Inspection on 06/09/05 for Grove Villa

This inspection was carried out on 6th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 05/08/08

Grove Villa 31/10/06

Grove Villa 25/04/05

Grove Villa 04/10/04

Grove Villa 20/04/04

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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 Michele Etherton Announced 06/09/05 at 10:00am 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 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 Stationary 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 H56-H05 S23436 Grove Villa V238669 060905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Grove Villa Address 24-28 Mill Road, Deal, Kent Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01304 364454 01304 367489 grovevillacare@aol.com Mr Tony Beales, Mr Henry Chamberlain, Mrs June Chamberlain, Mrs Jane Friend, Mrs Nicola Reseigh Ms Linda Saggs Registered Care Home 18 Category(ies) of Learning Disability registration, with number of places Grove Villa H56-H05 S23436 Grove Villa V238669 060905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25.4.05 Brief Description of the Service: Grove Villa the main house and its annexe provide a home to adults with learning disabilities some of whom may have challenging behaviours and complex needs. The main house is a detached Edwardian villa, located on Mill Road itself, and an annexe offering additional accommodation located to the rear of the garden. Access to this unit is via the main house although a small side road enables access directly to the unit. The home is Registered for 18, however, as double rooms drop to single usage it is the intention to enable all people using the service to have single occupancy of bedrooms, this has therefore reduced the number of residents to 17. Only one shared room is still in usage at this time. The annexe building has a large conservatory adjoining it, which serves as a day time activity centre for residents in both units. The property has an accessible garden, this is reduced in size owing to some redevelopment of the site. Those people in the service who have potential for greater independence are offered the opportunity to develop daily living skills and move on to smaller units within the residential provision owned by the providers in the Deal area some of which have lower staff support. 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 mins walk from the home. Grove Villa H56-H05 S23436 Grove Villa V238669 060905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, which took place over one day. The inspection focussed on the remaining key standards to be covered within the reduced methodology, and assessed progress made on requirements and recommendations highlighted at the last inspection. During the inspection a tour of the communal areas within the premises was undertaken, a reduced range of documentation was examined also. Four care staff in addition to the manager and one of the providers were spoken with during the course of the visit. Eleven of the people who live at the home currently were observed and spoken with throughout the day. A limited but positive response has been received in respect of feedback from relatives and professionals to CSCI in respect of the service. What the service does well: What has improved since the last inspection? The Home has actively sought to address outstanding criticisms of menus and the over reliance on convenience type foods. One of the providers who is also a trained chef now produces the main meal daily in the Home. The Home has overcome some of the initial obstacles to commencing work on the new extension, and work is likely to begin in the Autumn. An intense staff training programme has been established to ensure all care staff have completed their mandatory core skills training. Some improvements have been made to medication storage and documentation. The activity programme for service users has also become more structured and senior staff are actively seeking Grove Villa H56-H05 S23436 Grove Villa V238669 060905 Stage 4.doc Version 1.40 Page 6 more stimulating activities to provide in house for service users which will also benefit those users with limited attention spans. 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. Grove Villa H56-H05 S23436 Grove Villa V238669 060905 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Grove Villa H56-H05 S23436 Grove Villa V238669 060905 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Not assessed at this visit EVIDENCE: Grove Villa H56-H05 S23436 Grove Villa V238669 060905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 & 9 Service users are supported to make decisions about their daily lives, but the home could do more to engage with the least able users to make this process more meaningful. The Home actively supports service users to maximise their independence and the associated risks attached to this. EVIDENCE: Although individual care plans were not assessed on this occasion, the home had addressed a previous recommendation made in respect of one service user. Person centred planning is currently being introduced in one of the smaller units, for one service user, once accomplished the Manager will use this model to implement person centred care plans across all other units, including Grove Villa. Progress in this area will be monitored over the next 12 months. Feedback from discussions with more able service users living at Grove Villa, indicated that they have input into decisions around their daily lives and activities, including what to eat, clothing they choose to wear and buy, decorating their rooms, participation in activities etc. Most appeared satisfied with the level of decision-making they are required to do. One person indicated some frustration that they might be restricted in the decisions they Grove Villa H56-H05 S23436 Grove Villa V238669 060905 Stage 4.doc Version 1.40 Page 10 take in respect of activities by the need for staff supervision, and that this impacted on their ability to always do the things they wanted to do. Some people spoken to were experiencing some loss of activity, due to the closure of their college during the long summer break. As more service users make use of college courses the home will need to consider the development of stimulating activity programmes during holiday times to ensure users do not become bored and frustrated. Those less able service users with more complex behaviour and communication difficulties although given opportunities to make decisions would benefit from individually focused and intensive staff support to make use of such opportunities and to develop this skill in other aspects of their lives. Consideration should be given as to how the home staff can engage better with this group and maximise their potential. The Home is keen to promote independence for service users and to maximise their potential, this naturally will bring about increased and different risks, the home staff recognise potential risks for users but further development of risk assessments are needed. The home has worked with the local Learning disability team in this respect and will adopting a risk assessment format suggested by the team. Grove Villa H56-H05 S23436 Grove Villa V238669 060905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 14,15, 16 A structured activity programme is in place but needs further development to engage with all users. The Home provides appropriate levels of support to service users in respect of maintaining where possible their relationships with family and friends. There is a flexibility and element of choice within daily routines, but this is more evident amongst more able service users. EVIDENCE: Discussion with service users and staff highlighted an increased usage of college courses and external activity opportunities, staff indicated that there had been issues of access for some service users with mobility issues and this had prevented them attending some activities. There has been a turnover in staff and the staff group is predominantly younger, a senior staff member whilst recognising that this is initially limiting in what activities you can send new inexperienced staff out to with users, also saw a positive advantage of new staff coming into the service who do not have preconceived ideas or attitudes which place limitations on service users capabilities. A previous recommendation in respect of the activities programme has been implemented, but, consideration should now be given as to how more Grove Villa H56-H05 S23436 Grove Villa V238669 060905 Stage 4.doc Version 1.40 Page 12 imaginative programmes and staff intensive one to one work can engage less able service users. Feedback from discussions with staff and service users during the visit highlighted how a number of users are supported to maintain contact with their families and friends through visits home, or receiving visits, cards, letters and telephone calls. Staff confirmed that this is more successful where contact is actively sought by both parties’, unfortunately this is not the same in all cases. One service user was upset at a change in the visiting pattern of their relatives and was unclear why this had occurred, liaison by the home staff on the users behalf has failed to improve this situation. Staff confirmed that they are involved in facilitating trips home for some service users. Whilst there is a clear structure in place for each day for the service users, there is also flexibility within this for them to choose to actively participate or not, and service users were observed to absent themselves from some activities or areas where other users were gathered, throughout the day. Some service users have keys to their rooms, less able service users should be encouraged to use a key to open their rooms even if they do not have the capacity to keep the key securely, thus affording them the same rights and privacy as others, and this is a recommendation. A previous recommendation to remove an unsatisfactory lock and key arrangement established for a less able service user has been discontinued, although commendable of the home to try and facilitate a manageable system for the service user concerned, the wider implications had not been appropriately assessed on that occasion. One service user with a hearing difficulty has a doorbell fitted to their bedroom door. Staff were observed interacting with service users in a respectful, patient and kind manner. The Home are still to evidence feedback to service users and actions taken as a result of their contribution of ideas and suggestions at meetings etc in respect of activities, daily routines etc. The home have responded to a previous recommendation to employ a full time cook at the home. A qualified chef has been in post for the past month and has taken over responsibility for ordering and producing a balanced and nutritious menu and producing the main meal of the day. Upgrading of the kitchen has also been completed. Minutes of service user meetings evidenced that consultation in respect of menus is happening with users and a previous requirement for this to happen met. Grove Villa H56-H05 S23436 Grove Villa V238669 060905 Stage 4.doc Version 1.40 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20 The home has made progress in the management and administration of medication but poor security and storage facilities for the medication remain a cause of concern, shortfalls in these areas could place service users at risk. EVIDENCE: This visit assessed progress made by the home in addressing an outstanding requirement and recommendation for this standard. Mar sheets viewed were completed satisfactorily, with appropriate supporting documentation from GPs for changes to medication. Medication storage was reviewed, this was much tidier and liquid medications are now being dated upon opening, the importance of the separation of tablets from liquid medications must continue to be stressed with staff, although there had been a marked improvement and the outstanding requirement achieved. The medication procedure which has again been revised was discussed with the manager and additional amendments suggested to improve clarity. A controlled drugs book has been introduced and the home have been asked to ensure they record balances. Staff competency checks for those trained staff who do not routinely administer was discussed with the manager and provider, who will consider ways in which this can be reviewed from time to time and this remains a recommendation. Arrangements for managing leave medication have now been simplified by the adoption of a Medication Dosage system which allows the home to send the medication home with the respective service user. Grove Villa H56-H05 S23436 Grove Villa V238669 060905 Stage 4.doc Version 1.40 Page 14 Although storage of medication is under review as part of the building plans for the new extension, the current storage arrangements remain unsatisfactory, a recommendation to risk assess the storage facilities remains outstanding. Grove Villa H56-H05 S23436 Grove Villa V238669 060905 Stage 4.doc Version 1.40 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23 The Home has a satisfactory complaints system in place, but needs to more clearly evidence how issues raised by service users in other forums are dealt with. The Home has actively sought to protect service users by implementing appropriate checks and vetting of staff and raising staff awareness of adult protection issues through specific training. EVIDENCE: The home has a satisfactory complaints procedure in place, relatives indicated in the homes quality assurance survey that they understood the complaints procedure and one commented that they would have no difficulties in making a complaint if necessary. Although some relatives feedback indicated a lack of awareness as to how to contact CSCI, this information is clearly stated on the quality assurance survey information and complaints procedure for the home. The Home has a central record book, but this is currently empty and no complaints have been received at the home from users or relatives. A previous recommendation that service users receive feedback as a result of contributions they make in user meetings, quality assurance surveys etc is still to be implemented. In response to changes in legislation the home has increased the checks and vetting of new staff, and POVA checks were noted for new staff in addition to CRB disclosures. The Home has actively sought to provide adult protection training to all care staff through a previous training course and another planned within the next few months as a consequence all current staff should have participated in adult protection training by the end of the year. The manager was reminded of the need to ensure that staff are fully aware of the revised kent & Medway Adult protection protocols. Grove Villa H56-H05 S23436 Grove Villa V238669 060905 Stage 4.doc Version 1.40 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, The home is making progress in addressing previous good practice recommendations to ensure service users personal and communal space is homely, clean, safe and comfortable. EVIDENCE: On this visit, progress made by the home in implementing previous good practice recommendations for the following standards was assessed. An external bolt on an upstairs bathroom door has now been removed as recommended. Whilst communal spaces in the main house have received upgrading this has been delayed in respect of the annexe until problems involving the planned extension have been resolved, this is now the case and the provider is hoping to commence internal redecoration of the annexe over the next few months. This will include outstanding remedial works to a radiator located in the annexe upstairs shower room. A previous recommendation that the home review the installation of door handles onto bedroom doors in the main house is still to be undertaken, the use of slide bolts on some bathrooms has been reviewed and more appropriate Grove Villa H56-H05 S23436 Grove Villa V238669 060905 Stage 4.doc Version 1.40 Page 17 locks installed, this needs to be extended to those bedrooms where slide bolts are still in place and this remains an outstanding recommendation. Staff confirmed that appropriate measures are now in place for the separation of soiled from normal laundry, and that a previous recommendation has been implemented. Water soluble ‘red’ bags are in use, these were not visible in the laundry which has been greatly improved by the installation of several new machines and was much tidier. Senior staff advised that ‘Red’ bags are kept by senior staff and are given out on request to staff for soiled laundry only, this system is in operation to discourage the inappropriate use of red bags by some staff for normal laundry. It is recommended that a supply of red bags is kept in the COSSH cupboard of the annexe to enable easier access by staff using the laundry, this should still enable appropriate usage monitoring by senior staff. The home manager has enquired as to the provision of a lock for the clinical waste bin from the waste company, they are still to respond to this request and this remains a recommendation. Grove Villa H56-H05 S23436 Grove Villa V238669 060905 Stage 4.doc Version 1.40 Page 18 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34, 35, 36 The Home has a robust recruitment system in place, but shortfalls in required documentation in support of this are still to be addressed. The home has implemented an intensive mandatory training programme to ensure staff can appropriately meet service users needs. Supervisions of staff are commencing but shortfalls in frequencies and confusion over format means that service users could be placed at risk by inadequately supervised staff. EVIDENCE: The Home advised that they had not achieved this outstanding requirement although progress has been made in ensuring that all newly recruited staff have the appropriate documentation on file. Two new carer files were viewed one of which was found to lack some documentation, further work is needed to bring all files up to standard and this remains an outstanding requirement. The management team and staff confirmed that a range of training has been put in place to ensure all staff have completed mandatory core skills training, this should be accomplished over the next few months. The Home has a training matrix but this is still to be updated to reflect recent courses. Staff spoken with expressed concern that more specialised courses would not be sacrificed at the expense of the mandatory training programme and this is an area that the management team need to address with staff to identify relevant specialist training. The Home manager expressed an awareness of the LDAF Grove Villa H56-H05 S23436 Grove Villa V238669 060905 Stage 4.doc Version 1.40 Page 19 training programme and has been seeking information about this course in view of the number of new carers who have been employed at the home. It is an expectation that staff new to learning disability will undertake this course and the home manager has confirmed that the home will be progressing this for staff and this is a recommendation. The Home manager was reminded that care staff induction standards will be amended from September 2005 and that the changes will be compulsory from 2006, as a result the home should review its current induction package to ensure that the new amendments are incorporated. The Home have developed a supervision and appraisal system, however, this is proving to be rather onerous and lengthy, making it difficult for the senior staff to attain the required supervision frequencies, with all staff and only a few sessions could be evidenced. The current format and system were discussed at inspection and suggestions for improvement made. The manager and a senior member of staff will also be attending supervision training, at which time they will revise the current format and system used in the home. It is a recommendation that all care staff receive formal recorded supervision a minimum of six times per year, to ensure that work practice, training needs and general development which will benefit the service users are being appropriately monitored. Grove Villa H56-H05 S23436 Grove Villa V238669 060905 Stage 4.doc Version 1.40 Page 20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39, 42 The Home is undertaking some quality assurance but need to evidence that service users and other stakeholder views are influential in the review and development of the service. The Home are taking appropriate actions to ensure the health, safety and welfare of service users is protected. EVIDENCE: Standard 39 – The Home has developed a quality assurance system for receiving feedback from stakeholders including service users. An accessible version of their questionnaire has been developed for users. Users spoken with, confirmed they completed these questionnaires from time to time. Survey information received by the home from users, relatives and care managers was viewed at inspection. Feedback was positive, but the home were unable to evidence any system in place for the analysis of feedback or what actions are taken as a result of feedback, the home are still to publish a report annually of their quality assurance feedback and this was discussed at inspection, the Home manager and provider are considering ways in which this information can be made accessible to all stakeholders and have stated their Grove Villa H56-H05 S23436 Grove Villa V238669 060905 Stage 4.doc Version 1.40 Page 21 intention to address this in the near future, it is currently a recommendation that the home draw together all its quality assurance checks and surveys, including user and staff meetings, staff supervisions into a quality assurance policy and procedure, analyse feedback and publish a report. It is a recommendation that the Home consider seeking the views of staff about the service provided. Provider visit reports which were available for viewing at inspection should be submitted monthly to CSCI and it is recommended this is implemented accordingly. Standard 42 - in accordance with a previous requirement the manager has made further progress and reviewed the home fire risk assessment, however in view of some omissions the manager has been asked to do so again with reference to the Kent Fire and Rescue service Risk assessment format. Particular attention should also be paid to environmental factors e.g open doors on resident bedrooms, the installation of door guards, the changing needs of service users etc. A fire officer visited the premises in July 2005, no requirements or recommendations were issued as a result of that visit. The fire extinguisher in the upstairs hallway of the main house is still to be secured to the wall and remains a potential hazard. The fire book was viewed and indicated that fire alarm and equipment tests and checks are taking place in a timely manner. Fire drills are taking place, and the home should consider recording as fire drills fire training dates in the home where fire drills form part of the training. The accident book was examined and revealed a low level of accidents, where an individual had experienced several falls the home had taken appropriate action to refer the person for reassessment. Magnetic door guards are currently on order for service user bedrooms and some communal areas. Broken paving on garden steps has now been repaired. The swimming pool has been filled in and the area cleared in preparation for building works this is securely fenced off and a risk assessment is in place. Grove Villa H56-H05 S23436 Grove Villa V238669 060905 Stage 4.doc Version 1.40 Page 22 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 3 x x x 3 Standard No 11 12 13 14 15 16 17 x x x 3 3 3 3 Standard No 31 32 33 34 35 36 Score x x x 2 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Grove Villa Score x x 2 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 3 x H56-H05 S23436 Grove Villa V238669 060905 Stage 4.doc Version 1.40 Page 23 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 34 Regulation schedule2 CHR 2001 Requirement Staff files to contain information in keeping with schedule 2 (partially met within previous timescale 30.6.05) Timescale for action 31.12.05 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. 3. Refer to Standard 16 17 20 Good Practice Recommendations Home to encourage use of bedroom door keys by all service users irrespective of capacity to retain keys securely Home to ensure that the cook participates in any necessary mandatory training. Home to risk assess safety of current medication storage facility. Home to ensure a system is in place to assess staff competency to administer where not routinely doing so.To incorporate agreed amendments into medication procedure. Implement planned upgrade of bedrooms and communal areas within the annexe, including replacement or remedial works to 1st floor shower room radiator in the annexe. Home to review installation of door handles onto bedroom doors in the main house. Use of slide bolts in bedrooms to be reviewed. H56-H05 S23436 Grove Villa V238669 060905 Stage 4.doc Version 1.40 Page 24 4. 24 5. 26 Grove Villa 6. 7. 30 35 8. 9. 36 39 10. 42 Provision of lock to clinical waste bin to be pursued. Supply of Redbags to be installed in Cossh cupboard for ease of access by staff. Home to implement LDAF training or equivalent for all care staff new to learning disability. Home to review induction standards in respect of planned changes from September 05. To maintain an upto date training matrix. Home to review current supervision arrangements and implement formal recorded supervision sessions for all care staff in keeping with stated frequencies. Home to develop quality assurance policy and procedure, evidence feedback and given to all stakeholders including service users and staff. Evidence analysis of feedback in the development of the service and produce annual report. Copies of provider visit reports to be made available to CSCI. Review fire risk assessment in conjunction with Kent fire service format, send to fire officer for comment.Secure fire extinguisher in main house 1st floor hallway Grove Villa H56-H05 S23436 Grove Villa V238669 060905 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection 11th Floor, International House Dover Place Ashford Kent, TN23 1HU National Enquiry Line: 0845 015 0120 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 H56-H05 S23436 Grove Villa V238669 060905 Stage 4.doc Version 1.40 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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