Inspection on 27/02/06 for The Garden House

This inspection was carried out on 27th February 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Garden House 17/02/10

The Garden House 21/12/09

The Garden House 02/06/09

The Garden House 11/05/07

The Garden House 14/06/06

The Garden House 09/11/05

The Garden House 20/10/04

The Garden House 08/06/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Garden House 24 Humberston Avenue Cleethorpes North East Lincs DN36 4SP Lead Inspector Ms Matun Wawryk Unannounced Inspection 27th February 2006 09:30 X10015.doc Version 1.40 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 The Garden House DS0000038376.V264122.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 Older People. 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. The Garden House DS0000038376.V264122.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Garden House Address 24 Humberston Avenue Cleethorpes North East Lincs DN36 4SP 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) 01472 813256 Worcester Garden (No 2) Ltd position vacant Care Home 44 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (44), of places Physical disability (10) The Garden House DS0000038376.V264122.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th November 2005 Brief Description of the Service: The Garden House is a 44-bedded care home set in an exclusive area of Humberston, near the towns of Grimsby and Cleethorpes. The main house is in the style of an old manor house and retains many of its original features. The previous owner added a sympathetically designed extension in the grounds. There is ample car parking space and a well-designed and colourful garden. The home provides care for those with problems of old age and will take permanent, respite and emergency admissions. Some rooms have en-suite facilities, but there is ample bathroom and toilet facilities positioned around the home. There are several sitting rooms and a large dining room. All areas, including the gardens are accessible for wheelchair users. The owner of the home and the company secretary make frequent visits to the home. Staff working in the home are encouraged and supported to share ideas with the sister home in the Bristol area of the country. The management team have put together an extensive training programme for staff, using in house expertise, visiting trainers and outside courses. The home does not offer nursing care. Service users’ health needs are met with the assistance of other health care professionals for example general practitioners and district nurses. The Garden House DS0000038376.V264122.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on the 27th February 2006 and took seven hours and thirty minutes to complete. The Inspector spoke to five service users individually and more generally to a small group of service users and issued a number of comment cards for service users and their relatives to complete. Four completed service user comments cards were returned to the inspector. The inspector also spoke to the owner of the home, a senior care worker, three care workers, a cook and the activity co-ordinator. In addition the inspector looked at a range of paperwork in relation to staff recruitment, induction, supervision and training, the staff rota, a sample of care plans and activity records. What the service does well: What has improved since the last inspection? The Garden House DS0000038376.V264122.R01.S.doc Version 5.1 Page 6 Since the last inspection some improvement in the provision of formal supervision was noted. A new revised supervision record had been introduced and all staff had a named supervisor. The registered person had ensured service users are provided with a contact/statement of terms and conditions, which set out what’s included in the fees charged and other essential information. What they could do better: The registered person must address the outstanding requirements and the new ones issued from this inspection. All service users must have their needs properly assessed prior to admission to the home. Assessment reports must be updated if the service user’s needs change. This is needed to ensure the home is able to provide necessary care and support. The care that people required was written down in care plans. However they did not always reflect all the care that people needed and what staff needed to do to help people. One person did not have a care plan. This is needed to ensure staff know how to support service users from the date of admission and to ensure staff are able to provide the service user with the right care. Two service users said one or two staff members talked abruptly to them. Both the service users declined to give the inspector any further information concerning this issue. This matter was referred back to the owner of the home for her to address with staff. The home had not ensured two written references had been obtained for some new staff. The home must ensure required records are obtained before staff start working in the home. This is needed to ensure the protection of service users and must now happen. One service user who completed a questionnaire reported staff did not respect their privacy and dignity, but gave no reason for this. One of the service users who the inspector spoke to said they shared a bedroom and because of this their privacy and dignity was compromised. None of the shared rooms have privacy curtains fitted. Three service users who spoke to the inspector commented that they felt some service users were wrongly placed in the home and this view was also shared by some of the staff the inspector spoke to. This matter was referred back to the owner of the home for her to look into. Please contact the provider for advice of actions taken in response to this The Garden House DS0000038376.V264122.R01.S.doc Version 5.1 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Garden House DS0000038376.V264122.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Garden House DS0000038376.V264122.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Service users must have their needs assessed prior to admission to the home. This is needed to ensure the home is able to provide the necessary care and support. A review of the home’s registration category is needed. EVIDENCE: The inspector examined the care records for one service user who had recently been admitted to the home on an emergency basis. The responsible local authority had not provided the home with a needs assessment or care plan, and in the absence of a professional assessment the home had not carried out their own assessment of this persons needs. In the absence of a local authority needs assessment the registered person must ensure a needs assessment is completed. Failure to complete an assessment means there is no assurance that the home is able to provide necessary care and support. This remains an outstanding requirement from the last inspection and must now happen. The Garden House DS0000038376.V264122.R01.S.doc Version 5.1 Page 10 The home is registered to provide places for up to 10 service users with dementia. Three service users commented that they felt some service were wrongly placed in the home and this view was also shared by some of the staff the inspector spoke to. Service users stated that they were unable to hold a conversations with some service users and were troubled by the behaviours of one or two service users. Some staff reported they felt there were more than ten people with dementia living in the home. This matter was discussed with the owner of the home. The inspector advises that a review of the registration category is completed and where necessary an application to vary the registration category is submitted. This is needed to ensure the homes registration category accurately reflects the needs of service users and to meet legal requirements The Garden House DS0000038376.V264122.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Care plans did not consistently include all the information staff need to meet the service users assessed needs. The absence of important information potentially puts service users at risk and means their care needs may not be met. The arrangements for the management of the service users medication are satisfactory. Personal support is generally offered in such a way as to promote and protect the service users right to privacy and dignity. However the arrangements for ensuring the privacy and dignity of service users in shared rooms requires further consideration. EVIDENCE: The inspector examined four care programmes for service users with a range of needs. In the main the documentation system was found to be detailed and well maintained although a number of inconsistencies and gaps were identified through case tracking. For example: One service user who recently been admitted to the home did not have a care plan. The registered person must ensure interim care plan(s) are developed on The Garden House DS0000038376.V264122.R01.S.doc Version 5.1 Page 12 admission; these can then be built on over time. This is needed to ensure staff know how to care and support service users from the date of admission. Some care plans lacked detailed guidance for staff on care delivery arrangements and some care plans had not been updated to reflect changes in the service users care needs. For example: Records revealed one service user’s health had deteriorated and as a result the service user was now much more dependent on staff for moving and handling and personal care. This service user’s care plan(s) had not been revised to reflect these changes. The registered person must care plans set out all the service user’s care needs. Regularly monitoring of care plans must be carried out to ensure changes are picked up and interventions modified as needed. The home had a range of risk assessment tools for example, manual handling, water low and nutritional screening. Generally these were well maintained although again some deficiencies were noted. The moving and handling assessment for one service user had not been updated to reflect the service user now needed two staff for all transfers. The Water-low assessment for another service user indicated the service user was at high risk of developing pressure areas. Daily records revealed the service user had a pressure area and was receiving district-nursing support. However an individual care plan for pressure area care had not been developed. The inspector advises that for those service users at risk of developing pressure areas, individual care plans are developed. These must contain sufficient information to guide staff practice for example, they should set out in detail tasks staff are expected to carryout for that individual e.g. where ‘regular’ positional changes are advised care plans must be more specific in terms frequency, manoeuvres and monitoring arrangements etc. this is needed to ensure staff know what care should be provided. Records for two service users revealed both had memory impairment problems. Care plans for psychological health had not been developed, despite daily record indicating both service users were exhibiting some challenging behaviours. The registered person must ensure care plans cover all areas of assessed needs. This is needed to ensure all the service users’ needs are clearly identified and planned for. Records showed some service users were having their weight monitored. However this was not happening for service users who were unable to weight bear because the home did not have sit on scales. The registered person must ensure all service users have their weight monitored. Care Plans must set out how frequently this must happen. Sit-on scales must be provided or alternative arrangements must be in place for those service users unable to weight-bear. The Garden House DS0000038376.V264122.R01.S.doc Version 5.1 Page 13 A policy and procedure for the safe handling of medication was available in the home and the systems for the safe handling of medication were examined. Records had been maintained for the receipt, administration and disposal of medication and there was a procedure for handling and recording receipt and return of medications. The inspector examined a sample of medication administration records. These were found to be in good order no errors or omissions in recording administration of medication were noted. The inspector spoke individually to five service users and generally to a small group of three service users. Most service users spoken sated staff respected their privacy and most described staff as very kind and caring. Two service users commented that one or two members of staff could be sharp and impatient. Both service users declined to give the inspection any further information. This matter was referred back to the owner for her to address with staff. One service user who returned a questionnaire stated their privacy was not respected, but gave no explanation for this. Another service user who the inspector spoke to with said their privacy and dignity was compromised because they shared a bedroom. Privacy curtains are not provided in shared rooms. Staff reported they used mobile screens when assisting service users in shared rooms. The one service user who commented upon this matter did not substantiate this assertion. Please also refer to comments detailed on page 19 of this report. The Garden House DS0000038376.V264122.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above 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 A good range of activities are available to service users. Service users are encouraged and supported to maintain family links and friendships. The meals in the home are good offering choice and variety. EVIDENCE: The home employs an activity coordinator who works four afternoons per week. Up to date information about activities on offer in the home is made available on a weekly basis. All of the service users spoken to said they were happy with the range of activities provided. Staff reported that they helped service users to maintain family contacts by sending cards at significant occasions such as birthdays and Christmas and supported service users on outings. This was confirmed in discussion with service users. Service users spoken to confirmed that their visitors were made to feel welcome and could visit at any time. The inspector saw open visiting and visitors were offered refreshments. Service users spoken said they felt they were able to make choices about aspects of their lives. For example people felt able to spend time in their bedrooms if they chose to and mix with others during organised activities. The Garden House DS0000038376.V264122.R01.S.doc Version 5.1 Page 15 Service users were encouraged to furnish and personalise their bedrooms and the inspector saw evidence of this to varying degrees. People could choose where to have their meals, what clothes they wanted to wear and the times they chose to retire to bed and get up in the morning and which visitors to receive. Meals are served in the comfortable dining room. Meals can also be taken in other areas depending on the personal preferences of the service users. Service users spoken to reported they were very happy with the meals provided stating they had choices at mealtimes and food and drinks were in plentiful supply. Fresh fruit and vegetables are available. The Garden House DS0000038376.V264122.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 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 The arrangements for the management of adult protection matters must improve through the provision of training for staff. EVIDENCE: The home had a copy of the local authority Multi Agency Adult Protection Policies and Procedures and an internal abuse procedure. In addition the home had recently issued guidance to staff on the homes abuse procedure and a questionnaire, which they were required to complete and return to the home. In discussion with the inspector staff stated they would feel confident in raising issues and concerns with the deputy managers and other senior care staff. Examination of a sample of staff training records revealed a number of staff had completed adult protection training, however a number staff still needed to complete this training. This is needed to ensure staff are able to recognise adult protection issues and to ensure staff are fully aware of their responsibilities and reporting arrangements. Since the last inspection one adult protection matter had been referred by the home to the Local authority. The Garden House DS0000038376.V264122.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 & 26 The home was clean and was free from offensive odours. Service users’ bedrooms were found to be safe, homely and furnished with their own possessions to varying degrees. EVIDENCE: The home had a range of health and safety procedures including the control of infection in place and staff reported they had access to ample supplies of protective clothing. The inspector carried out a tour of the home. The home appeared clean and tidy and had a welcoming and homely feel. The registered person was not able to locate a copy of the homes fire risk assessment. Please refer to comments detailed on page 24 of this report. CCTV is not used in the home or grounds. All bedrooms examined were clean and tidy and were furnished and decorated in a homely style. All but one of the service users spoken to stated that they were happy with their rooms. One service user commented that her room was The Garden House DS0000038376.V264122.R01.S.doc Version 5.1 Page 18 far too hot. A fan had been provided but according to the service user this had not fully addressed the problem. This matter was referred back to the owner of the home for her to address. Some service users share a bedroom. Privacy curtains had not been provided. It was reported that when service users were being undressed or were using the commode mobile screens were used. This was not corroborated by one of the service user who the inspector spoke to. The registered person must review the arrangements for ensuring the privacy and dignity of service users in shared rooms are reviewed. Where needed privacy screens must be provided. The Garden House DS0000038376.V264122.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29 & 30 The inspector was not able to fully assess whether the home’s staffing levels were appropriate to dependency levels of service users. Some inconsistencies in recruitment practice were noted resulting in service users receiving care from some staff that have not been properly vetted. This potentially leaves service users who use the service at risk. EVIDENCE: The home had 43 service users in residence at the time of the inspection. Staff reported that generally staffing levels were satisfactory. However as a result of recent staff turnover rates and increased dependency levels of some service users some care staff stated that the amount of hours set on their rota was not adequate to give quality time to the service users. Information was not available on the day of the inspection to show how staffing ratios are worked out. The inspector advises that a review of staffing is undertaken using a dependency-rating tool to assess whether current staffing levels meet current needs of service users. Copy of the review should be provided to the Commission. From discussion with staff and records examined it was evident there was a commitment to NVQ training. A significant number of staff had achieved an award and a number of other staff were enrolled to complete one. The registered person must continue the programme of NVQ training to ensure a minimum of 50 of care workers obtain an NVQ or equivalent. This is needed to meet NMS 28. The Garden House DS0000038376.V264122.R01.S.doc Version 5.1 Page 20 The home had a recruitment policy and the owner of the home assured the inspector that the home works within equal opportunity policies and procedures. The inspector examined a random selection of three files for staff who had commenced employment since the last inspection. All required checks had been carried out for one of these workers. However records showed two workers had commenced working in the home prior to receipt of a second written reference. This practice potentially service users at risk and must cease. The registered person must ensure two satisfactory written references are obtained before any member of staff starts working in the home. The inspector examined a sample of individual staff training records. Records showed staff had been provided with a wide range of training opportunities, although some gaps were noted. Records and discussions with staff identified some staff had not had any recent moving and handling training or annual updates. The home employs its own moving and handling trainer and an assurance was given that training would be arranged as a matter of priority. Annual appraisals for staff were not up to date and these must now be provided. This is needed to ensure the home’s training plans and priorities accurately reflect the needs of the whole staff team. The Garden House DS0000038376.V264122.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 & 38 There is currently no registered manager for the home. The current management arrangements are generally satisfactory do not provide consistency for staff and service users. A quality assurance plan for the home must be developed. The management of health and safety is generally satisfactory, but improvement is needed in respect of some training for staff. EVIDENCE: The manager’s post was vacant at the time of the inspection. The owner of the home was taking steps to try and recruit a manager. In the meantime interim arrangements have been introduced. A previous manager of the home has been appointed to work ten hours per week and the two deputy managers are also taking some management responsibility for the home. The Garden House DS0000038376.V264122.R01.S.doc Version 5.1 Page 22 All of the staff spoken to stated senior staff were doing their best and commented that these staff were approachable and supportive. Nevertheless some staff commented that the current arrangements do not provide consistency. National Minimum Standard 31 and 32 cannot be met because there is currently no registered manager for the home. Since the last inspection some improvement in the provision of formal supervision was noted. A new revised supervision record had been introduced and all staff had a named supervisor. Examination of a sample of staff supervision records showed that the majority of staff had had one supervision session since the last inspection. However there were a small number of staff that had not had supervision since the last inspection. The registered person must ensure all staff receive formal recorded supervision. This is needed to ensure staff receive necessary guidance and support from managers. This remains an outstanding requirement from previous inspections and must now happen. A formal quality assurance plan for the home was not available on the day of the inspection. The inspector was advised that the quality system consisted of weekly and monthly audits, monthly regulation 26 visits and surveys of service users, their carers, staff and other key stakeholders. Although no recent surveys had been conducted. The registered person must develop a quality assurance plan for the home. This is needed to ensure everyone is consulted about the running of the home and to ensure continuous improvements are made. The home had a range of policies and for health and safety and a current insurance certificate was on prominent display in the home. The home had current maintenance certificates for the gas, electrical system and the fire system. Certificates were in place for the passenger lift, the fixed bath hoist and fire fighting equipment. The manager had ensured regular monitoring of the hot water, emergency lights and fire alarm and records seen during the inspection were satisfactory. Records indicated the last fire drill was carried out in March 05. The registered person must ensure fire drills are carried out as a minimum of twice a year. This is needed to meet health and safety requirements and must now happen. The Garden House DS0000038376.V264122.R01.S.doc Version 5.1 Page 23 Records showed the majority of staff were up to date with mandatory training. A number of staff needed fire training and training had been arranged. A small number of staff had not completed manual handling training and a number of staff had not been provided with an annual update. The homes employs its own manual handling trainer and assurances were given that further manual training would be provided as a matter of priority. The registered person must ensure staff are up to date with all mandatory training. Regular updates must be provided. This is needed to meet health and safety requirements and must now happen. Records revealed one service user had bedrails fitted. A completed risk assessment was not available in the service users care records. The registered person must ensure risk assessments for bed rails are completed; these must reflect guidance issued by the Medical Devices Agency for use of bedrails. This is needed to ensure the health and welfare of service users. As previously indicated the owner of the home was unable to locate the homes fire risk assessment on the day of the inspection. The registered person must confirm to the Commission that a current fire risk is available in the home. The Garden House DS0000038376.V264122.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 1 x x X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 2 X X X X 2 X x STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 2 X X 2 X 2 The Garden House DS0000038376.V264122.R01.S.doc Version 5.1 Page 25 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 OP36 Regulation 18 Requirement The registered person must ensure supervision programmes comply with NMS 36 and is linked to the training programme. Timescale of 28/11/03 and 20/3/05 not met The registered person must ensure staff are provided with adult protection training The registered person must ensure a needs assessment is completed for all service users prior to admission. Assessment reports must be updated to reflect changes in circumstances and needs. Timescale of 14.12.05 not met Timescale for action 31/03/06 2. 3. OP18 OP3 18 14 30/04/06 28/02/06 4. OP3 14(1)(d) The registered person must write 28/02/06 to potential service users or their representative following the assessment stating the home is able to meet their needs. Timescale of 14/12/05 not met The registered person must ensure all service users have a care plan. Care plans must DS0000038376.V264122.R01.S.doc 5. OP7 15 31/03/06 The Garden House Version 5.1 Page 26 identify all care needs. Care plans must be updated to reflect changing needs and circumstances. 6. 7. OP36 OP29 18 19(1)(b) The registered person must ensure staff are provided with an annual appraisal. The registered person must ensure staff do not commence working in the home until two satisfactory references have been obtained. Timescale of 14.12.05 not met The registered person must undertake a review of the homes registration category and where necessary make an application to vary the registration category. The registered person must ensure care plans reflect all areas of identified need including social, emotional, health and psychological health needs. The registered person must ensure staff do not commence working in the home until two satisfactory references have been obtained The registered person must produce and make available a quality assurance plan for the home. A summary of which must be included in the service user guide The registered person must ensure for those service users at risk of developing pressure areas, individual care plans are developed. These must contain sufficient information to guide staff practice. The registered person must ensure risk assessments for bed rails are completed; these must reflect guidance issued by the Medical Devices Agency for use DS0000038376.V264122.R01.S.doc 31/05/06 28/02/06 8 OP3 Schedule 3 14 15 30/04/06 9 OP7 30/04/06 10 OP29 19 27/02/06 11 OP33 35 31/05/06 12 OP7 15 14/04/06 13 OP38 13 14/04/06 The Garden House Version 5.1 Page 27 14 OP24 12 & 16 15 OP27 18 16 OP8 13 of bedrails The registered person must 30/04/06 review the arrangements for ensuring the privacy and dignity of service users in shared rooms are reviewed. Where needed privacy screens must be provided. The registered person must 30/04/06 complete a review of staffing using a dependency-rating tool to assess whether current staffing levels meet the current needs of service users. Copy of the review should be provided to the Commission. The registered person must 30/04/06 ensure service users have their weight monitored. Care Plans must set out how frequently this must happen. Sit on scales must be provided for service users who are unable to weight bear or alternative arrangements must be in place for these service users. 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 OP28 Good Practice Recommendations The registered person must continue the programme of NVQ training to ensure 50 of care workers obtain an NVQ or equivalent. The Garden House DS0000038376.V264122.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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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