Inspection on 10/06/08 for Larchwood Grove

This inspection was carried out on 10th June 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Larchwood Grove 01/08/07

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 08/11/2008.

CARE HOME ADULTS 18-65 Larchwood Grove 60 Parrock Road Gravesend Kent DA12 1QH Lead Inspector Anne Butts Unannounced Inspection 10th June 2008 09:30 Larchwood Grove DS0000023972.V365837.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.V365837.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.V365837.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 Ltd Care Home 10 Category(ies) of Learning disability (0) registration, with number of places Larchwood Grove DS0000023972.V365837.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD). The maximum number of service users to be accommodated is 10. Date of last inspection 1st August 2007 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 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 8 people with a learning disability on a permanent basis. The home also offers 2 respite care beds. 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.V365837.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was a Key Unannounced inspection that took place in accordance with the Inspecting for Better Lives (IBL) process. Key inspections are aimed at making sure that the individual services are meeting the standards and that the outcomes are promoting the best interests of the people living in the home. It is now a legal requirement for services to complete and return an Annual Quality Assurance Assessment (AQAA). This assessment is aimed at looking at how services are performing and achieving outcomes for people. The AQAA for this year has yet to be completed by the home. Judgements have been made with regards to each outcome area in this report, based on records viewed, observations and verbal responses given by those people who were spoken with. These judgements have been made using the Key Lines of Regulatory Assessment (KLORA), which are guidelines that enable The Commission for Social Care Inspection (CSCI) to be able to make an informed decision about each outcome area. Further information can be found on the CSCI website with regards to the IBL process including information on KLORA’s and AQAA’s. The actual site visit to the service was carried out over one day by one inspector, who was in the home from approximately 10.00 am until 6.30 pm. The main focus of the visit was to review any improvements made since the last visit and the well-being of the service users. Time was spent touring the building, talking to people living in the home, talking to staff, a visitor and reviewing a selection of assessments, service user plans, medication records, menus, staff files and other relevant documents. This was an unannounced visit, which meant that they did not know we (The Commission for Social Care Inspection) were visiting. What the service does well: The interaction between the members of staff in duty and the people who live in the home was good. Emotional and physical needs are acknowledged and recognised both within the care plans and by staff who are delivering the care. When giving out medication we saw that this was done sensitively and where a person had special needs they were supported well by the member of staff. Larchwood Grove DS0000023972.V365837.R01.S.doc Version 5.2 Page 6 There is a varied programme of activities that are available for the people living in the home. What has improved since the last inspection? What they could do better: The Statement of Purpose needs to be updated to reflect current staffing levels and training, and also the full range of needs of the people living in the home including when they reach the age of 65. Pre-admission checks for people staying in the home on respite would benefit from being more detailed with current and up to date information and this then incorporated into an updated care plan. Where risk assessments are updated – this information should feed into the care plans so that staff are aware of any changes in need and there is clear guidance for staff. Staff recruitment procedures are not robust and do not meet with the National Minimum Standards for Younger Adults and Care Home Regulations 2001. Not all staff have up to date training in mandatory areas such as movement and handling and fire training. Records maintained in relation to staffing, for example records of the hours worked by staff are not kept in accordance with Regulation 17 and the associated schedules of the Care Home Regulations. Food temperatures need to be monitored and maintained in line with the Foods Standards Agency Guidance. Larchwood Grove DS0000023972.V365837.R01.S.doc Version 5.2 Page 7 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.V365837.R01.S.doc Version 5.2 Page 8 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.V365837.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is provided to people who are looking to move into the home, but they would benefit if this contained current information. Permanent residents benefit from a comprehensive assessment of need when moving into the home. People staying for respite would benefit from this being updated at each visit. EVIDENCE: There is a Statement of Purpose and Service Users Guide in place and the manager confirmed that people are issued with copies of these. The Statement of Purpose sets out the residents’ rights and states the home’s commitment to respecting the individual person and the services they can expect from the home. We were given a copy of the Statement of Purpose and this document was last reviewed in 2006, and staffing details were not up to date. At the last inspection we also identified that the Statement of Purpose needed some minor amendment in order to reflect that the service would continue to provide care for people once they reach 65 if they can continue to meet their needs. A recommendation is being made in this report that the Statement of Purpose is reviewed and updated. Larchwood Grove DS0000023972.V365837.R01.S.doc Version 5.2 Page 10 We looked at the assessment process for three people, two permanent residents and one respite resident. We saw that there was an assessment of need had been carried out for each person living in the home and on the files of the two permanent residents there was also a care manager assessment in place. The assessment form covered the different needs of the individual. People who stay in the home on respite tend to return on a regular basis and we saw that the manager had implemented a pre-admission check that would be carried out at every visit – this was in order to make sure that they still had up to date details of the people they would be caring for. This would benefit from being more detailed as it does not fully explore any changes in need and information is not reflected into a care plan. A requirement had been at the last visit with regards to the pre-admission process and although this has now been met it is strongly recommended that the updating of respite people’s details is more robust. Through the assessment process the home takes into account the individual needs of the people and provides training in some specialist areas for staff so they can support people. We observed good interaction between staff and people living in the home. Larchwood Grove DS0000023972.V365837.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are supported to make their own daily living choices and decisions and benefit from having an active role in the home. Individual changing and ongoing needs could be better reflected in care plans that are more reflective of individual risk assessments. EVIDENCE: When we visited we asked to view a sample of care plans and we chose the care plans that we would like to look at. We looked at two care plans for people who live in the home on a permanent basis and one for a person who visits on a respite basis, and was staying in the home at the time. All of the care plans viewed showed that they had an assessment of their needs and that guidance was then generally reflected into these plans. However, there were parts of the care plan that were more of a record of Larchwood Grove DS0000023972.V365837.R01.S.doc Version 5.2 Page 12 events rather than giving actual guidance to care staff on how to support with these needs. For example we saw that information relating to appointments was incorporated within the care plans and gave details of events that had happened rather then guidance for staff. Other parts of the care plan, however, demonstrated that there was good guidance on how to support people and fully demonstrated how to support an individual person. The information provided in the care plans was intermittent and where in places this was seen to be good practice - there were other parts of the care plan that did not detail how to fully support people because the information that was detailed into the risk assessments had not been incorporated. This then meant that there were gaps in the information being provided to staff. The manager must make sure that all parts of the care plans give clear guidance for staff. There were parts of the care plan that gave clear guidance on how to support the individual, but there were other parts of the care plan that did not relate to any of the risk assessments that meant that in these areas staff were not given clear guidance. There are comprehensive risk assessments in place for individual people, and these were tailored to their needs and are aimed at supporting people with maintaining their independence. Risk assessments cover both environmental and individual risks but do not always link in with the care plans. This is an area that the home needs to continue to improve upon and this is being recommended Everyone living in the home has an opportunity to attend regular meetings and discussions with two people living in the home showed that they aware able to this. Everyone we spoke to confirmed that they were happy and that they felt well supported by staff. People are supported to the things that they prefer during the day, in accordance with staffing levels. One lady told us that she wished they could go out more but said that there was not always enough staff about to be able to do this. Larchwood Grove DS0000023972.V365837.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 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. There is a commitment to enabling people to develop their skills, including social, emotional, communication and household living skills. EVIDENCE: We spoke to people who are receiving the service and they stated that they enjoyed living in the home. Comments included: ‘I like it here very much – the staff are so helpful’ and ‘When I am feeling down there is always someone to help me’ 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. A computer has Larchwood Grove DS0000023972.V365837.R01.S.doc Version 5.2 Page 14 been purchased for use by the people living in the home and there are further plans to connect to the internet in the near future. People living in the home also said that they were going away on holiday to Butlins and were looking forward to this. People spoken with said they enjoy the activities provided at home. 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. 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. Each person, who is able, takes on the role of cooking for one day a week and are supported by a member of staff. The people we talked to during the course of our visit all said that they enjoyed this. We observed people being supported during the course of our visit and it was noted that staff support people and help them to undertake tasks rather than actually doing things for them. For example – one person said that they would like an orange and the member of staff then showed this person how to cut the orange up rather than doing it for them. Another person living in the home also described how staff help and support her. She said, “They let me do things but if I can’t manage they will always help me” One person told us “I help to do things in the house and I enjoy that’. She did however go onto say that she would like to go out more and would also like to try and find a part time job. This is something that the manager and provider could explore in more detail for the individual. Another person, who stays on respite, also told us that they enjoy staying here and that they are happy to stay as they have made some good friends here. A lady comes in on a fortnightly basis to give people a massage and when we spoke to people living in the home they all said how much they enjoyed this. There are plans to increase this to weekly visits. We saw people having their nails painted and at all times the staff on duty treated each individual with respect and courtesy. The staff ensure that people respect each others space and privacy and discuss any issues within the house meetings and at the handover period between staff. There is a four-week menu in place and people are supported to make their choices on a weekly basis. People also take it in turns, where they are able, Larchwood Grove DS0000023972.V365837.R01.S.doc Version 5.2 Page 15 to help make the meals. On the day of our visit the main meal was a chicken curry, but alternatives were offered. Everyone we spoke to said they like the meals in the home and one lady told us ‘when they do lasagne it is absolutely gorgeous’. Larchwood Grove DS0000023972.V365837.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s health care needs are met and the procedures for medication means that people are generally safeguarded. EVIDENCE: We looked at the records for two permanent residents and one person who was staying for respite. The records for people who are permanent gave clear guidance on how to support people with their individual needs. They are reflective of individual needs and give clear guidance with regards to personal preferences and how people want to be supported. This has improved from the last visit and when we looked at care plans we saw that individual preferences are taken into account. When we spoke to people they also confirmed that they are helped in accordance with their individual needs. Again, however, there needs to be more up to date information for people who are staying on respite. Feedback from people living in the home was that they are supported by staff to keep healthy and well and are helped to keep healthcare appointments such Larchwood Grove DS0000023972.V365837.R01.S.doc Version 5.2 Page 17 as visiting the GP, Optician or Dentist etc when they wish to. They are supported in going to appointments when they need this. Each person has their health needs identified in their care plan and records show that health needs have been responded to quickly. Care plans clearly identify how to support people with their well-being and are reflective of both emotional and physical needs. Care plans for all of those we viewed emphasised the importance of communication and we also saw this being put into practice. We observed medication being administered and saw that they followed good practice guidelines. The record keeping was generally good, with only one error in the records we checked and the manager was able to clarify this. We also saw that where a person was being given medication through a specialised procedure the member of staff was talking to him and informing him of what the medication was for. Only staff who are trained in this area give out medication. Not all bottles and boxes are dated when they are first opened and although the manager recognised that this should be happening it is being recommended that that this occurs as good practice. The manager stated that there is currently no one living in the home who wants to manage their own medication, although they will support people to do this. Larchwood Grove DS0000023972.V365837.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. 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. 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. We have not received any complaints about the home since the last inspection. There is a comments book in the reception area and we looked at this. There were no negative comments in this book. We also spoke to people who use the service and there were no complaints. One person who was visiting to arrange a respite stay for her daughter also confirmed that she did not have any complaints about the service but if she did, she had confidence that she would be listened to. Staff records that we looked at all showed that people had been trained in procedures relating to safeguarding adults. Larchwood Grove DS0000023972.V365837.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. 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. EVIDENCE: There are 10 single bedrooms and some have en-suite 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. There are two lounges, a dining room, kitchen and laundry. All areas are designed to be accessible to people living in the home. At the last inspection it was identified that some people with mobility difficulties may have problems using the fire doors but this had been addressed at the time of this visit. Larchwood Grove DS0000023972.V365837.R01.S.doc Version 5.2 Page 20 The shower room that was not in use at the last visit had also been fixed. On this visit we did not look in all the bedrooms but of the ones, which we viewed, we saw that they reflected individual needs and where specialist equipment was needed, that this was in place. There was a patio area to the rear of the property and a garden area that people can access as they wish. 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. They also said that they were happy living in the home. Larchwood Grove DS0000023972.V365837.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People can be confident that they are supported by caring staff that respect their choices and preferences, although they will further benefit when all staff have received appropriate training. Staffing levels do not always allow service users to be supported in a manner that that suits their individual needs. Recruitment procedures do not serve to protect the people living in the home. EVIDENCE: During our visit we observed good practice and good interaction between people living in the home and the members of staff on duty. The procedures in place, however, are not robust enough to fully protect the people living in the home. For example although the service appears to be staffed adequately to enable key support needs for people’s daily support to be met, staff rotas do not evidence this. Larchwood Grove DS0000023972.V365837.R01.S.doc Version 5.2 Page 22 There is a service user who is allocated 1 – 1 support and at the last visit we identified that the member of staff allocated for this was included in the general staff rota. At this visit we saw that this had not changed. The manager was not able to produce robust records of previous weeks worked and although there was an additional member of staff on duty at the time of our visit this was because they were on probation and could only ‘shadow’ other staff on duty. The manager stated that they are also using Agency Staff, although they aim to make sure that there is continuity. Of the rotas that we were shown – it was evident that there are only two members of staff on at any one time which results in only leaving one member of staff on duty to care for the other people living in the home. It is acknowledged that there is a member of staff on duty to carry out kitchen duties – but this is to support people in this area and also cook the meals and again still leaves only one person on duty for the remainder of the people living in the home. Recruitment records are not robust with gaps in employment not being investigated, inappropriate references and a lack of pre-employment checks in place. The Regulations state about the records that must be maintained within the home and overall there was no evidence of this. We then looked at the training records and these showed that some specialist training has been undertaken to meet individual needs for example use of suction / how to peg feed / epilepsy awareness / first aid and protection of vulnerable adults. We did see, however, that there were some areas of mandatory training in relation to movement and handling / fire safety and infection control that had not been addressed. There are requirements being made in relation to staff recruitment and staff training. Larchwood Grove DS0000023972.V365837.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 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 have their health and welfare generally safeguarded but they would benefit from better management of staffing arrangements and training to fully ensure their safety and well being. EVIDENCE: Since our last visit the manager has completed the Registered Managers Award. She also stated that she intended to continue with updating herself with regards to other training. The Annual Quality Assurance Assessment (AQAA) was completed by the manager and returned to us. This showed a commitment to promoting Larchwood Grove DS0000023972.V365837.R01.S.doc Version 5.2 Page 24 equality and diversity within the home with people being assessed in accordance with their individual needs. There are regular meetings with people living in the home and the AQAA stated that quality assurance questionnaires are distributed on a regular basis. The Registered Provider carries our regular monitoring visits. The Registered Provider is active in supporting the running of the home. The AQAA also stated that all relevant health and safety checks had been carried out including maintenance of electrical appliances and fire equipment. When we visited we saw that the home was well maintained with health and safety procedures being maintained. We did see, however, that the fridge temperatures were not consistent in that the recorded reading varied from 5° to 21°. The food standards agency states that chilled food must be kept at below 8°, we discussed this at the time of the visit and the manager stated that she would look into this. A requirement is being made in this report. There are environmental risk assessments in place and individualised risk assessments for people living in the home. Record keeping in relation to staff files are not maintained appropriately with previous staff rotas not available and staff files not being maintained in a robust manner. Larchwood Grove DS0000023972.V365837.R01.S.doc Version 5.2 Page 25 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 3 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 1 34 1 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 3 15 2 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X 1 2 X Larchwood Grove DS0000023972.V365837.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA33 Regulation 18(1) (a) Requirement Timescale for action 30/09/08 2. YA33 17 (2) (4) 3. YA34 19 (5) (d) 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. This requirement remains outstanding with an original timescale of 14/09/07 15/08/08 The registered person shall maintain in the care home the records specified in Schedule 4. The records shall be retained for not less than 3 years from the date of entry. In that there must be copies kept of the duty roster of persons working in the care home and a record of whether the roster was actually worked. The registered person shall not 15/08/08 employ a person at the care home unless full and satisfactory information is available in respect of each of the matters in paragraphs 1 – 9 in Schedule 2. In that: There must be a full DS0000023972.V365837.R01.S.doc Version 5.2 Larchwood Grove Page 27 4. YA35 18 (1) (c) 5. YA42 13 (4) (c) employment history together with a satisfactory written explanation of any gaps in employment. There must be 2 written references which satisfies the requirements of schedule 2. The registered person shall 30/09/08 having regard to the size of the care home, the statement of purpose and the number and needs of the service users ensure that the persons employed by the registered person to work at the home receive training appropriate to the work they are to perform. In that staff are trained appropriately in mandatory areas including movement and handling and fire training. The Registered Person shall 15/08/08 ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. In that fridge temperatures are maintained in accordance with the Food Standards Agency Guidelines. 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 YA1 YA2 YA6 Good Practice Recommendations That the Statement of Purpose is reviewed to make sure that all the information contained within is up to date. That when people are re-admitted for respite care the preadmission process is more robust – in that they explore in more detail the current needs of the individual. That where risk assessments are updated – then this DS0000023972.V365837.R01.S.doc Version 5.2 Page 28 Larchwood Grove 4. YA20 information should be incorporated into the care plans. That when bottles and boxes of medication are opened they are dated appropriately. Larchwood Grove DS0000023972.V365837.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Larchwood Grove DS0000023972.V365837.R01.S.doc Version 5.2 Page 30 - 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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