Inspection on 05/08/08 for Grove Villa

This inspection was carried out on 5th August 2008.

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 Villa 31/10/06

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 27/09/2008.

CARE HOME ADULTS 18-65 Grove Villa 24-28 Mill Road Deal Kent CT14 9AD Lead Inspector Mark Hemmings Unannounced Inspection 5th August 2008 08:45 Grove Villa DS0000023436.V369164.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.V369164.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.V369164.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 24 Category(ies) of Learning disability (0) registration, with number of places Grove Villa DS0000023436.V369164.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following category: 2. Learning disability - LD The maximum number of service users who can be accommodated is: 24 31st October 2006 Date of last inspection Brief Description of the Service: Grove Villa (the Service) is registered to provide accommodation and personal care for 24 people who have a learning disability. The property is divided into three parts. There is the main house that is a two storey detached property. Then there is a new build single storey wing that is separate to the main house. To get to it you go down the garden. Attached to the new wing there is another older two storey property. All of the people who use the Service can have their own bedroom. Each bedroom has a private wash hand basin. Five of them also have a private shower and another six have a toilet as well as a shower. There are two main lounges and a number of bathrooms and toilets. The Service is set in a quiet residential area of Deal. It is only a short walk to main shops. There is a bus stop nearby. There is plenty of off-street car parking. The Service has its own transport. The Registered Providers are private individuals. People who might want to move in can get information in several ways. There is a Service Users’ Guide. This is a brochure that outlines the main things available in the Service. There is also a document called a Statement of Purpose. This gives a more detailed account than the Guide. The Registered Providers ensure that a copy of the most recent Inspection Report from the Commission is available for people to read. Grove Villa DS0000023436.V369164.R01.S.doc Version 5.2 Page 5 The range of fees charged currently for each person to live in Grove Villa runs from £577.00 to £850.30 per week. The amount actually charged depends upon the amount of personal care needed and the bedroom occupied. The fees include all accommodation, meals, personal care, laundry and in-house entertainment. They do not cover things such as personal toiletries and hairdressing. Grove Villa DS0000023436.V369164.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this Service is 2 Star. This means that the people who use this Service experience good quality outcomes. Since 1 April 2006, we have developed the way we do our inspection of care services. This inspection of the Service was an unannounced “Key Inspection”. We arrived at the Service at 08.45 and were in the Service for about eight hours. It was a thorough look at how well the Service is doing. It took into account detailed information provided by the Registered Providers in their self assessment. This is called the Annual Quality Assurance Assessment (the Assessment). Further, it considered any information that the Commission has received about the Service since the last inspection. This includes questionnaires that we asked the people who live in the Service and members of staff to complete. During the inspection we spoke with one of the five registered providers. In this report we refer to him as being “the Registered Provider”. We spoke with the Manager and with the Deputy Manager. We also spoke with five of the people who live in the Service and with five of the support workers. We saw the lounges, some of the bathrooms and toilets and some of the bedrooms. We walked around the grounds and we looked at a selection of key records and documents. What the service does well: There is a relaxed and homely atmosphere. People say that the support workers are kind and attentive. They also say that they receive the support and assistance they need and that this is in line with their expectations. People are served with good quality meals. Grove Villa DS0000023436.V369164.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: People who live in the Service should be enabled to take a more active role in preparing their individual plans of care. Some people could do more to handle their own medication. Several people who have particular medicines as and when they are needed, should be more involved in their use. This is so that they know why they might be used and have agreed to it. The complaints procedure is not user-friendly. This might make it difficult for people to use and might put people off from saying anything. A part of the recruitment system is not robust. This might mean that some security checks are not completed. The quality assurance system does not seek the views of members of staff. Also, it does not tell people what is going to be done to respond to suggested improvements. This means that people won’t know what will be done as a result of their contributions. Grove Villa DS0000023436.V369164.R01.S.doc Version 5.2 Page 8 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.V369164.R01.S.doc Version 5.2 Page 9 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.V369164.R01.S.doc Version 5.2 Page 10 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): Standards 2 and 5. People who use the Service experience good quality outcomes. This judgement has been made using available evidence including a visit to the Service. People who might want to move in have their needs for support assessed and their wishes acknowledged. EVIDENCE: The Manager says that she completes an assessment of each prospective person’s needs for assistance. This is done before a decision is made about whether or not the Service can meet the person’s needs. She says that this assessment is completed in consultation with the person concerned. As appropriate, members of their family are involved. Usually, everyone is invited to the Service so that they can get a first hand feeling of what the place is like. The Manager can then answer any questions about points of detail and can help the person decide if Grove Villa is the right place for them. We looked at some of the information that is collected. It includes useful and practical things that support workers need to know if they are to help a person from the time they move in. For example, there is information about the person’s special health care needs and about what they can get on with doing Grove Villa DS0000023436.V369164.R01.S.doc Version 5.2 Page 11 for themselves. We asked three support workers about how admission arrangements work out in practice. They say that the Manager shares the information she has collected with them. They are confident that they know what they need to so that new people receive the assistance they need as soon as they arrive. Grove Villa DS0000023436.V369164.R01.S.doc Version 5.2 Page 12 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): Standards 6, 7 and 9. People who use the Service experience good quality outcomes. This judgement has been made using available evidence including a visit to the Service. People should be more involved in preparing and reviewing their individual plans of care. People are helped to manage their money. People are helped to not take unnecessary risks. EVIDENCE: The people who live in the Service say and indicate that the support workers offer them all the assistance they need. There is a written individual plan of care for each person. These are important documents. This is because they form one of the means by which people can decide about the support they need. Also, they are a way for them to show their agreement with how this is going to be delivered. The plans are a source of information for staff. This then helps them to provide support in the right way. Grove Villa DS0000023436.V369164.R01.S.doc Version 5.2 Page 13 We looked in some detail at five sets of these plans. They contain information about a number of relevant things. For example, there is information about how to help the people say what they want and about how to help them with practical things such as getting dressed and using the bathroom. We spoke with three of the support workers about what is in these plans. They have a good knowledge of the needs and wishes of the people concerned and about particular support they need. However, parts of the plans are not written in a user-friendly manner. Also, there is a lot of paperwork and various complicated-looking forms to go through. This makes it very difficult for the people who live in the Service to make a meaningful contribution to how their needs and wishes are recorded. The Manager is going to look into this matter to see what can be done to make the plans easier to use. A good start will be inviting people to write some of the stuff themselves in ways that are meaningful to them. Three people can have a medicine that a doctor has said can be used as and when they need it to help when they are anxious about something. There aren’t clear plans in place to make sure that the medicines are used consistently. Also, we think that more can be done to talk to the people concerned. This needs to be done to make sure that they know about the medicines and about when they will be offered to them. The Manager is going to sort this out by 1 October 2008. Some of the people have their own bank accounts. They are helped to run these by support workers who go along with them to make withdrawals. This is done to make sure that things are in order and that cash doesn’t get mislaid. Other people do not have accounts because their financial affairs are handled by their families or by the local authority. The Service holds small amounts of cash for each person. This is done to help them to budget. We looked at one set of the records of the various transactions. The amounts spent were for reasonable things. For example, for meals out. The cash balance in the person’s individual wallet matches what the record says should be there. People are helped not to take unnecessary risks. For example, one person who goes into town on their own has been asked to take extra care when doing things such as crossing the road in safety. We looked at three sets of these risk assessments. They show that sensible consideration is given to the personal safety of the people concerned. For example, one person who smokes is reminded to make sure that they put out finished cigarettes safely. However, parts of these assessments are not written in a user-friendly manner. This might make it difficult for people to take an active part in their preparation. Again, the Manager is going to look into this to see how the assessments can be made easier to use. Grove Villa DS0000023436.V369164.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): Standards 12, 13, 14, 15, 16 and 17. People who use the Service experience good quality outcomes. This judgement has been made using available evidence including a visit to the Service. People have the opportunity to do occupational and social activities. People are helped to keep in touch with their families. They can spend their days as they wish. Good quality meals are served. EVIDENCE: People are free to do things that interest them. Six people go to a local day centre where they can do a range of craft and occupational activities. There is also the chance to do craft activities at home. We sat in on one of these craft sessions. We saw people doing bead-work and craftwork. One person was doing a large jigsaw. They showed us ones that had been done before and that had been framed and put in their bedroom. At the moment, no one is doing Grove Villa DS0000023436.V369164.R01.S.doc Version 5.2 Page 15 any college courses or working in the local community. However, the Manager says that this is kept under review so that someone can do these things if they want to. The Annual Quality Assurance Assessment says that people will be encouraged to try new and different occupational activities. All of the people are encouraged to help out around the place doing things such as cleaning, laying tables and tidying up. Some people do these sorts of things. One person helps out in the garden and other people help with laying tables and clearing away. People have the opportunity to take part in social activities. We looked at the records of what person has done over a period of four weeks or so. These show that they went out into the local town on several occasions, went to the day centre, saw an occupational therapist and joined in a musical event. Ten people attend a regular social club in the area. Here, they can meet up with their friends and relax in their company. People say and indicate that the pace of daily life in the Service is relaxed and unhurried. While they have considerable choice about how to spend their day, there are broad expectations about some of the things they will do. For example, they are expected to adopt reasonable personal practices such as not going to bed too late so that they are then too tired to do things the next day. People are helped to keep in touch with members of their families. Family members and friends are welcome to call to the Service at any reasonable time. People go to visit family members sometimes with assistance from a support worker. Most people have regular contacts with their families. The Manager in consultation with the person concerned, keeps in touch with family members. This is done so that they know how things are going. People say and indicate that they receive good quality meals and that they have enough to eat. They consider meal times to be a relaxed and pleasant experience. We saw people having their lunch. Things weren’t rushed at all and people chatted about this and that as they dined. There is a choice of dish available at each meal time. At lunch and dinner, there is a main meal and then people can have something different if they prefer. We looked at the menu to see what variety is provided. We think that it gives people the chance to have an interesting and varied diet. Grove Villa DS0000023436.V369164.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): Standards 18, 19 and 20. People who use the Service experience good outcomes. This judgement has been made using available evidence including a visit to the Service. People are helped to support themselves. This includes using health care services. Medicines are handled safely. EVIDENCE: People are assisted in ways that are right for them. For example, some people need more personal space than do others. Or another example is that some people need more support than do others when choosing clothes that are right for the weather at the time. Support workers are courteous in their manner and they respect each person’s individuality. People say and indicate that they can rely upon support workers to be there when they are needed and to be approachable. We observed support workers giving people the time they need to express themselves and then responding in a helpful manner to their Grove Villa DS0000023436.V369164.R01.S.doc Version 5.2 Page 17 requests. In their questionnaire responses, two people sum up the general mood when they say, “I decide what I like to do” and “I am very happy”. People are assisted to maintain their health. Support workers are alert to the need to identify occasions when someone is becoming unwell. This is so that medical assistance can be sought promptly. Since the last inspection, people have been supported to consult with family practitioners and other medical personnel. One person has been in hospital for a chest infection. Since returning home, they have been helped to maintain their recovery. This includes support workers contacting the doctor as soon as there are any signs of the person becoming chesty. People are encouraged to promote their good health. For example, there is evidence that some of the people have been supported to manage their weight. Also, people are helped to attend for regular check ups with the dentist. All of the people have their medicines handled by the Service. Medicines are checked when they are received into the Service to make sure that they are correct. They are then stored securely and in an organised manner. The support workers who dispense medicines know what they are doing. They have been assessed to ensure that they follow a clear procedure. This is designed to ensure that each person takes the right medicine at the right. We looked at five sets of records relating to the medicines dispensed. There are no errors. In more detail, we looked at three medicines in particular. This was done to check that the record of their use matches the stock that is left in the store. Again, we did not find any errors. Some people might be able to do more to manage their own medication or to do bits of the process. The Manager says that she is going to look into this so that people can be offered any support they need. Grove Villa DS0000023436.V369164.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): Standards 22 and 23. People who use the Service experience good quality outcomes. This judgement has been made using available evidence including a visit to the Service. The complaints procedure is not user-friendly. The wellbeing of people is safeguarded. EVIDENCE: There is a written complaints procedure. However, it uses a lot of typed words that might not be that easy for the people who live in the Service to use. The Manager says that she is now going to redo this using pictures and other things to make the procedure more user-friendly. It is best for most complaints to be dealt with at a local level so that they can be informally sorted out as quickly as possible. However, people do have the right to come to us straightaway if they want to. This right is not explained in the current procedure. The Manager is going to sort this out when the new one is done. This will be done by 1 October 2008. Since the last inspection, the Registered Providers have not received any complaints. We spoke with the Registered Provider about how complaints will be dealt with. He says that they will be carefully looked into so that any lessons that need to be learned will be learnt Grove Villa DS0000023436.V369164.R01.S.doc Version 5.2 Page 19 People say and indicate that they feel safe living in Grove Villa. The Registered Providers have a written policy and procedure that tells support workers what to do if they become concerned about someone’s wellbeing. For example, if someone is being bullied or having their freedom limited without good cause. We spoke with three support workers about this matter. They are aware of what to look out for and who to contact if they become concerned. They say that they have seen or heard anything to worry them. Indeed, they are confident that the people who live in the Service are safe and well supported. Grove Villa DS0000023436.V369164.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): Standards 24, 29 and 30. People who use the Service experience good quality outcomes. This judgement has been made using available evidence including a visit to the Service. People live in a generally comfortable setting that promotes their independence. The kitchen is clean and well equipped. There is a separate laundry. EVIDENCE: Most areas of the accommodation are decorated and furnished to a normal homely standard. There are some exceptions. In the new build there are some unsightly settlement cracks where the walls meet the ceiling. The Registered Provider says that this whole area is due to be decorated once the new plaster has completely dried out. In the conservatory, there are various areas of chipped woodwork and on the outside some of the sills are rotten in places. Grove Villa DS0000023436.V369164.R01.S.doc Version 5.2 Page 21 The bathrooms and toilets are rather stark. Little has been done to make them into welcoming spaces. The premises are fitted with an automated fire detection system. This provides a high level of fire safety protection. The Registered Providers have prepared a fire risk assessment. This has been done to ensure that the fire safety system works as intended. The assessment was completed in 2005. Another one is currently being prepared. This is being done by a fire safety expert. We understand that it has not identified the need for any major improvements to be made. Once it has been finished, the Manager is going to send the assessment to the Kent Fire and Rescue Service. This needs to be done so that fire safety people can double-check that things are okay. The local Department of Environmental Health has recently called to the Service to see how things are going in the kitchen. Its report says that the food handling arrangements are “very satisfactory”. We looked at the kitchen. It is clean and well equipped. There is a system to make sure that foods are used within their best-by dates. There is also a system to make sure that the refrigerators are cold enough to store foods safely. Sensible steps are taken to promote hygiene. For example, there are different chopping boards for use when preparing uncooked meats. Some of the people who live in the Service find it a bit difficult to get about. This is particularly so in the bathroom. Support workers help these people as and when it is needed so that they are safe and comfortable. The laundry is equipped with a commercial washing machine and dryer. People are encouraged to do their own laundry, but in practice most rely upon support workers to organise this for them. The arrangements used work well. Each person has a sufficient supply of clean and presentable clothes from which to choose. There are new regulations that have been introduced to ensure that used water does not leak back into the main pipe-work. The Registered Providers are going to check with the local water supply company to make sure that it complies with these provisions. This will be done by 1 October 2008. Grove Villa DS0000023436.V369164.R01.S.doc Version 5.2 Page 22 Grove Villa DS0000023436.V369164.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): Standards 33, 34 and 35. People who use the Service experience good outcomes. This judgement has been made using available evidence including a visit to the Service. There are enough staff on duty to make sure that people get the support they need. Most of the required security checks are being completed on staff. Support workers know what they are doing. EVIDENCE: There are four support workers on duty during the day and three in the afternoon and evening. At night time, there is a waking staff presence. During the week, the Manager works normal office hours. There is also a cook and housekeepers. We looked at the staff roster and we found that the various shifts are being filled on a regular basis. We asked two of the people who live in the Service if there are enough staff on duty. They say that there is and that they get all the support that they need. We asked three support workers about the staff cover. They also think that it is adequate to enable them to give people the support and attention they need. Grove Villa DS0000023436.V369164.R01.S.doc Version 5.2 Page 24 There is an on-call system. This means that someone senior can be contacted for advice out of office hours. The Registered Providers complete a number of security checks for new support workers. These include checking the person’s identity and their employment history, seeking references and obtaining a police check. This is done to ensure that they are suitable and trustworthy people. We looked at the records for two new support workers. Most of the checks have been completed. However, there are some gaps in the employment histories. This means that we cannot be sure that all of the necessary references have been sought. We do know that one reference is outstanding. The Manager is going to sort out these problems by 1 October 2008. New support workers receive introductory training before they work without direct supervision. After that, there is ongoing training for all support workers in a number of key subjects. We looked at the records of who has done which courses to see how the system is working in practice. Most of the support workers have done some training in the various subjects. However, there are some gaps to note. For example, seven people have not done recorded training in food hygiene, 11 support workers have not done the first aid course, 10 support workers have not done the medication course and 12 people have not done the course to do with keeping people safe. Of the 20 support workers, eight have completed a relevant National Vocational Award to level 2. Six people have also done the higher level 3 award. These qualifications are important because they are designed to help support workers to give high quality help to people. The Manager is going to complete an organised review of the skills and knowledge of each of the support workers. This is going to be done to make sure that they know in practice what they need to know if they are going to effectively help the people who live in the Service. This review is going to be completed by 1 January 2009. In the meantime, we looked at the know-how of four support workers. They have a good knowledge of the individual needs of people for support. For example, they know how people prefer to express themselves and we saw them using their expertise to good effect. They respond to people in a flexible and appropriate manner. Also, they know what to do if someone becomes anxious and needs to be reassured. This includes understanding what behaviour means and responding to it in an informed way. The Manager says that she is confident that all of the support workers have the skills and knowledge they need. Grove Villa DS0000023436.V369164.R01.S.doc Version 5.2 Page 25 Grove Villa DS0000023436.V369164.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): Standards 37, 39 and 42. People who use the Service experience good quality outcomes. This judgement has been made using available evidence including a visit to the Service. The Service is reliably managed. The quality assurance system does not collect enough information. People’s health and safety is promoted. EVIDENCE: We have registered the Manager. This means that she has shown us that she knows what she is doing. She has recognised management qualifications. There are various systems used to promote good team-work. These include handover meetings at the beginning and end of each shift. Also, there are staff Grove Villa DS0000023436.V369164.R01.S.doc Version 5.2 Page 27 meetings. The last one took place in April 2008. The records show that relevant things were discussed. These include the need to fit some hold-open devices to some of the bedroom doors in order to help people get about more easily. The Manager says that these have now been fitted. Support workers say that there is very good team work. We saw plenty of evidence of this. For example, support workers check out with each other who is going to do what, with whom and when. One support worker summarises the tone of the questionnaires completed by members of staff when they say, “ I think the staffing level is good. Occasionally staff go sick but it’s always covered so it doesn’t stop us meeting needs. We work well as a team to meet needs”. Several things are done to consult with people about how well the Service is running. These include informal everyday discussions and more organised house-meetings. All of the people who live in the Service are invited to attend these meetings and they can raise any subject they like. We looked at the records of the last meeting that took place in July 2008. Five of the people who use the Service took part. The meeting discussed things such as the menu and social activities. There is also a system of asking the people who live in the Service and their relatives to complete questionnaires about once a year. This is so that they can have their say about how things are going. We looked at some of these questionnaires and they say positive things about Grove Villa. One relative sums up the general tone when they say, “I am very happy with the care my daughter receives at Grove Villa. I realise that she can be very difficult at times and the staff appear to be kind and patient. I consider (my daughter) fortunate to have been placed there”. However, members of staff are not invited to complete questionnaires. Also, there is no system to tell stakeholders what is going to be done to respond to improvements that are suggested. The Manager says that this is going to be sorted out. This will be done in time for the results to be included when the Registered Providers send us their next Assessment in 2009. Regular checks are completed to ensure that the Service’s fire safety equipment remains in good working order. This includes a weekly test of the fire alarm bells and periodic more detailed checks completed by a contractor. There are unannounced fire drills. Each member of staff should attend a fire safety lecture each six months. This is taught by a fire safety expert who comes into the Service. We looked at the records of who has had this lecture so far this year. We found six people to be overdue. The Manager said that this was because it can be difficult to arrange for everyone to attend a course on a particular day. She says that she is going to get round this by introducing a new system. This will involve one of the management team ensuring that each member of staff has been regularly assessed as knowing how to reliably use the Service’s fire safety procedure. This is very important because the actions taken by staff largely determine the level of fire safety protection available in the Service. The Manager says that the new system will be introduced by 1 October 2008. Grove Villa DS0000023436.V369164.R01.S.doc Version 5.2 Page 28 The electrical installation and the gas-fired appliances have been certified as being in a safe-worthy condition. We looked at the record of accidents and other untoward events that have occurred in the Service this year. There is nothing exceptional in their nature or frequency that needs us to make any further enquiries. The Registered Providers check the premises and the accommodation. This is done to ensure that there are no hazards that might cause someone to have an accident. We looked at the records to see what sorts of things are considered. They are sensible and include things such as trip hazards. The Manager says that no such particular problems have been found. She says that there is no need at the moment to take special steps to reduce the risk of someone being scalded by hot water or burnt by a radiator. Also, she says that none of the people who live in the Service are likely to fall from one of the first floor windows. We didn’t identify any particular hazards. For example, things like bleach are stored securely when not being used. Grove Villa DS0000023436.V369164.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 X 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 3 32 X 33 3 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 X X 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 3 X 3 X 2 X X 3 X Grove Villa DS0000023436.V369164.R01.S.doc Version 5.2 Page 30 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. Standard Regulation Requirement Timescale for action 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 Villa DS0000023436.V369164.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Maidstone 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.V369164.R01.S.doc Version 5.2 Page 32 - 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!