Inspection on 05/07/06 for Grovelands

This inspection was carried out on 5th July 2006.

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 found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Grovelands 25/10/07

Grovelands 22/11/05

Grovelands 01/08/05

Grovelands 07/03/05

Grovelands 11/11/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Grovelands 38 Grovelands Road Purley Surrey CR8 4LA Lead Inspector Claire Taylor Key Unannounced Inspection 5th July 2006 12:50 Grovelands DS0000025786.V288895.R01.S.doc Version 5.1 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 Grovelands DS0000025786.V288895.R01.S.doc Version 5.1 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. Grovelands DS0000025786.V288895.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Grovelands Address 38 Grovelands Road Purley Surrey CR8 4LA 020 8660 1806 020 8660 1806 themanor@thfce.wanadoo.co.uk 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) THF Care Estates Limited Miss Josephine McHugh Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Grovelands DS0000025786.V288895.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd November 2005 Brief Description of the Service: The Manor, 38 Grovelands Road in Purley is registered to provide residential care to fourteen young adults with learning disabilities. The Manor is a detached Edwardian house constructed around 1912, with a single storey extension. Situated in a quiet residential area of Purley, the home is well placed to access local transport links, amenities and resources. The home consists of fourteen single bedrooms, a good-sized lounge and spacious dining area with an annexed side lounge. The kitchen is spacious and there is a laundry room in the basement. Access to the first and second floors of the home is via a set of stairs. There are sufficient numbers of bathroom/shower and toilet facilities located throughout the home to meet the service users needs. There is a garden with lawn and patio area equipped with tables and seating and a barbecue facility. All service users attend day services and the home offers a varied and structured programme of activities and outings. The Manor provides its own transport and supports service users to access various public transport links. There is a large landscaped garden to the front of the house with ample space for parking. Fees range from £523 - £936.00 per week and were accurate at the time of this inspection. Additional charges may be payable for personal items and would be discussed prior to admission. Grovelands DS0000025786.V288895.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home has recently undergone ownership changes and in February of this year, Caring Homes / Consensus Healthcare took over as the registered providers. In accordance with the Commission’s “Inspecting for Better Lives” programme, the standards considered to be key to the inspection process were assessed at this inspection. The total time spent in the home was five hours. Time was spent with several service users to seek their views on what it is like to live at The Manor. Some information was taken from the questionnaire the manager filled in prior to the inspection and from written comment cards returned by seven relatives. The home manager, Josie McHugh facilitated most of the inspection and several staff members were also spoken to. Various records, policies and care plans were examined. The premises were viewed, as were several of the residents’ bedrooms. All those involved are thanked for their cooperation and the service users and staff for the hospitality shown throughout the inspection process. What the service does well: The manager and staff team work hard to ensure that the service users lead meaningful and fulfilling lives both within the home and local community. There are many social activities offered in a variety of ways to service users that are based upon their needs and choices. Each person has a full timetable of activities during the week, and some evenings, which they attend with support from the home’s staff, or independently if they can and want to. When asked what they liked best about their home, service users commented “ I like going out in the minibus” and “having a drink in the pub”. Service users complimented the staff saying that they were “nice and they take us out”. Staff members were seen to talk openly and inclusively with service users in a warm, respectful manner that promoted choice. The plans of care and intervention are well created, and reflect very closely the needs of the specific person. The move towards person centred planning is seen as good practice as this is a more service user focused way of meeting their needs. The manager is knowledgeable and experienced and provides good support and leadership to a stable staff team who clearly understand the service users’ needs. Comment cards received from relatives gave complimentary views about the home and the way it is run. Service users appeared well cared for and happy in their home. There is a friendly and welcoming atmosphere within The Manor; the home is well furnished and provides comfortable and homely surroundings for the service users to live. Grovelands DS0000025786.V288895.R01.S.doc Version 5.1 Page 6 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. Grovelands DS0000025786.V288895.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Grovelands DS0000025786.V288895.R01.S.doc Version 5.1 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 the following standard(s): 1 and 2 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. Prospective service users and their representatives are provided with good information in order to make an informed choice about whether the home is the right choice. Arrangements are in place for assessing service users’ needs so that staff are aware of how to support them. EVIDENCE: Since the last inspection, the Statement of Purpose and Service User’s Guide have been reviewed; these provide the service users and their representatives with full information about the home and what services are available. The same group of service users have lived at the home for many years and there have been no new admissions to the home. Suitable admissions policies are in place however to ensure that the home would only admit service users whose needs can be met. A needs assessment is available that is detailed and covers all areas to ensure that any new service user’s needs would be fully assessed prior to admission. This provides staff with comprehensive information about the individual and how they should be supported. Copies of needs assessments were seen on file for each service user as well as detailed needs assessments completed by their placing authorities. I.e. undertaken by their care managers. Grovelands DS0000025786.V288895.R01.S.doc Version 5.1 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 the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. Plans of care clearly identify their needs and how service users are supported to achieve their planned goals. Staff encourage service users to make decisions about their lives that maximises their involvement and opportunities to contribute to the running of the home. Overall, service users are supported to take risks as part of an independent lifestyle, although some risk plans need reviewing to fully safeguard individuals from potential harm. EVIDENCE: Care Plans are well structured and developed by service users’ keyworkers, with evidence of regular reviews involving service users and other significant parties. Specific programmes and support plans are in place to guide staff to meet service users’ needs. Daily records indicated that staff have clearly developed a working knowledge of each service user’s individual needs. Records and discussion showed that staff support service users to make decisions about their lives. Minutes of monthly meetings showed that service Grovelands DS0000025786.V288895.R01.S.doc Version 5.1 Page 10 users are consulted about what they want to do and that their views have an influence on the running of the home. Additionally, service users are treated very much as individuals and their rights respected. Relevant risk assessments, matched to individual needs were in place for all the service users and were being reviewed every three months. A risk assessment tells the people that support the service user if there are activities that a person undertakes, or things that might happen, that put them at risk of being harmed. E.g. use of the kitchen, accessing the home / wider community, safety around the home and money management. Some risk plans are now in need of review however in relation to use of the community. One incident record revealed that one service user did not return to the home at the planned time following a trip to the supermarket. Although the home took appropriate action following the incident, the service user’s risk plan had not been updated. In addition, risk plans regarding community access need to be reviewed for all service users to maximise their personal safety and protect their vulnerability. Grovelands DS0000025786.V288895.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. Service users are supported to continue education and appropriate activities within the home and local community so that they can maximise fulfilment and achievement in their lives. The daily routines and house rules promote service users’ rights and encourage independence. Appropriate contact between service users and their families and friends is encouraged to help them maintain relationships. Dietary needs are catered for and a well balanced diet is provided, to ensure health and enjoyment of food. EVIDENCE: Records related to lifestyle were examined for five service users. Most of the daily activities offered are through local college courses, day centres and local community facilities. Most service users attend Tandridge Hill Farm five days a week, which provides them with a wide variety of opportunities to develop their educational, vocational, and practical life skills through animal care, gardening, horticulture, and art and crafts. Working at the farm forms part of Grovelands DS0000025786.V288895.R01.S.doc Version 5.1 Page 12 the service users contract / fees. Some of the other service users attend a day centre in Sutton where they are provided with a range of recreational activities. Two service users had been to college and made some pottery. There is a wide range of in house entertainment facilities including television, videos/ DVDs, music system, art and craft activities, jigsaws, computer and board games. During the inspection, one service user at home was occupied doing jigsaws. When others returned from their respective colleges and workplaces, staff supported them with their preferred routines and interests. Individuals chose to watch television, look at magazines and spend time in the garden. All the service users went on holiday to Scarborough in June and were in the process of planning various summer activities including a trip to Brighton and a Chinese meal for one person’s birthday. In February of this year, the home held a party to celebrate a 60th birthday for one individual. The service user has a particular interest in mediaeval history and the party was based upon this theme. Service users and staff wore costumes and made various creative decorations including personalised shields. Service users spoke favourably about these events and it was clear that their views have an influence on the way the activities are organised and the way the home is run. Records also confirmed use of local community resources such as shops, pubs, bowling, and a social club run by Mencap. When asked what they liked best about their home, service users commented “ I like going out in the minibus” and “having a drink in the pub”. Service users complimented the staff saying that they were “nice and they take us out”. When an outing is arranged, service users are expected to pay for staff costs as well as their own. E.g. admission fees, meals out, travel cards any other costs. With the exception of travelling to the farm, service users also contribute towards petrol expenses for the home’s own vehicle when going out socially. Given that the majority of other organisations contribute funds towards service users social activities, the registered provider should provide a budget for staff expenses and /or social outings. Records showed that family, friends and guests are welcome at the home and that the manager maintains very good communication links with the service users’ respective families. Relatives are involved in social events and functions. Menus are written in conjunction with the service users, based on their likes and dislikes. A copy of the current menu is displayed in the kitchen. The meals offered by the home are varied, nutritious and the service users spoken to confirmed that they enjoy the meals and can choose alternative dishes if they prefer. Staff support service users to shop for their chosen foods at a local supermarket. Grovelands DS0000025786.V288895.R01.S.doc Version 5.1 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 the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. Service users welfare is closely monitored and suitable arrangements are in place to ensure that their physical, healthcare and emotional needs are met. The home’s systems regarding medication are well organised to ensure the safety and consistent treatment and support for each service user. EVIDENCE: The service users require varying degrees of assistance with their personal care. Where support is required with personal physical care, this is identified and guidance is available on how specific tasks should be undertaken. Support is often given on a one to one basis, offering service users quality time with their key worker staff. One service user said she enjoys going shopping for clothes with her keyworker. Records concerning healthcare needs were in very good order and involvement with specialist services highlighted where necessary. They showed that potential complications and problems are identified and dealt with through prompt referrals to the appropriate health professional. Information relating to healthcare needs including both routine and one off health interventions were well recorded. E.g. blood tests and hospital appointments for one service user. Care plans and specific strategies identify individual and specialist needs, which also reflect any changed needs. Grovelands DS0000025786.V288895.R01.S.doc Version 5.1 Page 14 Literature about health conditions such as epilepsy was available. Staff have received training on epilepsy to enable them to fully support those service users with such specialist needs. Access to other NHS facilities is supported and plans include detail of GP involvement as well as Consultant, dentist, chiropodist, optician and hospital outpatient appointments. These systems are good examples of assurance that healthcare needs are being met and monitored appropriately. Medication records are appropriately maintained by staff and no errors were noted on the sampled administration sheets. An appropriate healthcare professional reviews medication regularly and each service user has a written profile to specify what medication is required. Certificates showed that adequate staff are trained to administer medication. The local pharmacist provides an audit service and no concerns were identified following their most recent. Storage of medication was not checked on this occasion. Grovelands DS0000025786.V288895.R01.S.doc Version 5.1 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 the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. Arrangements for complaints and protection from abuse are well managed and ensure that service users feel listened to and safe. An appropriate complaints procedure is in place to ensure that the views of service users, their families and friends are listened to and acted upon. EVIDENCE: The home has a complaints policy, which is also provided in a user-friendly format with pictures and symbols for those service users who have limited expressive speech. There is a complaints book and records showed that no complaints have been made since the last inspection or indeed within the last twelve months. Service users who spoke with the inspector were clear about who they would speak to if they felt unhappy or worried about something. Likewise, feedback from relatives showed confidence that the home would deal with any complaints appropriately and that staff are approachable and receptive to any concerns raised. The home manager has completed Croydon’s Training for Trainers adult protection course, and is able to deliver this training to the home’s staff. Records confirmed that staff are properly inducted on abuse awareness and policies and procedures regarding the protection of vulnerable adults. Grovelands DS0000025786.V288895.R01.S.doc Version 5.1 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 the following standard(s): 24, 26, 27 and 30 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The home is kept comfortably furnished so that service users live in homely and pleasant surroundings. Bedrooms are designed and furnished to meet the personal preferences and individual lifestyles of the service users. Facilities are clean and safe although the two bathrooms would benefit from refurbishment due to general wear and tear. EVIDENCE: The Manor is a spacious house that provides comfortable furnishings and facilities for the people who live there. Service users have been consulted and involved with arranging the décor in the home. There are many “homely” touches around the premises such as the service users’ artwork creations and photographs of family and friends and social events such as holidays and parties. Some new leather sofas have been purchased for the lounge with more on order. In response to the last inspection, the staircases had been repainted. Bedrooms viewed clearly reflected service users’ individuality and identified needs. The décor and furnishings were highly personalised to reflect individual personalities and lifestyles. One service user had various pictures of Grovelands DS0000025786.V288895.R01.S.doc Version 5.1 Page 17 sports cars, numerous music tapes and musical instruments that reflected his chosen interests and hobbies. Good hygiene practices are in place and the home appeared clean, tidy and free from offensive odours. Two minor shortfalls were identified in relation to the environment. Both bathrooms are now in need of redecoration. The lino flooring and the sealant around the bath in both rooms were discoloured in places and the paintwork in need of attention. The new providers also need to develop a written plan for the home’s redecoration and maintenance. This will show how the home monitors the upkeep of the premises and makes improvements where necessary. Grovelands DS0000025786.V288895.R01.S.doc Version 5.1 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. Service users benefit from a competent and knowledgeable staff team, who are provided with the necessary training and guidance to support their needs. Recruitment practices are securely managed to maximise protection for the service users. EVIDENCE: Valuably, staff turn over at the home remains low resulting in stability and consistency of care for the service users. The home’s allocation allows for three members of staff on each day shift and two staff on sleep in duty at night. Service users appeared comfortable, and staff members have clearly established positive and cooperative relationships with each individual. Staff are provided with good support and the necessary training to meet the service users collective and individual needs. Examples include training in the management of epilepsy and person centred planning. Regular staff meetings are held on a monthly basis and in depth consultations about the home’s care practices and service users needs are routinely discussed. Records and observation showed that good communication processes are upheld in this home. Service users’ feedback on staff was very positive and observations showed that staff respect their individuality as well as demonstrate an understanding of their specific needs. The home’s recruitment procedures are Grovelands DS0000025786.V288895.R01.S.doc Version 5.1 Page 19 thorough to ensure that staff are vetted correctly and service users are safeguarded from people who should not be working there. Since the last inspection the home has employed two members of staff; both files were examined and contained the required checks including a completed job application, the terms and conditions of their employment, two references, proof of identity and a CRB disclosure/POVA check. New staff complete an induction process whereby an experienced staff supervises and supports the new worker. Learning topics include the particular needs of the service user group, the worker’s role in the home and general principles of care. Grovelands DS0000025786.V288895.R01.S.doc Version 5.1 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The manager has good experience and relevant professional qualifications to run this home and service users benefit from a well run home. Some minor improvements are needed with the quality assurance systems to ensure that quality of care is regularly appraised and the home is meeting its objectives. Overall, health and safety practices are well observed to ensure that service users live in a safe environment although some radiators need to be covered or replaced with a low surface temperature type. EVIDENCE: The manager has gained vast experience in working with people who have learning disabilities and began employment as a support worker at The Manor in 1991. She demonstrated a sound knowledge of the service users specific needs and has periodically attended various training courses to keep her knowledge and skills up to date. She has achieved a relevant management qualification as well as a D32 and D34 N.V.Q. Assessors award. Staff spoken to Grovelands DS0000025786.V288895.R01.S.doc Version 5.1 Page 21 gave positive views about the leadership style of the manager and felt that the team worked very well together. Likewise, the service users were observed to enjoy respectful and open relationships with the manager. A range of quality assurance systems are used to measure the success of how the home is achieving its aims and serve the best interests of the people who live there. Examples include care plan reviews, meetings, monthly visits from the registered provider and environment checks. The Manor has also achieved accreditation with Investors in People. Although the home does have systems in place, some improvements are still needed to fully meet the standard. Questionnaires have yet to be offered to the service users and an annual quality assurance action plan for the home needs to be drawn up and implemented. This will further show that the views of the service users, their relatives and other interested parties influence the running of the home. Overall, health and safety practices are well observed. As previously required, magnetic closures had been fitted to the identified fire doors. Radiators are not guarded, nor are they of low surface temperature, but the manager has risk assessed each service user’s awareness of the dangers regarding hot surfaces. Although risk plans have been completed with regard to the uncovered radiators in the communal areas, the home is still required to guard radiators or replace them with a low surface temperature type. This will further safeguard service users from potential harm. The manager advised that there are plans to fit radiator covers The servicing and maintenance records for the home were sampled at random and up to date. Safety checks on gas and electrical systems and portable electrical appliances had been completed. Records showed that fire drills were being held and alarms and equipment had been checked regularly. A regular check of the environment is carried out weekly to ensure that it remains safe for service users, the staff and any visitors. Risk assessments for safe working practices and the premises were up to date. Accurate records are kept for accident and incident reporting. Key health and safety training for staff continues to be well organised and planned so that staff update their skills and knowledge at appropriate intervals. Grovelands DS0000025786.V288895.R01.S.doc Version 5.1 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 Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 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 2 X Grovelands DS0000025786.V288895.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA9 Regulation 13(4)(5) Requirement Risk assessments regarding the service users accessing the local community must be reviewed as and when needs change and kept up to date. The registered provider must develop and maintain a written plan for the home’s maintenance and redecoration programme. The two bathrooms need redecoration due to the discoloured floorings and sealant trim surrounding each bath. A written annual quality assurance development plan needs to be developed for the home that is based upon the views of service users and other relevant parties. The registered provider is required to guard radiators or replace them with a low surface temperature type in the communal areas. Timescale for action 31/08/06 2. YA24 23(2)(b) (d) 23(2)(a,c & d) 24 31/08/06 3. YA27 30/09/06 4. YA39 31/08/06 5. YA42 13(4) 31/10/06 Grovelands DS0000025786.V288895.R01.S.doc Version 5.1 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA14 Good Practice Recommendations The registered providers should consider alternative ways of funding service users activities i.e. pay towards staff expenses and/ or provide a budget for social activities. Grovelands DS0000025786.V288895.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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. 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