. People who use the service all have their own keys to their bedrooms and the majority have a lockable space in their bedrooms. At the previous inspection it was noted that one room did not have a lockable space, this has now been rectified. There is a small garden to the rear of the property, which is lawned and surrounded by flowerbeds. It is clearly well used in the summer months, as there was garden furniture and barbeque. Grove Road (45) DS0000007131.V354570.R01.S.doc Version 5.2 Page 23 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 good 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 people who use the service live fulfilling lives. In general, staff are supported through their line managers with supervision taking place on a regular basis, this will impact on the quality and calibre of care given to people who use the service. EVIDENCE: Grove Road has an establishment of five full time staff and two part-time staff, the managers’ post is vacant and the deputy is currently on maternity leave. There are ten bank staff, although the acting manager stated that four bank staff are from other homes and three are ex-permanent staff from Grove Road. The acting manager stated that in the two months that he has been in post he has reduced the number of agency hours from eighty to twenty per week. Grove Road (45) DS0000007131.V354570.R01.S.doc Version 5.2 Page 24 The reduction in agency hours is positive, however, number of bank staff is of some concern and will need to be monitored and reviewed. The inspector was informed that of the permanent and bank staff at Grove Road, all are either working towards or having NVQ Level 2. (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 department had recently informed the home that this constituted 55 of the staff team.) Check on AQAA The staff team are mixed in terms of gender, age, ethnic background and experience. There are four male members of staff; and other staff have a range of experiences. Documentation was checked regarding the recruitment of three 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. 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. It was noted that one individual member of staff had not completed a set of core refresher training at the required time. This had been as a result of illness. The duty rota was checked randomly over a series of weeks. There is an expectation that the home has three members of staff of duty in the morning and three in the afternoon, with a waking night member of staff and a sleep in. It was noted that on one shift, during the day there had only been two members of staff on duty. A requirement has therefore been made; that they home ensures that there are sufficient staff on duty to meet the needs of the people who use the service. Whilst the home has been without a registered manager, supervision of staff has been ad hoc. A requirement was made at the last inspection that supervision must be completed to the required level. There has been much progress in this area with supervision now being undertaken regularly and appraisals having been completed. However, it was noted that a bank member of staff who had recently started work at the home, had had no supervision at all. Therefore a requirement remains that all staff, must receive supervision at the required level. Grove Road (45) DS0000007131.V354570.R01.S.doc Version 5.2 Page 25 Grove Road (45) DS0000007131.V354570.R01.S.doc Version 5.2 Page 26 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): 37,39,40,41and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The absence of a registered manager was beginning to impact on the home. However, the acting up manager who has been in post for two months has already made a significant impact to the running of the home and is ensuring that the people who use the service continue to have a high level of care. EVIDENCE: The last registered manager of the home left in July 2006, since then there was a period when the deputy was in the acting up role, she has subsequently gone on maternity leave. Currently, Mr. P. Bennett is in the acting manager position; Mr Bennett has some previous management experience, although it should be recognised that Grove Road (45) DS0000007131.V354570.R01.S.doc Version 5.2 Page 27 he has only been in post for two months. In addition, Mr Bennett has no deputy in post and the regional manager who is new to the organisation has been in post for a month. Mr. Bennett’s presence is already apparent within the home; paperwork has improved dramatically, with the files that he has reviewed, being exemplary. Additionally, the members of staff that the inspector was able to speak to were very positive about Mr. Bennett’s approach, stating that he was ‘approachable and easy to talk to’. Likewise, people who use the service when asked if they liked the new manager, all said ‘yes’ However, until such time that the company appoint and register a new manager, a requirement remains in this regard. 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. With regard to quality assurance, the home completes very thorough Regulation 26 visits, copies of which are made available to the Commission. The inspector was informed that the home conducts annual quality assurance surveys, which are sent out to people who use the service and all other stakeholders. 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 feedback from people who use the service. It was very positive to note that the minutes of the residents meetings were being completed in a pictorial format. Documentation relating to health and safety checks was viewed. Fire equipment was tested weekly and drills were completed monthly; there was some discussion that fire drills need only be completed on a quarterly basis; fire equipment was last checked on the 27.3.07 Electrical testing was completed on the 17.8.06; the gas certificate was completed on the 15.5.07; Legionella on the 5.7.07 and the employers liability was expires on the 31.3.08. Grove Road (45) DS0000007131.V354570.R01.S.doc Version 5.2 Page 28 Grove Road (45) DS0000007131.V354570.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 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 3 25 X 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 3 2 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 2 3 3 2 X 3 3 2 3 X Grove Road (45) DS0000007131.V354570.R01.S.doc Version 5.2 Page 30 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 YA7 Regulation 14(2)(a) Timescale for action Key worker meetings with people 29/12/07 who use the service must all be recorded, as a way of ensuring that changing needs are identified Risk assessments for all people 29/12/07 who use the service must be reviewed at least annually People who use the service must 29/12/07 have their weight monitored on a monthly basis to ensure health and well being The home must always ensure 29/11/07 that there are sufficient staff on duty at all times to ensure the welfare of people who use the service Supervision of all staff must take 29/01/08 place on a regular basis The home must recruit a manager All files must be maintained and constructed in accordance with the Data Protection Act 1998 29/01/08 29/01/08 Requirement 2. 3. YA9 YA19 14(2)(b) 12(1)(a) 4 YA33 18(1)(a) 5. 6. 7. YA36 YA37 YA41 18(2) 8(1)(a) 17(3)(a) Grove Road (45) DS0000007131.V354570.R01.S.doc Version 5.2 Page 31 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 Refer to Standard YA7 Good Practice Recommendations Additional staff undertake PCP training before any PCP’s are completed for people who use the service Grove Road (45) DS0000007131.V354570.R01.S.doc Version 5.2 Page 32 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. 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