Inspection on 01/08/07 for Larchwood Grove

This inspection was carried out on 1st August 2007.

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

Other inspections for this house

Larchwood Grove 10/06/08

Larchwood Grove 13/09/06

Larchwood Grove 11/05/06

Larchwood Grove 01/09/05

Larchwood Grove 17/08/04

Larchwood Grove 20/05/04

Similar services:

Insight - Eastchurch

Southfields

Thorndene

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 09/07/2008.

CARE HOME ADULTS 18-65 Larchwood Grove 60 Parrock Road Gravesend Kent DA12 1QH Lead Inspector Jo Griffiths Key Unannounced Inspection 1st August 2007 10:45 Larchwood Grove DS0000023972.V341228.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 Larchwood Grove DS0000023972.V341228.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. Larchwood Grove DS0000023972.V341228.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Larchwood Grove Address 60 Parrock Road Gravesend Kent DA12 1QH 01474 352722 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) Larchwood Court Limited Janet Zimba Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Larchwood Grove DS0000023972.V341228.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users with a learning disability may also have a physical disability. 13th September 2006 Date of last inspection Brief Description of the Service: Larchwood Grove is situated in a residential area in the town of Gravesend. The home has a large rear garden and accommodation is provided over 2 floors. The building has recently been extended and refurbished to provide modern accommodation and single bedrooms. There are 4 single wheelchair accessible bedrooms on the ground floor and 6 single bedrooms upstairs. The home is registered to provide accommodation and support to 10 people with a learning disability. The home offers some respite care. The home is staffed 24 hours a day with 1 waking night staff and 1 sleep over staff member. Public transport is available to access the town centre and there are a range of pubs, shops and cafes within walking distance. The fees charged by the service range from £570 to £1660 per week depending on an assessment of individuals needs. Larchwood Grove DS0000023972.V341228.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection under the Commission’s ‘Inspecting for Better Lives’ programme. The inspector did not tell the provider that she was visiting the home so that the service could be seen as it is on a normal day. The registered Manager was on holiday at the time of the inspection, but one of the directors of the company was at the home. The senior carer was in charge of the home whilst the Manager was away and was on duty during the visit. To help make a judgement about the quality of the service provided the inspector had a look around the home and inspected some of the care plans and documents. Some of the people living at the home spoke with the inspector and gave their views of the service. Surveys were also received back from some people in the home. The inspector spent time observing the support that is provided to people in the home in the communal areas. Two district nurses were visiting the service at the time of the inspection and gave positive feedback about the home. What the service does well: What has improved since the last inspection? What they could do better: The Manager must make sure that they know exactly what a person’s needs are before they move into the home, particularly around medication. The care plans could now be developed to make it easier for people to understand their own plan. Staff would benefit from training in Person Centred Planning to help them involve people in their plans. People living in the home said they would like more activities outside of the home and that they would like to be able to see friends outside of the home more often. There needs to be enough staff on duty to meet peoples needs and this should not include any 1-1 staff that is paid for separately by a person. The staff need some further training to ensure that they can keep people safe in the home. Larchwood Grove DS0000023972.V341228.R01.S.doc Version 5.2 Page 6 The Manager must ensure that staff know exactly how much support to give each person so that they meet their needs but do not take away their independence. The Manager needs to talk to the fire department about the internal fire doors as these are heavy and cause problems for people with mobility difficulties. The Manager must ensure that peoples mobility needs are assessed in the home to ensure they can get around as independently as possible. The shower on the first floor requires repair. The Manager must ensure that a quality review of the service is carried out regularly and that the results of the review are made available for people in the home and visitors to see. 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. Larchwood Grove DS0000023972.V341228.R01.S.doc Version 5.2 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 Larchwood Grove DS0000023972.V341228.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 2 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People looking to move the home are provided with the information they need to make a decision about the home. People have an assessment of their needs before they move in. The assessment process for emergency placements does not always provide staff with the information they need. EVIDENCE: Each person moving to the home is provided with a copy of the Service User Guide. This has been completed using some symbols and pictures to aid understanding. Whilst the home is not registered to routinely admit people over the age of 65 years, the home is usually able to continue to provide care to people already living in the home once they reach 65 years. The Statement of Purpose and Service User Guide need minor amendment to reflect this. Each person moving to the home has an assessment of their needs that is carried out by the Manager of the home. In most circumstances an assessment from the placing authority is also received before the person moves into the home. Where people are placed for emergency respite care the placing Larchwood Grove DS0000023972.V341228.R01.S.doc Version 5.2 Page 9 authorities assessment has not always provided full information about the person’s needs with regard to their medication. This has led to one incident of confusion about a person’s medication. The Manager must ensure that full information on people’s medication is received before the person moves into the home. Larchwood Grove DS0000023972.V341228.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People have an individual plan that generally meets their needs, but they would benefit from the plans being made user-friendly so that they can be involved in writing them. People are supported to make some day-to-day decisions. They would further benefit from staff receiving training in Person centred planning to assist them in supporting people to make wider decisions about their lives and futures. People living in the home are supported to take reasonable risks. EVIDENCE: People have a care plan that is written following an assessment of their needs. The care plans have greatly improved since the last inspection and now give staff clearer and more directive information on how to support people. The care plans cover all areas of people’s lives although for some of the people on Larchwood Grove DS0000023972.V341228.R01.S.doc Version 5.2 Page 11 respite there is not information about their social and cultural needs. This information would be useful for staff to know to ensure they are able to meet the diverse needs of people staying in the home on a respite basis. The care plans had been reviewed recently and were all up to date. The people spoken with said they were not really sure what was in their care plans. It is recommended that the Manager explore ways of making the care plan user friendly for people. People would benefit from being involved in deciding what needs to be in their plan and reviewing it when needed. Staff training in Person Centred Planning is recommended to help staff to support people with devising their plans. This will also help staff to support people to make decisions about their lives and their futures and to include these decisions in their plan. People living in the home have the opportunity to attend a weekly house meeting. The minutes of these meetings were seen. They are used as a forum for people to raise any concerns or suggestions about the home and to plan menus and activities. The minutes of the meetings are held in a central file. The Manager should make sure that issues raised in the meeting are responded to and the outcome recorded in the next meeting minutes so that the people in the home can see what action has been taken. Feedback from people that use the service evidenced that they are supported to make decisions about how they spend their time during the week and at weekends. Each person has risk assessments included as part of their care plan. The risk assessments reflect the care plan and assessment of need and have been reviewed recently. Larchwood Grove DS0000023972.V341228.R01.S.doc Version 5.2 Page 12 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 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People are supported to take part in the activities they enjoy. They would benefit from more opportunities to take part in activities outside of the home and to develop their personal skills. People in the home can receive visitors when they wish but should be further supported to develop and maintain personal relationships. They are aware of their responsibilities and their rights. People in the home enjoy their meals and have a varied diet. EVIDENCE: When the inspector arrived at the home some people were out at day centres, one person had gone out for a haircut and the rest o0f the people were joining Larchwood Grove DS0000023972.V341228.R01.S.doc Version 5.2 Page 13 in a cookery session making scones for lunch. There was a relaxed atmosphere and everyone appeared to be enjoying the activities. The activity record shows that there are regular activities within the home including massage, art and crafts, music, cookery, games, and DVDs. There is an activity board displayed on the lounge wall to show people what is planned each week. This accurately reflected the activities for the day. People spoken with said they enjoy the activities provided at home. They said that they also go out for some activities including swimming, church and the ‘gateway’ club (a social club). Feedback from most people living in the home was that they would like more opportunities to go out for activities. The registered Manager had identified, in the Annual Quality Assurance Assessment that she returned to us, that this was an area she wished to improve in the home. There is no one in the home that is currently employed. One person has expressed an interest in attending a college course and should be assisted to arrange a course that suits her interests and needs. Again, Person centred planning training for staff will help them to support people to plan their wishes regarding education and employment. The Manager is advised to contact the ‘Supported Employment’ scheme through the local job centre for support with finding employment for those that express and interest. Visitors are welcome at any time. People spoken with said that they could see their visitors in private if they wish and that they could use the phone when they want to. Some people said they would like more opportunities to visit friends or partners that live outside the home. It would benefit people in the home if their care plans were to reflect their needs with regard to their personal relationships. Where people have personal relationships or would like to develop one it should be clear for staff on what support the person needs to achieve this. This should include arrangements for visits outside the home or within the home. There are no set roles and responsibilities within the home but people are supported to keep their rooms clean, to do their laundry and to help with cooking. People are offered a key to their room, but nobody would like one at present. The staff ensure that people respect each others space and privacy and discuss any issues within the house meetings. There is a four-week menu in place and people are supported to make their choices on a weekly basis. Records are kept of the actual meals eaten. People said they like the food and the menu appears to meet people’s nutritional needs. Mealtimes were observed to be a relaxed and social occasion and plenty of choices were offered throughout. Larchwood Grove DS0000023972.V341228.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People have their personal care needs met but would benefit from more support to develop or maintain their independence. Peoples’ health needs are fully met and they are supported to manage their medication safely. EVIDENCE: Individuals’ personal care needs are now more clearly outlined in the care plans. This gives staff more guidance on the correct way to support each person. Not all the records regarding personal care were up to date but people spoken with said they are supported to have a bath or shower each day if they wish and that the staff help them with everything they need. At present the shower upstairs is not working and therefore most people on the first floor are using the bath. One assessment seen showed that a person can shower fairly independently but requires more support with a bath. The person said that they felt their independence had been restricted slightly by having to use the bath and rely on staff. There was also some feedback from people using the service that they feel that sometimes staff do things for them Larchwood Grove DS0000023972.V341228.R01.S.doc Version 5.2 Page 15 because it can be quicker than allowing them to do it themselves. The Manager must ensure that staff understand the importance of supporting people to maintain independence. Feedback from people living in the home was that they are supported by staff to keep healthy and well and can see their GP when they wish to. Each person has their health needs identified in their care plan and records show that health needs have been responded to quickly. Two district nurses were in the home at the time of the visit and gave positive feedback about the way staff manage people’s health needs. They said that the staff competently carry out any instruction regarding peoples’ health. Staff were observed administering medication following good practice guidelines. Only trained staff give medication. The Manager completes regular audits of the medication and staff said that they the Manager had observed their practice in giving medication. The records of these checks were not available at this inspection as the Manager was on leave. Self-administration has been agreed for some people in the past following a risk assessment. There is one person who currently manages their own medication. Staff check with this person daily that they are managing this well. Larchwood Grove DS0000023972.V341228.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People living in the home know how to make a complaint if they need to and feel they will be listened to. People using the service are not fully safeguarded against abuse and would benefit from all staff being trained and aware of safeguarding adults’ policies. EVIDENCE: There is a complaints procedure in the home that people using the service or any visitors can use. There have been no complaints received by the home. CSCI have not received any complaints about the home since the last inspection, but some concerns have been raised about the staffing levels in the home. People that use the service said they knew that they could make a complaint if they needed to and knew they could speak to the Manager or any staff. They said they felt the Manager would try to do something to resolve the problem. There are weekly house meetings that people can attend to raise any concerns or suggestions about the home if they wish to. The home has a policy for the protection of vulnerable adults. Records showed that not all staff have completed training in safeguarding adults. Since the last inspection the safeguarding adults investigation that was underway has been completed and the allegations were unfounded. The staff spoken with were not all aware of the correct procedures to follow for reporting allegations of abuse. The Manager needs to make sure all staff are aware of both the homes policy and how this fits with the Kent County Council multi agency policy. Larchwood Grove DS0000023972.V341228.R01.S.doc Version 5.2 Page 17 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, 25, 27, 28, 29 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People live in a safe and comfortable environment. Their bedrooms are suitable for their needs and they have access to sufficient communal areas. People with physical disabilities are not able to move freely around the home at present. They have the equipment they need to assist their mobility but would benefit from repair of the first floor shower. The home is clean and hygienic. EVIDENCE: The service has now increased the number of registered places from 8 to 10. There are 10 single bedrooms and some have ensuite facilities. The ground floor bedrooms are large to allow movement of wheelchairs and other mobility equipment. The home is clean and well maintained and equipped to meet the needs of people with physical disabilities on the ground floor. One person has recently been moved to a first floor bedroom, but has some physical Larchwood Grove DS0000023972.V341228.R01.S.doc Version 5.2 Page 18 disabilities. The Manager must ensure that the person is able to access their bedroom easily and safely and that being on the first floor does not restrict their right to move around the home freely. There are two lounges, a dining room, kitchen and laundry. All areas are designed to be accessible to people living in the home. However, it was observed during the inspection that people that use walking frames have trouble opening the heavy fire doors between communal areas. When asked they said that they did have some difficulties with this. Staff said that they are always around to support people but this does pose some restriction on peoples’ rights to get around the home independently. The director was advised that the fire officer should be contacted to discuss a solution that will allow people to move freely within the home without compromising people’s safety. People living in the home said they were happy with their rooms and that they found the home to be kept clean and comfortable at all times. The rear garden has not yet been completed to allow safe access for people but a decked area is available for people to use. As described under standard 18 the shower on the first floor is not useable at present. There is a shower room on the ground floor and a bathroom on the first floor. Some of the rooms have ensuite facilities. The range of bathrooms cater for all levels of physical disability but some people are having to rely on staff support to use a bath instead of being to shower independently until the shower is repaired. Larchwood Grove DS0000023972.V341228.R01.S.doc Version 5.2 Page 19 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 32, 33, 35 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The home does not consistently provide sufficient numbers of staff in a safe way to support people. People benefit from the staff’s qualifications but they are not protected by a fully trained team. EVIDENCE: There have been some concerns raised with CSCI about the staffing levels in the home. On the day of the inspection there was a senior carer and two care staff on duty. One of the company directors was also in the home. The rotas were inspected and it was found that whilst there were meant to be three staff on duty per shift in the day time there were a number of occasions when on two staff were on duty as cover had not been found. One person in the home has a funded one-to-one support and this is included in the numbers. Therefore if only two staff are on duty one staff is allocated to work on a oneto-one with the person and the other staff is responsible for all the other people in the home. Larchwood Grove DS0000023972.V341228.R01.S.doc Version 5.2 Page 20 Activity records show that some people are out at day centres during the day but there can be 6 or 7 people in the home during the daytime. The Manager must ensure that enough staff are on duty to meet peoples needs. The Manager must ensure that contract for the person to have one-one support is fulfilled and that the staff member is not used to substitute for staffing shortages elsewhere. This issue has been raised in previous inspections and must be addressed. Some staff are still working long hours. One example on the rota was where a staff member had started work at 7.30 am on a Saturday and had not gone off duty until 09.30 am on the Tuesday (this includes sleep in shifts). Whilst the Director states that this is staff’s choice this cannot be considered safe practice and people in the home may be at risk from staff that are tired, particularly when carrying out medication administration, driving to activities, or using hoists. This issue has also been raised previously and must be addressed. As there have been several inspections that have found that staffing arrangements have not met the needs of people in the home enforcement action will be considered by CSCI if the requirement is not met on this occasion. The inspector spoke with the Manager following the site visit and the Manager stated that she would address the issue of long working hours and that she is currently recruiting staff at present. The training records were inspected. These showed that most staff are working toward their NVQ award or have already achieved this. Some new staff are working on their induction at present. Most of the required training has been completed by staff but some training was required in the areas of safeguarding adults, food hygiene and infection control. Training for staff in safeguarding adults was required at the last inspection but it is noted that there have been some staff changes since then. Training must be provided for those staff that have not completed it as soon as possible. It is recommended that the Manager arrange training for staff in Person centred planning, as this will help them to support people to plan for their futures. The training will also help staff to provide a service that is focussed on the needs and wishes of each individual. It was also recommended in the previous report that training for staff on sexuality would be beneficial to help them support people in this area of their lives. This recommendation continues to be made. Larchwood Grove DS0000023972.V341228.R01.S.doc Version 5.2 Page 21 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 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People in the home benefit from a Manager that is skilled and working toward a qualification. They would benefit from a full quality review of the home each year so that improvements can continually be made. People in the home have their health and welfare generally safeguarded but they would benefit from better management of staffing arrangements to fully ensure their safety and well being. EVIDENCE: The Manager is working toward the Registered Managers Award (RMA). She has completed training courses since the last inspection in some areas of care. The Manager would benefit from attending training in Person centred planning, Larchwood Grove DS0000023972.V341228.R01.S.doc Version 5.2 Page 22 as this would assist her in providing a user-focussed service to the people in the home. The Manager has made a number of improvements to the service since the last inspection. There are still some areas that require improvement, in particular the staffing arrangements for the home. There are weekly meetings for people in the home to share their views and ideas. Each person also has an allocated key worker that they can talk to. The Manager sends out questionnaires to people and their relatives each year to gather their views of the home. The results of this were seen in the office. The Manager should arrange for a full quality review of the service to be completed each year and the results, with an action plan, to be published for people in the home and visitors to see. Risk assessments are in place in the home. The Manager has ensured that all equipment for use by staff and people in the home has been serviced and safety checked. There are no current areas of health and safety concern in the home, but the fire officer should be contacted to discuss the heavy fire doors that are preventing easy access for people, with mobility difficulties. Larchwood Grove DS0000023972.V341228.R01.S.doc Version 5.2 Page 23 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 2 2 2 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 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 2 28 3 29 2 30 2 STAFFING Standard No Score 31 X 32 3 33 1 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 3 12 2 13 2 14 3 15 2 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 2 X 2 X X 2 X Larchwood Grove DS0000023972.V341228.R01.S.doc Version 5.2 Page 24 No 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 YA2 Regulation 14(1) Requirement Timescale for action 01/09/07 2 YA6 15(1) 3 YA29 23(2)(a) The registered person must ensure that a full assessment of peoples needs is carried out before they move into the home, whether on a permanent or respite basis. The registered person 14/09/07 must ensure that care plans are fully completed for people in the home for a period of respite. The registered person 30/09/07 must ensure that people with mobility difficulties are able to get around the home as independently as possible. The internal fire doors must be reviewed to ensure they do not restrict people’s mobility. People accommodating first floor rooms must have a review of their mobility needs to ensure this does not DS0000023972.V341228.R01.S.doc Version 5.2 Page 25 Larchwood Grove 4 5 YA27 YA33 23(2) (j) 18(1) (a) 6 YA33 YA42 YA37 18(1)(a) 7 YA23 13(6) 8 YA42 13(3) 9 YA42 13(4) restrict their independent movement around the home. The first floor shower needs to be repaired for people’s use. The registered person must ensure there are sufficient numbers of staff on duty to meet peoples needs. Staff employed to support one person on a 1-1 basis must not be included in these numbers. The registered person must ensure that staff are not working excessively long hours without an appropriate break. This is to ensure that people in the home are not put at risk by staff that may be tired from working long hours. The registered person must ensure that people in the home are safeguarded from abuse and harm. Training should be provided for staff and they must be aware of policies and procedures to follow. The registered person must make suitable arrangements for minimising the risk of infection in the home. Staff training in this area should be arranged. All staff must complete appropriate training in DS0000023972.V341228.R01.S.doc 30/09/07 14/09/07 14/09/07 30/10/07 30/10/07 30/10/07 Larchwood Grove Version 5.2 Page 26 1st Aid. 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 YA35 Good Practice Recommendations It is recommended that a training plan for the home be devised and that other training that would benefit service users be explored. This could include Person centred planning, sexuality and communication. This recommendation was made in the last report 2 YA37 It is recommended that the Manager begin the NVQ 4 in care once she has completed the RMA. This recommendation was made in the last report 3 YA1 It is recommended that a minor amendment be made to the service user guide to reflect the registration arrangements of the home. It is recommended that it be made easier for people to understand and be involved in their own care plans. It is also recommended that staff are made aware of the support that people need with personal care so that they are not doing too much for a person and taking away their independence. 5 YA12 It is recommended that people be supported to look for employment if they wish to and to access training and education courses. It is also recommended that the range activities available to people away from the home be expanded in response to requests from people in the home. 6 YA39 It is recommended that the results of the annual quality review of the home be published and displayed for people in the home and their visitors to see. DS0000023972.V341228.R01.S.doc Version 5.2 Page 27 4 YA6 Larchwood Grove Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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