Inspection on 31/10/06 for Grove Villa

This inspection was carried out on 31st October 2006.

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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Grove Villa 05/08/08

Grove Villa 06/09/05

Grove Villa 25/04/05

Grove Villa 04/10/04

Grove Villa 20/04/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Grove Villa 24-28 Mill Road Deal Kent CT14 9AD Lead Inspector Chris Randall Key Unannounced Inspection 31st October 2006 09:20 Grove Villa DS0000023436.V306088.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 Villa DS0000023436.V306088.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 Villa DS0000023436.V306088.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grove Villa Address 24-28 Mill Road Deal Kent CT14 9AD 01304 364454 01304 367489 grovevillacare@aol.com 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) Mr Tony Beales Mr Henry George Chamberlain, Mrs June Chamberlain, Mrs Jane Friend, Mrs Nicola Reseigh Ms Linda Saggs Care Home 23 Category(ies) of Learning disability (23) registration, with number of places Grove Villa DS0000023436.V306088.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One Service User whose date of birth is 02/11/1950. Date of last inspection 6th September 2005 Brief Description of the Service: Grove Villa together with its annexe and new wing, provides a home for up to 23 adults with learning disabilities some of whom may have challenging behaviours and complex needs. The property is divided into three parts, the main house at the front and the annexe and new wing which although separate from the main house are accessed through this property. There is an accessible garden which has recently been upgraded. Service users with the potential for greater independence are offered the opportunity to develop and move on to smaller units owned by the providers in the Deal area. Grove Villa, itself is well established and is set in a quiet and pleasant residential area of Deal, it is located opposite to a community recreation area, close to local shops and the local swimming/leisure centre. A bus service runs in the road and the local train station is within two minutes walking distance. The main shopping centre is approximately 5 minutes walk from the home. The current fees for the service at the time of the visit range from £450 to £850 per week. Information on the Home’s services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. The e-mail address of the home is Grovevillacare@aol.com. Grove Villa DS0000023436.V306088.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The information on which judgements in this report are based was obtained from a pre-inspection questionnaire completed by the manager; service user questionnaires; and an unannounced site visit to the home of 7:25 hours. The site visit consisted of talking with service users, staff, and management; observation of interactions between service users and staff, a staff meeting, and a meal being served and eaten; a tour of the building; and examination of various records. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Grove Villa DS0000023436.V306088.R01.S.doc Version 5.2 Page 6 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 Villa DS0000023436.V306088.R01.S.doc Version 5.2 Page 7 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, & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are provided with sufficient information, their needs are assessed, and they are able to have trial visits in order to make an informed choice about admission to the home EVIDENCE: The homes statement of purpose has recently been updated to include the registration changes for the new extension. The service user guide is also in the process of being updated. Comment cards from service users confirmed that they had received enough information about the home before they moved in. A full needs assessment is carried out by the home for any prospective service user. A copy of the single Care Management assessment is also obtained. These two documents form the basis of the service users plan of care. Grove Villa DS0000023436.V306088.R01.S.doc Version 5.2 Page 8 Following the needs assessment the home will only admit service users if they are confident that they can meet the assessed needs. The opportunity of a series of trial visits and a three month settling in period gives extra opportunity for the home to ensure that all needs can be fully met; and gives the service user the chance to be sure that this is the place they want to live. All service users are issued with a contract or statement of terms and conditions. Contracts include the room to be occupied, the fees payable and by whom, any additional costs, and the responsibilities of the service user and the home. The service user or their representative and the registered manager sign all contracts. Grove Villa DS0000023436.V306088.R01.S.doc Version 5.2 Page 9 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, 9, & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each service user has an individual and personalised care plan detailing the care they require; they are encouraged to make decisions about their lives and to take appropriate risks; and they can be confident that information regarding them will be held in confidence EVIDENCE: The home produces a comprehensive and personalised care plan for each service user based on the information gained during assessment. Care plans are regularly reviewed and amended to reflect the service users changing needs. Service users are involved in making decisions about their lives with staff support wherever needed. A monthly residents meeting is held when joint Grove Villa DS0000023436.V306088.R01.S.doc Version 5.2 Page 10 decisions are made regarding such things as holidays, activities, and meals. Some of the service users assist with interviews for new staff both at the home and at the day centre that they attend. Service users who are capable are supported in dealing with their own finances. Families or independent appointees deal with the finances of the remainder. Staff assist those who need help to deal with their pocket money and all monies are kept safe, regularly balanced, and transactions are properly recorded. Staff assist service users to take responsible risks subject to risk assessment and hazards being minimised. Risk assessments are carried out to cover most eventualities and these are reviewed regularly. The home has a confidentiality policy and staff only pass on information regarding service users to those who have a right and need to know the information. Service users records are kept in a secure place in the home. Grove Villa DS0000023436.V306088.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, & 16 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users lead a lifestyle that meets their needs and choices; they are supported to take part in appropriate education, leisure and cultural activities; they are encouraged to maintain links with families, friends and develop links with the local community; and they are offered a healthy and varied diet. EVIDENCE: Although currently none of the service users at Grove Villa are in paid employment, three assist with interviewing prospective staff for the home and the day centre. Those service users who choose are supported in applying for and attending educational courses at college. Grove Villa DS0000023436.V306088.R01.S.doc Version 5.2 Page 12 Service users are encouraged to mix in the local community this includes going to clubs, pubs, church, day centre, shopping or out for meals. Service users commented, “I go to the disco, I like dancing”, “I am going fishing tomorrow”, and “I have been to the centre”. All service users are invited to go on an annual holiday and commented, “we went to Camber Sands on holiday, I joined in the karaoke”, and “Camber Sands was good”. All are escorted when they go out of the home. The home supports service users in registering to vote, and accompany those who wish to attend the polling station. There is a 7-seater bus and 4-seater car available at all times for service user transport. The home encourages and support service users to pursue their own interests and hobbies. Service users commented, “I like playing patience”, “I play my records in my room”, “I like football, I support West Ham”, and “I like the craft sessions” Entertainment provided includes a weekly occupational therapy session. Service user comment cards all indicated that there are activities the service users can take part in. Their written comments included, ‘Activities the home provides, music man, disco, OT’, ‘Music man, O.T. magic show, clubs’ and ‘I enjoy all activities, the best activity is the O.T. where we make things’. A service user said, “we had a Halloween disco last night”. Families, and friends of service users are welcomed and encouraged into the home, and service users are supported in maintaining both family and personal relationships. Service users can choose whom they see and where and when they see them. Service users are given choices in all aspects of their daily lives and staff help to promote their choices and their independence. Service users commented, “I like cooking”, and “I make cups of tea and coffee”. All service users have been offered a key to their own bedroom door although only some have chosen to take up this opportunity. Interaction between staff and service users is relaxed, friendly and appropriate. Staff were observed treating service users with respect. Service users were observed moving freely between the separate units of the home; choosing which area they wished to have lunch or to sit; and whether they wished to be with other people or alone. Most service users take some responsibility for the cleanliness and tidiness of their own bedroom, some unaided and some with the assistance of staff. The home employs a dedicated cook. There is a four-week menu that gives a good variety and balance of meals, and this is currently being changed to reflect the change of season. Service users are involved in choosing what foods should be on the menu and meals are always discussed at the residents Grove Villa DS0000023436.V306088.R01.S.doc Version 5.2 Page 13 monthly meetings. Comment cards from service users indicated that they usually or always like the meals at the home with one card indicating ‘sometimes’. Service users spoken to on the day of the site visit commented, “the food is usually good”, “I like my food, she is a good cook”, and “the food is good”. Staff said, “the food is lovely”, and “I love the food”. Service users nutritional needs are assessed and their likes and dislikes are recorded. Where service users need assistance with eating this is given sensitively. Grove Villa DS0000023436.V306088.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff of the home, supported by a multi-disciplinary health care team, meet service users health and personal care needs. The completion of the new medication room and its associated storage facilities will further improve the safety of service users medication. EVIDENCE: Personal support is given to service users in a way that encourages their independence and promotes their privacy and dignity. Staff members commented, “I always knock on service users doors before going in”, and “I make sure they have their housecoats on when going from the bedroom to the bathroom”. The amount of support needed is recorded in the care plan, together with details of the way in which the service user prefers to receive assistance. Service user comment cards received confirmed that they received the care and support they needed. A service user spoken with on the day of Grove Villa DS0000023436.V306088.R01.S.doc Version 5.2 Page 15 the inspection commented, “they look after me”. Daily routines are flexible, with service users having choices in all aspects of their daily lives. Service users choose their own clothes and were observed expressing their own individuality in choice of clothes and jewellery worn. A service user commented, “I have had my nails done this afternoon”. Staff members said, “we assist when needed but also encourage their independence”, and “we encourage them to help dress themselves and choose their own clothes to wear”. The staff of the home supported by a multi-disciplinary team of health care professionals meet the health care needs of service users. All service users have annual health checks and medication reviews. All contact with professionals is recorded in the care plan. Service user comment cards confirmed that they receive the medical support they need. A staff member commented “the chiropodist visits monthly; we take them to the doctors when they need to go; reflexology comes in; some go to the dentist and the dentist comes in to visit others; the district nurses come in if needed; and we escort clients to the hearing clinic when necessary”. The home has a medication policy and procedures for the receipt, administration, storage and disposal of medication. A new medication room has been provided in the recently completed extension. This will be fitted with a sink, and appropriate storage cupboards. A dedicated drugs fridge is also being sited in the room. Although the home has a policy on self-medication currently no service users have chosen to do this. All care staff who administer medication have attended medication training. A recommendation has been made that the new medication room is fitted out and brought into use as soon as possible and that staff are reminded of the importance of accurate recording in the MAR book. Grove Villa DS0000023436.V306088.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that their complaints will be taken seriously and investigated and that they will be protected from abuse. EVIDENCE: The home has a clear and effective complaints procedure and a copy is on display in the hallway. There have been no complaints recorded since the last inspection. Observation of the complaints register confirmed that when complaints are made they are properly recorded, and that a record of the outcome is shown. Service user comment cards confirmed that they all knew who to speak to if they were not happy and that they all knew how to make a complaint. Staff spoken to all confirmed that they would know how to deal with a complaint made to them. Service users are protected from abuse. The majority of staff have attended Adult Protection training and the remainder are booked to attend forthcoming courses. Staff spoken with during the inspection were all aware of the need to report suspected abuse; most were aware of the whistle blowers policy and those who were sure have now been reminded. All new staff are checked against the Protection of Vulnerable Adults register before starting their Grove Villa DS0000023436.V306088.R01.S.doc Version 5.2 Page 17 employment in the home. Staff spoken with during the site visit all understood how to deal with physical or verbal aggression by service users in a non-confrontational way, they commented, “I try to calm them down by gentle talking”, “if its verbal aggression I ask them politely not to do it”, and “I would get a senior if it was physical aggression and I was not able to control it myself”. The home does not use restraint procedures. The home have input from the professionals at Cairn Ryan in planning management strategies for service users who exhibit challenging behaviour Grove Villa DS0000023436.V306088.R01.S.doc Version 5.2 Page 18 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, 27, 28, & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a home that is clean, comfortable, and well maintained with accommodation to suit their needs, and an accessible garden area. EVIDENCE: The home is divided into 3 distinct parts, the main house, the annexe/bottom house, and a new wing. The recently been completed wing provides 6 additional single bedrooms all with en-suite shower and toilet, and additional communal facilities. The new wing is linked to and accessed through the bottom house. Although the new rooms were not occupied at the time of the inspection, a variety of personal belongings had been moved in. One service user commented, “I’m moving into one of the new rooms”. Grove Villa DS0000023436.V306088.R01.S.doc Version 5.2 Page 19 The home is safe and well maintained. Furnishings and fittings throughout are comfortable and homely. The garden is accessible to wheelchair users and has recently been improved with new lawn and flowerbeds, wheelchair friendly paths, and patio areas with outdoor furniture. The location of the home is suitable for the needs of the service users with a local bus route nearby and the town within walking distance. Staff commented, “the home is nicely planned out, the new bit is really nice”, and “its got a homely feel”. The recommendations shown on the last report have been addressed Service user bedrooms are individualised to suit their needs and choices, some service users having chosen to provide their own furniture and others to provide a variety of personal possessions varying from pictures, televisions, and music centres, to canopied bed heads. Service users commented, “I’ve got a nice room”, and “this is my record player”, and a staff member said, “the bedrooms are nice” Sufficient toilet, bath and shower facilities are provided to meet the needs of the service users. A variety of shared space is available. The main house has a dining room, a lounge, and a quiet lounge; the bottom house has a large lounge/dining/ kitchen area and a conservatory, and the new wing has a lounge/kitchen area. Sleep in facilities for staff are provided in the main house and the new wing with the bottom house being served by waking night staff. Smoking is only permitted outside the building. An effective infection control policy is in use, and the home is clean and free from offensive odours throughout. Service user comment cards received confirmed that the home is fresh and clean with one comment made ‘I think the home is very clean’. A member of staff said, “its very clean, we have a cleaner in every day and the wake night does some cleaning for the next day”. Clinical waste is now kept in a locked storage container. Grove Villa DS0000023436.V306088.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported b y a team of staff who are trained to meet their needs Although recruitment procedures are generally good, gaps in employment history of staff could put service users at risk EVIDENCE: 50 of care staff have now been trained to NVQ level 2 or above, and further staff are undertaking training. It is now the policy of the home that all staff will be enrolled for NVQ 2 in care, with particular emphasis on dealing with service users with learning disabilities, once they have completed their initial induction period. Staff commented, “I have just completed NVQ 2 and am now going on to do level 3”, and “I started my NVQ last week”. The home has updated their induction to comply with the recommendations of the Skills for Care common induction standards. Grove Villa DS0000023436.V306088.R01.S.doc Version 5.2 Page 21 The home has an effective staff team. There is now a dedicated full time cook and cleaner and they are currently advertising for a second cleaner. Overnight a sleep in carer is on duty in the main house, there will be a sleep in carer in the new wing, and there is a waking carer in the bottom house. A staff member commented, “we take it in turns to do wake nights”. Regular staff meetings are held and one was taking place on the day of the inspection site visit. Service user comment cards confirmed that the staff listen and act on what they say, and that there are staff available when they need them. One comment card stated, ‘the staff look after me very well’. The majority of staff spoken to during the inspection site visit confirmed that they consider there are sufficient staff on duty, but one commented, “some days, dependent on the clients”. Recruitment processes are fairly thorough and no new member of staff is employed until 2 satisfactory references have been received, an enhanced disclosure has been submitted to the Criminal Records Bureau, and a satisfactory check has been made on the Protection of Vulnerable Adults register. All staff are given a statement of terms and conditions of employment and all are issued with a copy of the General Social Care Council code of conduct. However there has been a requirement on the last 2 inspection reports that staff files should be updated to meet the requirements of Schedule 2. As the home has not yet obtained a full employment history for all staff this requirement has been repeated. The home has a training matrix and all staff are trained in the mandatory subjects once they have completed their basic induction. All staff receive training in Adult Protection, and all staff responsible for the administration of medication undertake safe handling of medication training. Various staff have also been trained in challenging behaviour, managing aggression, drug and alcohol awareness, and health and safety awareness. Staff commented, “I have just finished my induction”, “my fire training is coming up but I covered the basics on induction”, and “I have not done adult protection yet but it is coming up soon” Staff have regular documented supervision sessions at least six times a year. Staff spoken with commented, “I had supervision last week”, and I have just had supervision”. Service user comments about staff included, “the staff are all good, and “the staff are nice”. General comments from staff included, “I enjoy it”, “I like the clients and the staff”, and “I get on well with all the clients”. Grove Villa DS0000023436.V306088.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42, & 43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a positive atmosphere in a home that is effectively managed; their health, safety and welfare are promoted but installation of additional radiator covers would further protect their safety EVIDENCE: The manager has the relevant qualifications and experience to run the home effectively. She is approachable and operates an open door policy for both service users and staff All staff spoken to confirmed that they get support from the manager. The atmosphere in the home is open, friendly, and positive. Grove Villa DS0000023436.V306088.R01.S.doc Version 5.2 Page 23 Quality assurance strategies for the home have been further developed since the last inspection. Annual questionnaires are now sent to service users, family, and professional visitors. The manager also intends to develop questionnaires for staff. An analysis of the answers will be produced once the questionnaires are returned. Regular documented audits are carried out including Health & Safety checks. Medication audits take place but at present are not documented. The home holds regular staff meetings and one took place on the day of the inspection site visit. Client meetings are held monthly, amongst other things menu’s are discussed each month plus suggestions for outings. The provider carries out monthly visits and a copy of his reports are kept in the home. The home has a development plan and all policies and procedures are reviewed annually and are currently being further updated. The home promotes the health, safety and welfare of service users and staff. Staff are trained in the mandatory subjects. Accident reporting is in order. Safety certificates viewed were all up to date and relevant. Under floor heating has been provided in the new wing and therefore no radiators are necessary. At present the only radiators in the main house and bottom house that have been covered are those assessed as causing the greatest risk. It is recommended that to ensure the safety of the service users the home schedule a planned implementation to cover the remaining radiators. Grove Villa DS0000023436.V306088.R01.S.doc Version 5.2 Page 24 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 3 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 3 3 X X 2 X Grove Villa DS0000023436.V306088.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA34 Regulation Schedule 2 CHR 2001 Requirement Staff files to be further updated to show a full employment history for all staff to comply with the revised Schedule 2 the new medication room is fitted out and brought into use as soon as possible and that staff are reminded of the importance of accurate recording in the MAR book. (previous requirement with timescale of 31/12/05 partially met) Timescale for action 28/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA20 YA42 Good Practice Recommendations The new medication room should be fitted out and brought into use as soon as possible and staff should be reminded of the importance of accurate recording in the MAR book. To ensure the safety of the service users the home should schedule a planned implementation of providing covers for DS0000023436.V306088.R01.S.doc Version 5.2 Page 26 Grove Villa the remaining uncovered radiators. Grove Villa DS0000023436.V306088.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Villa DS0000023436.V306088.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!