Inspection on 30/01/08 for The Granleys

This inspection was carried out on 30th January 2008.

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

Other inspections for this house

The Granleys 22/08/07

The Granleys 25/08/06

The Granleys 02/02/06

The Granleys 05/07/05

The Granleys 05/03/05

The Granleys 17/06/04

The Granleys 02/02/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 The Granleys 21 Griffiths Avenue St Mark`s Cheltenham Glos GL51 6SJ Lead Inspector Mr Paul Chapman Key Unannounced Inspection 30th January 2008 09:00 The Granleys DS0000016610.V356481.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 The Granleys DS0000016610.V356481.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. The Granleys DS0000016610.V356481.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Granleys Address 21 Griffiths Avenue St Mark`s Cheltenham Glos GL51 6SJ 01242 521721 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) Mrs Brenda Tapsell Miss Tracy Green Care Home 17 Category(ies) of Learning disability (17) registration, with number of places The Granleys DS0000016610.V356481.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate 3 named service users who are over the age of 65yrs. This condition will be removed once the named service users no longer reside at the home. 22nd August 2007 Date of last inspection Brief Description of the Service: The Granleys is a detached property approximately 1 mile from the centre of Cheltenham. The home provides care and accommodation to 17 adults with learning disabilities. The house is set in large grounds and is a listed building. The accommodation is arranged over two floors and all of the rooms have en suite facilities. A copy of the Statement of Purpose and Service User Guide are kept in the main office and are available upon request. The Granleys DS0000016610.V356481.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This inspection site visit took place in January 2008. The registered manager was off duty but visited the home for a short period of time to see us. A senior support worker supported us throughout the day. Time was spent observing the care of people and their interactions with staff. All of the people home at the time were given the opportunity to speak with us. Three people chose to speak to us. Six people’s bedrooms were seen with staff. The care of four people was looked at in depth that included looking at their financial, medication and personal records. Other records examined included staff files, health and safety information and quality assurance records. What the service does well: What has improved since the last inspection? What they could do better: The Service User’s Guide needs to be reviewed to ensure that it contains all of the information required by these regulations and enables people to make an informed decision. The Granleys DS0000016610.V356481.R01.S.doc Version 5.2 Page 6 Needs assessments, care plans and person centred plans need to be completed and kept under review to ensure that people’s current needs are being met. People living in the home must be involved in re-developing their care plans and person centred plans. There must be clear evidence of them being empowered to do this. Thorough risk assessments need to be completed for each person living in the home to ensure that they are not being put at unnecessary risks. All people living in the home must have access to the complaints procedure to enable them to make voice their concerns when necessary. Staff files must be reviewed to ensure that people living in the home are not put at unnecessary risks by the home’s recruitment procedures. The manager has made progress towards meeting the requirements of the previous inspection report. People living in the home are still at risk due to requirements still not being fully met. The quality rating for this service is 0 star. This means the people who use this service experience Poor quality outcomes. 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. The Granleys DS0000016610.V356481.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 The Granleys DS0000016610.V356481.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): 1 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home’s Statement of Purpose provides sufficient information to meet the criteria of the regulations. The Home’s Service User’s Guide does not provide people with sufficient information about the service people could expect if they wished to move into the home. EVIDENCE: A requirement of the 2 previous inspection reports has been that the home review the Statement of Purpose and Service User’s Guide and forward the completed copies to the CSCI. In addition to this they were to ensure that all people living in the home have access to the documents. Another requirement of the 2 previous inspection reports related to the Statement of Purpose and ensuring that it makes reference to the home’s policy and procedure for emergency admissions, and that respite care is not provided. The Granleys DS0000016610.V356481.R01.S.doc Version 5.2 Page 9 The manager has completed a review of both of these documents and sent copies to us. Reading the Statement of Purpose it now makes reference to the above-mentioned policies. Reading the Service User’s Guide the manager has re-written it in the form of a resident’s charter, explaining people’s rights whilst living in the home. This is a good document, but unfortunately does not meet the criteria of the regulations. This was discussed with the manager and it was agreed that they would look at the regulations and develop a document to provide the required information. The manager should incorporate the information in the current Service User’s Guide as it makes it clear that people’s rights will be respected. Standard 2 was assessed at the previous site visit. The Granleys DS0000016610.V356481.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): 6, 7, 9 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans do not provide sufficient information to enable staff to meet people’s needs consistently. People are empowered to make decisions about their lifestyles and staff provide support where necessary to enable them. People are still being put at unnecessary risks due to the poor risk assessments that do not identify and minimise potential risks. EVIDENCE: The previous inspection report made a requirement that the person centred plans for each person must be reviewed and re-written with the involvement of the people they are for. The care files for 4 people were examined in detail. The Granleys DS0000016610.V356481.R01.S.doc Version 5.2 Page 11 Each • • • • • • • • person has a personal file that is divided into 8 sections: Personal information Guidelines Health needs Finance Activities Personal plans Risks Behaviour management The senior support worker on duty stated that as a result of the previous inspection report each key worker had been asked to complete a review of each person’s file by the beginning of February. Each of the files examined provided evidence that this was being done. Some shortfalls were brought to the attention of the manager. One related to the consistency in which staff were completing the forms that make up people’s files. An example of this was the guidelines/care plans for people. We spoke about ensuring that each person’s plans contain the following 4 elements. • Assessment of the person’s needs. • Identify the goal to be achieved. • Provide a detailed plan to achieve that goal. An example of this is where a person requires support with their personal care. How exactly do staff need to support the person? • Review – ensure that reviews are completed at regular intervals (and when required). Other shortfalls identified include: • The files are made up of a number of standard forms. Some of these forms do not apply to people, or are not used. They should be removed, or N/A should be written on them with a date. This will simplify the file. • There were guidelines to support someone to maintain their independence which were written up in their personal plans section, when it should have been the activities section. • All documents should be dated when they are written. • Each of the files contained at least two different copies of a form identifying people’s daytime activities. They were dated as being reviewed at the same time, but the forms identified the person as doing different activities. This must be addressed. As a result of examining people’s files and identifying the shortfalls the requirement of the previous inspection will be carried forward as part of this inspection report. At the next site visit we will expect to see the shortfalls identified as part of this site visit addressed as well. The Granleys DS0000016610.V356481.R01.S.doc Version 5.2 Page 12 We sat with a couple of people and spoke to them about their personal files whilst looking through them. Both people were aware that they had these files but were unable to give examples of their input into them. In one file we noted that the person signed some documents. The manager and staff team must ensure that wherever possible people are involved in the process of updating their files. Time should be spent explaining to each person the documents in their files. Whilst speaking to people we asked them whether they were able to make decisions about their lives. People gave examples of being able to decide what they ate, the activities they took part in, holidays and how their bedrooms are decorated. A good practice recommendation of this inspection report is to ensure that records of these occasions are kept. A requirement of the previous inspection report was to ensure that risk assessments were in place for all of the people living in the home. The assessments should cover all areas of people’s lives and provide strategies to minimise potential risks. The risk assessments seen had been reviewed and alterations made where required. It would be better practice to re-write these documents rather than alter them. A number of the assessments did not make sense due to the alterations and did not show how the risk was going to be minimised. As a result this requirement will be carried over as part of this inspection report. Section 6 of each person’s file was called “personal plans”. When examining them with the senior support worker it became clear that this section appears to ask staff to repeat information recorded in previous sections. We question the value of this section. The Granleys DS0000016610.V356481.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, 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home are benefiting from the increased number and range of activities that are now being made available to them. EVIDENCE: The previous inspection report made a number of requirements against standards 12, 13 and 16. The requirements were around the service continuing to develop a range of needs led activities and enhancing people’s rights and responsibilities. At the time of the previous site visit the manager explained that they had employed an activities co-ordinator. The Granleys DS0000016610.V356481.R01.S.doc Version 5.2 Page 14 At this site visit we spent some time with the co-ordinator. They were asked how they have developed their role, and what activities people are offered. They explained that they had started in post in August last year and by September/October they had spoken to all of the people in the home about what they like to do and developed a programme of activities. An example of this programme was given to us and showed that the following activities take place: - recycling, art and crafts, cooking, gardening, swimming and various trips in the local community. The co-ordinator spoke about people going out for tea, meals and doing shopping with people individually. Records in people’s daily notes provided good evidence of various activities being completed regularly. This was supported by the comments from people spoken with during the day. One person commented, “I enjoy cooking sponges with the staff”, and another person spoke about enjoying the trip to the pub for lunch on the day of this site visit. People have chosen some holiday destinations already. A couple of people spoke about going to Blackpool with the staff. When speaking to the staff they confirmed this and talked about the importance of supporting people to have a great holiday. The co-ordinator explained that not all people wish to go away on holidays and they are planning weekend and day trips. Examples of this include day trips on steam trains and visits to the zoo. Another plan for the future is the development of a vegetable patch in the garden. The co-ordinator explained that this will start in the next couple of months and people will be able to grow flowers and vegetables. People living in the home stated that their friend and family are able to visit when they wish. People living in the home are involved in completing the shopping for groceries. This was confirmed by speaking to the people living in the home. Menus run on a 3-week rolling rota. There is a summer and winter menu. People spoken with stated that the food was nice and there was enough to eat. A recommendation of the previous report was to review the practice of having a rolling rota and look at other methods which would enable people to have more choice. This recommendation is carried over as part of this inspection report. The Granleys DS0000016610.V356481.R01.S.doc Version 5.2 Page 15 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, 20 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s personal care needs are not clearly identified and it is impossible to confirm that people’s needs are being met currently. Medication administration is generally well managed and does not put people at unnecessary risks. People’s needs around ageing and illness are being addressed and will enable staff to meet people’s needs at the appropriate time. EVIDENCE: The previous inspection report made a requirement that each person’s personal care needs should be reviewed and re-written to provide staff with greater detail of people’s needs. This is being completed as part of the total review of people’s care in the home. This requirement will be carried over, as it has not yet been achieved. The Granleys DS0000016610.V356481.R01.S.doc Version 5.2 Page 16 Since the previous inspection staff have been completing people’s health action plans with them. A number were sampled and showed that they were at different stages of development/completion. The senior support worker stated that the manager had asked the staff to do this by the end of February. It is a recommendation of this report that the manager ensures that all of these documents are completed. The previous inspection report made a requirement against standard 20. This was to ensure that medication administration was regularly monitored and that any discrepancies are addressed promptly. Examining the records showed that there were a couple of gaps that should have been signed by staff to confirm people had received their medication. This was brought to the attention of the senior support worker on duty. Since the previous inspection a pharmacist has completed inspection of the home’s medication. They highlighted no concerns. Since the previous CSCI inspection was completed staff are now dating creams and ointments when they are opened and 4 staff have completed a safe handling of medication course. It is recommended that the manager continue to monitor the medication administration. The previous inspection report made a requirement against standard 21. This was that each person must be given the opportunity to record their wishes in the case that they become seriously ill. Speaking to the senior support worker and examining records showed that this was being completed at present. A discussion took place about this being very difficult to achieve and what steps staff should take. The use of advocates was suggested as a way to achieve the outcome for this standard. The plans completed so far were good and provided the reader with all of the appropriate information they may require. The requirement of the previous inspection report will be carried over as part of this inspection report as it is not yet completed. The Granleys DS0000016610.V356481.R01.S.doc Version 5.2 Page 17 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, 23 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people spoken to in the home confirmed that they are able to make complaints, and if they did they feel it would be addressed correctly. Safeguarding adults training for the staff team should enable review of current practices and enable improvements where necessary. EVIDENCE: The home has a complaints procedure. Speaking with some of the people living in the home they were aware of the procedure. The senior support worker stated that each person should have a copy of the complaints procedure and Service User’s guide in their bedroom. Whilst completing a tour of the premises it was noticed that some people had a copy of the complaints procedure, but not all. When speaking to some of the people they said that if they made a complaint they would be listened to by the staff. No complaints have been made to the home, or the CSCI since the previous inspection was completed. A requirement of the previous inspection report was that all staff should complete safeguarding adults training. The senior support worker stated that 50 of the staff team are due to complete this training in March, and that the other 50 will be booked into as soon as possible after this date. This will be followed up at the next site visit. The requirement from the previous inspection report will be carried over in this report. The Granleys DS0000016610.V356481.R01.S.doc Version 5.2 Page 18 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, 25, 26, 27, 28, 29, 30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides people with a homely and comfortable environment with sufficient communal space to meet their current needs. The standard of the accommodation has improved since the previous site visit was completed. The home is clean and tidy due to the home employing a dedicated cleaner. EVIDENCE: A tour of the premises was completed with the member of senior care staff on duty at the 1st site visit. All of the communal areas were seen and with the permission of people living in the home a sample of the bedrooms. The entrance hall to the home is nicely decorated and contained a sofa, chairs and a piano. On the wall was a copy of the home’s fire escape procedure. The Granleys DS0000016610.V356481.R01.S.doc Version 5.2 Page 19 The home provides people with a large lounge/diner with 3 tables, a range of chairs and sofas, a television, DVD player and a stereo. The previous inspection report made a number of requirements against these standards relating to the home’s environment. One of the requirements included supplying us with a maintenance program for some of the shortfalls identified around the home. This was supplied and as stated in the program a number of areas have been addressed. This has included the re-decoration of a number of bedrooms. The maintenance programme will be examined as part of the next site visit. Six of the seven shortfalls identified at the previous site visit have been addressed; the only shortfall still outstanding is to repair the water damage on the ceiling of the lounge/dining room. The maintenance programme states that this will be completed by September 2008. This is an acceptable timescale. The home was clean and tidy when this site visit was completed. The home employs a cleaner. The home’s laundry is to the rear of the property in an outhouse. There were colour coded mops and buckets for different areas of the home. Hazardous products are stored securely and COSHH data sheets are in place. The Granleys DS0000016610.V356481.R01.S.doc Version 5.2 Page 20 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, 34, 35 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Some of the previous recruitment procedures have not met the criteria of these regulations and may have put people living in the home at unnecessary risks. Staff training has improved in recent months but specific training needs remain outstanding, which is putting people at unnecessary risk. EVIDENCE: The previous inspection report made a requirement against standard 34. Examination of staff files had shown us that they were in need of review to ensure that they contained all of the information required by these regulations. Examining the files where shortfalls were identified at the last site visit showed that this task has been started but is yet to be completed. As a result this requirement will be carried over in this inspection report. The Granleys DS0000016610.V356481.R01.S.doc Version 5.2 Page 21 The previous inspection report carried over a requirement that staff should receive training appropriate to the needs of the people they support, such as learning disabilities, older persons needs and dementia. The senior support worker stated that they are currently organising for staff to complete LDAF (Learning Disability Award Framework) and that the whole staff team have been booked on a dementia course in April/May. Other training records were not examined on this occasion as they were found to be satisfactory at the previous site visit. The Granleys DS0000016610.V356481.R01.S.doc Version 5.2 Page 22 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, 42 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager has successfully completed the CSCI registration process showing that they are fit to manage this service. People living in the home continue to become more involved in planning the service but a quality assurance system that involves them will help to promote this. Health and safety checks are recorded more consistently but all areas identified need to be addressed to minimise potential risks to people living in the home. The Granleys DS0000016610.V356481.R01.S.doc Version 5.2 Page 23 EVIDENCE: Since the previous inspection site visit was completed the manager has successfully completed their registration with the CSCI. The manager has been in post since April 2007 and has 10 years managerial experience in similar settings. This site visit has shown that manager’s commitment to improve the quality of the service provided at the home and work with us to achieve good outcomes for people. Although a number of requirements have not been met fully, there were clear indicators that progress is being made. The home’s certificate of registration was displayed, and the employer’s insurance certificate was displayed in the entrance hall. A requirement of the previous inspection report (standard 39) was for the manager to establish a system for evaluating the quality of services provided at the home, taking into account and producing a summary report. Since the previous site visit was completed the manager has developed a questionnaire for people living in the home to complete about the quality of the service they receive. This was examined and we would make the following recommendations. • The manager should consider the use of pictures and symbols to enable people with communication difficulties to be able to understand the questionnaire. • People should not have to write their name on the questionnaire if they do not want to. • If staff help people to complete a questionnaire then they should write their name on it. This questionnaire is still under development and we would recommend developing a similar document for use with other professionals and family involved with people living in the home. This will all add to the value of the information gathered as part of the quality assurance process. The requirement identified above will be carried over in this inspection report, because as yet there is no quality assurance process. Another requirement against standard 39 in the previous inspection report related to regulation 26 visits being completed by the proprietor of the home. Speaking to the senior support worker and examining records we were unable to find any evidence of them being completed. It is important that the provider completes these visits as they are not in the day-to-day charge of the home. As a result of the provider’s continued failure to meet this requirement we have sent them a letter warning. If they do not meet this requirement we will start enforcement action against them. The Granleys DS0000016610.V356481.R01.S.doc Version 5.2 Page 24 Health and safety was examined: • • • • Hot water outlet temperatures are not being monitored monthly. This must be addressed with the temperatures being recorded monthly. Fridge and freezer temperatures are being recorded more regularly than at the previous site visit, but the manager must ensure that the temperatures are taken twice a day. A food probe is now being used regularly to record the temperature of food produced. At the time of this site visit the stair lifts had not been serviced by a qualified engineer. The senior support worker stated that they knew that the home’s owner was getting this done. We asked the staff to put a notice on the stair lift saying it was not to be used. During a telephone conversation with the senior support worker two days after the site visit they told us that the stair lift was to be fixed the following week. The equipment in the assisted bathroom was serviced in July 2007. • The areas highlighted in the above list must be addressed by the registered person and become requirements of this inspection report. After we completed the previous site visit a fire officer visited the home and completed an inspection. They identified a number of shortfalls around the home that were putting people at unnecessary risks. A tour of the premises provided evidence that corrective actions had been taken, although the CSCI are not the regulatory authority responsible for confirming whether this work meets the appropriate standards. It is recommended that the manager contact the fire officer to arrange another visit to inspect the work completed. The Granleys DS0000016610.V356481.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 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 2 26 2 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 2 3 X 2 X X 2 X The Granleys DS0000016610.V356481.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 YA1 Regulation 6 Requirement The Service User’s Guide must be reviewed to ensure that it meets the criteria of these regulations. (This requirement has been repeated from the last inspection-timescale for action 04/01/08). The Person Centred Plans must be reviewed and re-written. All PCP’s and care plans must then be reviewed regularly. (This requirement has been repeated from the last inspection-timescale for action 01/03/08). People living in the home must be involved in the development of their Person Centred plans. Risk assessments must be in place for all of the people living in the home. These risk assessments must cover all areas of their lives and provide strategies to minimise potential risks. Timescale for action 01/04/08 2 YA6 15(c) 01/06/08 3. YA7 15 01/06/08 4. YA9 13(4)(c) 01/05/08 The Granleys DS0000016610.V356481.R01.S.doc Version 5.2 Page 27 5 YA18 12(3), (4) a, 15 Care plans relating to peoples personal care needs must be review and re-written to provide greater detail. This will enable staff to meet people’s needs consistently and allow for reviews of peoples changing needs in this area. (This requirement has been repeated from the last inspection-timescale for action 01/02/08). Each person living at the home must be given the opportunity to record their wishes in the case that they become seriously ill. (This requirement has been repeated from the last inspection-timescale for action 01/03/08). All staff must complete safeguarding adults training. (This requirement has been repeated from the last inspection-timescale for action 01/03/08). The maintenance program for the updating of the decoration around the communal areas of the home must be completed. The maintenance program for the updating the decoration of people’s bedrooms must be completed. Staff files must be reviewed to ensure that all of the information required by these regulations is present. 01/06/08 6. YA21 15 01/06/08 7. YA23 13(6) 01/06/08 8. YA24 23 01/12/08 9. YA25 23 01/12/08 10. YA34 19(1) Sch. 2. 01/06/08 The Granleys DS0000016610.V356481.R01.S.doc Version 5.2 Page 28 11. YA39 26 Regulation 26 visits must be completed by the proprietor of the home. (This requirement has been repeated from the last inspection-timescale for action 07/12/07). The registered person must establish a system for evaluating the quality of services provided at the home, taking the views of service users into account and producing a summary report. (This requirement has been repeated from the last inspection-timescale for action 01/03/08). Hot water outlets must tested monthly to ensure that they remain within the safe working parameters. 01/04/08 12. YA39 24 01/08/08 13. YA42 13(4) a, c 01/06/08 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. 4. 5. Refer to Standard YA17 YA19 YA20 YA22 YA23 Good Practice Recommendations The process for choosing meals should be reviewed. Health action plans should be completed for each of the people living in the home. The manager should monitor medication administration and address any shortfalls. Each person should have a copy of the complaints procedure. Substantial amounts of money should not be kept in the home’s safe and should be deposited in their individual bank accounts. The Granleys DS0000016610.V356481.R01.S.doc Version 5.2 Page 29 6. YA34 The home’s staff application form should be reviewed to ask potential staff for a full employment history, and for the dates they started and finished previous positions. Policies and procedures should be reviewed to ensure that they accurately reflect the current practices around the home. The fire officer should be contacted and asked to review the work completed as a result of their previous inspection. 7. YA40 8. YA42 The Granleys DS0000016610.V356481.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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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