Inspection on 02/08/06 for The Grove

This inspection was carried out on 2nd August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 29 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Grove 20/04/09

The Grove 22/04/08

The Grove 03/05/07

The Grove 27/09/06

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 The Grove The Grove 74 King Street Dawley Telford Shropshire TF4 2AQ Lead Inspector Rebecca Harrison Key Unannounced Inspection 2nd August 2006 08:55 The Grove DS0000066733.V296529.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 Grove DS0000066733.V296529.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 Grove DS0000066733.V296529.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Grove Address 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) The Grove 74 King Street Dawley Telford Shropshire TF4 2AQ 01952 501 202 www.dimensions-uk.org Dimensions (UK) Ltd Care Home 5 Category(ies) of Learning disability (5) registration, with number of places The Grove DS0000066733.V296529.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: No conditions apply Date of last inspection 17th October 2005 (under the previous registered provider) Brief Description of the Service: The Grove is registered with the Commission for Social Care Inspection (CSCI) to provide accommodation and personal care for a maximum of five adults with a learning disability. The Grove is a large detached property situated in the town of Dawley, Telford. The home is within an easy walking distance of local amenities such as shops, a library, pubs and medical facilities. Dimensions (UK) Ltd is the new service provider and was registered with CSCI on 1st April 2006. The responsible individual is Ms Susan O’Loughlin and the manager is Mr Andrew Shouli who is yet to apply for registration with CSCI. Managers were unaware of the current fees charged per person and agreed to forward this information to CSCI. The Grove DS0000066733.V296529.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection started at 08.55 a.m. and lasted just over 8 hours. It was carried out by talking with service users, staff on duty, the manager and area manager, case tracking two people, observing work practices, reviewing a number of records and a full tour of the home. 22 key National Minimum Standards for younger adults were assessed in addition to Standards 1,3,4,5,14,27,33,36,40 and 41 and a quality rating provided based on each outcome area for service users. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. The service users, manager and staff on duty were welcoming and co-operated fully throughout the inspection. The purpose of this unannounced inspection was to take into consideration the nine requirements made at the last inspection undertaken on 17th October 2005 under the previous provider and to review the progress made under the new registered service provider. No complaints have been referred to the Commission for Social Care Inspection (CSCI) since the last inspection and there have been no referrals made under adult protection procedures. What the service does well: Staff spoken with had a good understanding of the individual needs of the people they support. They spoke positively about their roles and responsibilities and appear committed to their work. They demonstrated good values and clearly advocate for the people they support. People living at the home are provided with good opportunities to access the community and partake in a number of activities and links with families are well established. The homes daily routines are flexible and continue to promote independence and individual choice. Service users have a responsibility to assist with basic household tasks according to their ability. Menus seen indicate that people are provided with a balanced diet. Detailed dietary information was also available on the files reviewed which included information relating to preferred seating arrangements for mealtimes and the equipment and level of assistance/ support required. The Grove DS0000066733.V296529.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: A number of shortfalls were identified in relation to current medication practices, staff training in safe working practices and the lack of maintenance and infection control procedures, which potentially places service users at risk. A planned programme of maintenance and renewal for the fabric and redecoration of the premises needs to be developed and outstanding maintenance issues completed as a matter of priority. Support plans contained information concerning the individuals health needs however health action plans have yet to be developed. A Statement of Purpose, Service User Guide and contract between the organisation and individual service users needs to be made available to service users/relatives, staff and significant others as soon as possible to ensure that everyone is familiar with the philosophy of the service offered under the new registered provider. The homes complaints procedure should be readily available and service users/representatives and staff made familiar with the process. The Grove DS0000066733.V296529.R01.S.doc Version 5.2 Page 7 A training needs assessment should be undertaken for the team and a training plan developed following staff appraisals. Quality assurance needs to be developed. The manager has set up a quality assurance file but has not yet had the opportunity to seek the views of service users, family/representatives, staff and stakeholders in relation to how the service is meeting service aims and objectives. It was evident through discussions held with the manager that he has a clear understanding of the areas requiring improvement and appears fully committed to developing the service. Five immediate requirements were served as a result of this inspection in relation to shortfalls found in medication procedures, the environment, health and safety and staff training. A letter of serious concern was also sent to the responsible individual and area manager following this inspection. 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 Grove DS0000066733.V296529.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 The Grove DS0000066733.V296529.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4 and 5 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Prospective service users and their representatives are not provided with sufficient information about what the service has to offer and the terms and conditions of residency. EVIDENCE: The manager reported that a Statement of Purpose and Service User Guide have been developed and forwarded to the organisations area office to be amended; therefore these were not available for inspection on this occasion. The home currently has one vacancy and a referral to the service has been made. An Overview Assessment completed by the local authority has been obtained and the manager and a number of staff have also visited the prospective service user in his current living accommodation and undertaken a needs assessment. Trial visits are currently underway and the prospective service user visited the home during the inspection. Observations made evidence that he was made very welcome during his visit to the home. An advocate has also visited the service to provide support to existing service users in preparation of the new person being admitted. A pictorial board with a photograph of the person was seen in the conservatory and a photo displayed on the prospective service users bedroom door to help familiarise the new The Grove DS0000066733.V296529.R01.S.doc Version 5.2 Page 10 person who is due to be admitted on 08.08.06. Discussions held with the manager evidence that the outcome of introductory visits has not been documented. The staff and manager considered that the transition has been rather quick and the team are not fully prepared for the admission. Contracts between the new registered provider and individual service users remain outstanding. The Grove DS0000066733.V296529.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Current care planning systems provide staff with sufficient information for care delivery. Service users are appropriately supported with decision-making processes and enabled to take responsible risks. EVIDENCE: Two service users were case tracked and their care files reviewed. Since the last inspection, new support plans have been developed by the previous provider incorporating a person centred approach using a pictorial format. Plans seen were comprehensive and provide staff with sufficient information for care delivery with evidence of review. Both people case tracked had been formally reviewed by the previous provider and significant others prior to the transfer of service provider. Discussions held with the manager and area manager during the inspection evidence that they are fully aware that service reviews are due shortly. The Grove DS0000066733.V296529.R01.S.doc Version 5.2 Page 12 Staff spoken with had a good understanding of the individual needs of the people they support and key workers are provided to ensure consistency and continuity of support. Daily records seen were comprehensive. As previously stated an independent advocate has visited the home to provide support to existing service users in relation to the admission of a new service user. Staff and the relatives of service users also advocate on behalf of the people living at the home. Various risk assessments to support people with activities have been developed by the previous manager and these were comprehensive with evidence of review. During the inspection one service user was being supported in the kitchen with preparing a fresh fruit smoothie and a risk assessment to support the use of the kitchen was seen on his file. Risk assessments were also available to include use of the vehicle, community participation, shopping, environment, bathroom and personal care tasks. The Grove DS0000066733.V296529.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 at least once during a 12 month period. 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. Service users are provided with opportunities for community presence and participation. Family links are maintained, rights and responsibilities promoted and people provided with a varied and balanced diet in accordance with their personal preferences. EVIDENCE: None of the current people accommodated access day provision provided by the local authority or attend college although certificates seen on one file indicate that one person has previously accessed a local college. Records seen on the files of two service users case tracked evidence that people are part of their local community and are provided with good opportunities for community presence and participation. Activity records were available and daily records evidence in-house and community activities partaken. A library card and cinema card was seen in one of the service users rooms and staff reported that activities have improved due to finances being more readily available, although providing community activities of a weekend The Grove DS0000066733.V296529.R01.S.doc Version 5.2 Page 14 has proved challenging due to staffing resources. A staff member expressed concerns in relation to service users financing holidays. Arrangements for this should be clearly stipulated in the contract between the organisation and individual service user. As previously stated contracts between the new provider were not available for inspection. The homes daily routines continue to promote independence and individual choice. Preferred routines were seen documented on the care files reviewed and observations made indicate that service users are supported to develop their independence as much as is possible and have a responsibility to assist with basic household tasks according to their ability. Daily records also indicate that individuals have been supported with personal shopping and food shopping for the home. There was evidence of regular family contact, which was confirmed during discussions held with staff on duty. During the inspection the manager and staff were observed to knock on service users doors prior to entry and personal care was provided in private. Menus seen indicate that people are provided with a balanced diet. Service users were offered a choice of meal at lunchtime and one service user was seen laying the table and also preparing fresh fruit smoothies with support from a staff member who provided clear assistance and an appropriate level of support and encouragement. A record of all meals eaten by individuals and discussions held with staff confirmed that the home is able to meet the dietary needs of the people accommodated. Detailed dietary information was also available on the files reviewed which included information relating to preferred seating arrangements for mealtimes and the equipment and level of assistance/ support required. The refrigerator was well stocked and food opened was covered but not dated. Large amounts of fresh fruit and vegetables were readily available during a tour of the home. Lunch was well presented and the mealtime relaxed and unrushed. The Grove DS0000066733.V296529.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Systems to monitor the healthcare needs of service users require further development. Current medication practices and lack of adequate recording places service users at risk. EVIDENCE: Preferences in relation to personal support were clearly documented on the two support plans reviewed and daily records indicate that times for rising and retiring are flexible in accordance with individual needs and preferences. Support plans contained information concerning the individuals health needs however health action plans have yet to be developed. As previously stated staff spoken with had a clear understanding of the needs of the people they support. Records seen evidence people are supported to attend NHS Healthcare facilities and appointments and outcomes recorded. Letters seen on file evidence referrals to specialists are made as required. The Grove DS0000066733.V296529.R01.S.doc Version 5.2 Page 16 CSCI received a duty call from the manager on 19.05.06 in relation to missing medication. Discussions with the manager during the inspection indicated that the situation was resolved and the medication found. Since the last inspection new medication storage cabinets have been purchased and fitted in service users own bedrooms, which were seen during an environmental tour of the home. The medication administration records (MAR) charts are held in the staff sleep-in room situated on the ground floor. It was reported that most of the staff team have recently completed the ‘Aset’ Certificate in Managing and Safe Handling of Medicines distance learning course provided by a local college. A review of the MAR charts for all service users evidenced numerous gaps in the recording of administered medication, in relation to two service users in particular. MAR charts do not provide staff with clear instructions in relation to applying creams and ointments and state ‘Apply as directed by the medical practitioner’. On 14.06.06 records indicate that a staff member sought the advice of the health practice after running out of a particular medication for one individual. Three further completed incident forms evidence that on 28.05.06, 01.06.06 and 11.07.06 medication was not administered at the time directed by the prescriber. On 17.07.06 an incident record stated that a tablet was found underneath the dining table. Incident records state the action taken following missed medication etc including telephoning for advice from on call, GP and the Shropdoc service. An immediate requirement was left in relation to current poor practice identified as a result of this inspection. The Grove DS0000066733.V296529.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users do not have access to a complaint’s procedure that enables their/or their representative’s views to be listened to and acted upon. Not all staff have undertaken training in adult protection procedures to provide them with the relevant knowledge to fully safeguard service users from potential abuse. EVIDENCE: The homes complaints procedure was not readily available for inspection although the manager reported that a complaints procedure is available on the intranet. One complaint was found recorded in the complaints book since the last inspection. Discussions with the manager and area manager indicated that the complaint should have been dealt with under the grievance procedure as it concerned action relating to a staff member from a sister home. There have been no complaints received by CSCI or referrals made under adult protection procedures and two out of the three staff spoken with confirmed that they had attended training in adult protection. A report from a management audit undertaken on 24.04.06 identifies that staff require training in adult protection and one member of staff reported that he has not attended such training. Staff spoken with said that they are confident that financial procedures used within the home safeguard service users. Service users are now provided with their own coded safe to store their money and valuables and new finance books have recently been introduced. The Grove DS0000066733.V296529.R01.S.doc Version 5.2 Page 18 The finances of the two people case tracked were checked against records held with the manager. One was an accurate reflection of the record held, however the other was found 5p over despite two staff signing twice daily to state that they have checked the balances of service user monies. The Grove DS0000066733.V296529.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The standard of the environment is poor with little evidence of improvement through maintenance or future planning. The home does not therefore present a homely and safe place to live or work. EVIDENCE: The home is located in Dawley close to local amenities and within walking distance of Dawley centre and a short journey from Telford Shopping Centre. A full environmental tour of the home was undertaken. Service users are provided with spacious communal areas and extensive gardens. The lounge has been recently redecorated and awaiting new curtains and carpet. Bedrooms are personalised however the bathroom and toilet facilities are in need of urgent attention. The bathroom on the groundfloor is out of use as a result of an accident involving a service user on 29.07.06, which damaged the toilet pan. The box covering pipework at the back of the toilet has broken and exposes residue and ants and staff reported they are unable to clean the area and have sought quotes for a new toilet but the problem remains outstanding. The Grove DS0000066733.V296529.R01.S.doc Version 5.2 Page 20 One staff reported that ‘The bathrooms are a disgrace and the clients deserve better, the maintenance is non-existent’. Other staff supported these concerns in relation to the poor maintenance and also the rubble that has been left on the walkway at the back of the home, following a water leak some weeks ago. It was reported that service users and staff are currently unable to use this area as it poses a trip hazard. The floor covering in bathrooms and a bedroom is heavily stained and a kitchen drawer broken. Cleaning schedules and frige/freezer and meat temperatures are not being maintained. No soap or paper handtowels were readily available in a number of areas to include the kitchen and bathrooms although handtowels were later found. It was reported that the home had run out of plastic aprons. The COSHH cupboard was found disorganised. The home was generally clean throughout with the exception of the carpet on the stairs and landing. An odour was detected in a bedroom belonging to one service user and the flooring heavily stained. The Grove DS0000066733.V296529.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported by a committed staff team who work positively with the people they support and are safeguarded by the recruitment procedures in place. Discussions held indicate that staff are feeling undervalued and require opportunities for training, personal development, formal supervision and increased staffing levels at weekends to effectively meet the individual needs of the people they support. EVIDENCE: Staff were seen to be accessible and interacted with service users positively and appropriately throughout the inspection. Discussions held with three members of staff evidence that they are knowledgeable and have a good understanding of the individuals they support. They spoke positively about their roles and responsibilities although it was evident they have concerns regarding staffing levels of a weekend and the lack of priority given to health and safety aspects, maintenance and staff training. Staff spoken with have worked at the home for a long time and appear committed to their work. They demonstrated good values and discussions held indicate that they strongly advocate for the people they support. They reported that staff morale has been low but is improving and that the team functions well. The Grove DS0000066733.V296529.R01.S.doc Version 5.2 Page 22 One staff member reported that he holds an NVQ level 2 award however the manager was unable to confirm the NVQ status for the rest of the team as the training matrix developed by the previous registered provider is in need of updating. As previously stated; staff expressed concern regarding staffing levels at weekends, which can present difficulties providing community activities with individuals. The duty rota evidenced that staffing levels of a weekend falls to two staff on per shift. It was reported that this is a regular occurrence. The duty rota was only available up until 05.08.06, which staff reported poses difficulty for planning life outside of work when they are not provided with rotas in advance. Under the new registered provider one person (the manager) has been recruited and the personnel file was reviewed by separate appointment at the organisations area office on 21.07.06. The personnel file was well presented and contained the relevant documentation required. It was reported that original CRB disclosures are maintained at the head office although there was evidence from the personnel department that the original document had been seen and disclosure number stated. The area manager stated that an independent advocate and parent of a service user was part of the interview panel for interviewing applicants for the position of manager. It is envisaged that for service users will be involved, where possible for any future recruitment. One out of the three staff spoken with had received a five day induction to the organisation called ‘Our Approach’ and spoke very positively about the training provided to include the values and beliefs of the organisation. Two staff reported that they have been offered training in Autism but have not attended due to the training being held in Worcester. Staff reported that they have not received mandatory training in safe working practices and considered a number of these undertaken with the previous provider are now out of date. A training matrix developed by the previous provider needs updating. The manager has developed a training file however information on courses available is not yet readily available. A team training and development plan has not yet been developed. A regional ‘path’ with aims for the forthcoming year was displayed in the office and the area manager reported that they are looking to develop a ‘path’ for each service. Staff on duty reported that they have had formal supervision with the new manager but not at the required frequency. Appraisals have yet to take place however the manager is hoping that the outcome of these will feed into the team and development plan and identify individual and team training needs. Staff reported that team meetings are held monthly. The Grove DS0000066733.V296529.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41 and 42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The manager is committed to his role, however the service is not currently being effectively managed and therefore is failing to fully promote and safeguard the health, safety and welfare of service users and staff. EVIDENCE: Mr Andrew Shouli is the manager of the home and was appointed by the new registered provider and commenced on 01.04.06. Mr Shouli reported that he has completed his application to be registered with CSCI and is currently waiting payment from his employer for his CRB to be sent off prior to submitting his application to CSCI. The manager has worked in learning disability services for a number of years. His previously role being a Team Leader for Shropshire County PCT in a sister home and has recently gained a qualification in counselling, NVQ level 3 and basic teaching. He reported that he has also attended a First Line Managers course provided through his The Grove DS0000066733.V296529.R01.S.doc Version 5.2 Page 24 previous employer. He has yet to register on the Registered Managers Award and NVQ 4 Care but reported that he has been told to make enquiries. Mr Shouli stated that since his appointment he has attended a five-day induction with the organisation and has had three probationary meetings with the Area Manager, Mr Steven Dunn. It was evident through discussions held with the manager that he has a clear understanding of the areas requiring improvement and appears fully committed to developing the service. Staff reported that the manager is approachable and has introduced some new ideas and that the team is now working well with an improvement in staff morale. The manager has set up a quality assurance file but has not yet had the opportunity to seek the views of service users, family/representatives, staff and stakeholders in relation to how the service is meeting service aims and objectives. The area manager reported that the organisation is considering looking to recruit a part time quality assurance offer to assist with this. A Quarterly Food Audit was undertaken by the organisation on 14.05.06 and highlighted concerns to include food in the refrigerator not being labelled when opened and the refrigerator and kitchen floor found unclean. A Management Audit Report from an audit undertaken on 18.05.06 by the Area Manager was forwarded to CSCI and identified a number of shortfalls to include the lack of mandatory training undertaken and the lack of staff supervision and appraisal. Reports of a visit undertaken by the organisation on 26.06.06, as required under Regulation 26, clearly identify some environmental issues within the home, health and safety checks not being undertaken at the required frequency, cleaning schedules not being maintained, support plans and risk assessments need updating and the need for Dimensions paperwork to be introduced across the service. As identified throughout the body of this report a number of records required by regulation are not being appropriately maintained. It was reported that the administration officer has recently visited to assist in the home record keeping systems and colour code files for easier accessibility. A health and safety file is available and this was reviewed. Service certificates were available and valid with the exception of the landlords certificate for gas safety and there was no certificate available for hard wiring testing. The passenger lift and baths have been serviced since the new provider was registered. Risk assessments for safe working practices are available, however staff have not signed to say that they have read and understood these. A maintenance/ health and safety check form is available to evidence that checks are undertaken on a monthly basis however there is insufficient room on the form to identify what action needs to be taken to address concerns identified, which was fully acknowledged by both the manager and area manager. The policy for health and safety is not readily available. Mandatory training in safe The Grove DS0000066733.V296529.R01.S.doc Version 5.2 Page 25 working practices require updating, which was identified at the last inspection undertaken under the previous provider. Accident and incident reports were available and appropriately recorded however the home has failed to report an accident as required under Regulation 37 that occurred on 29.07.06. The accident caused serious injury to a service user who required urgent medical assistance. Two staff were on duty at the time of the accident and it was reported that a staff member was left lone working supporting three people at the home for an hour whilst the other member of staff accompanied the service user to hospital. A risk assessment has been developed following the accident, which identifies a need for two staff to assist with all aspects of personal care leaving the other three service users unsupervised at times when only two staff are on shift. Staff expressed their concerns during the inspection in relation to the lack of priority given to maintaining a safe environment. It was reported that officers from the Fire or Environmental Health Departments have not visited the home since the take over of provider. The manager was advised to contact these departments to inform them of the change in provider. The Grove DS0000066733.V296529.R01.S.doc Version 5.2 Page 26 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 3 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 1 25 x 26 x 27 2 28 x 29 x 30 1 STAFFING Standard No Score 31 x 32 3 33 2 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 1 x 2 x 2 x 2 1 x The Grove DS0000066733.V296529.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? N/A under the new provider. 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 2 3 Standard YA1 YA1 YA5 Regulation Requirement Timescale for action 31/08/06 31/08/06 31/08/06 4 YA19 5 YA20 6 YA20 4 A Statement of Purpose must be Schedule 1 accessible at the home. 5 Each service user/representative must be provided with a copy of the Service User Guide. 5(c) The registered person must develop and agree with each service user and their representative a written contract/statement of terms and conditions between the home and the each individual to include all items specified in NMS 5.2 and each service user be provided with a signed copy. 12 Service users health must be 13(1)(b) monitored through annual health checks and outcomes recorded via a Health Action Plan. 13(2) All staff must be made are aware and adhere to the homes policy and procedure for the safe handling of medicines. 13(2) An acceptable procedure must be developed for dealing with the administration of medication for service users away from the home when they are due to take any prescribed medication and staff must adhere to it. DS0000066733.V296529.R01.S.doc 30/09/06 31/08/06 21/08/06 The Grove Version 5.2 Page 28 7 YA20 13(2) 8 9 10 YA20 YA20 YA22 11 YA23 12 YA24 13 YA24 14 15 YA27 YA30 15 YA30 All medicines administered must be recorded at the time of the transaction with either a signature or a defined abbreviation 13(2) The prescriber’s directions must be adhered to without fail. 13(2) All “as directed” directions must be clarified in writing by the prescriber. 22 The complaints procedure for the new provider must be available and a copy provided to each service user/their representative. 13(7) All staff must receive training in adult protection and made familiar with the local procedure and receive accredited training in physical intervention - MAPA 13(4) The homes premises must be 23(2) safe and well maintained; meet service users individual and collective needs in a comfortable and homely way. 23 A planned programme of maintenance and renewal for the fabric and redecoration of the premises must be developed and records kept. 23(2) The broken toilet on the ground floor must be replaced. 13(3)(4) The premises must be kept 16(2)(j)(k) clean, hygienic and free from offensive odours and systems must be put in place to control the spread of infection and cleaning schedules maintained. 13(3) Risk assessments and data sheets must be available for all COSHH products used and the COSHH cupboard organised. 02/08/06 02/08/06 21/08/06 31/08/06 30/09/06 09/08/06 31/08/06 09/08/06 14/08/06 31/08/06 The Grove DS0000066733.V296529.R01.S.doc Version 5.2 Page 29 16 YA30 13(3) 16(2)(j) 16 YA33 18(1)(a) 17 YA35 18(1)(c) 18 19 20 21 YA35 YA36 YA37 YA39 18(1)(c) 18(1)(c) 8,9 24 22 23 YA39 YA41 24 17 24 YA42 13 (6) 23 (4) (d) Policies and procedures for the control of infection to include the safe handling and disposal of clinical waste; dealing with spillages; provision of protective clothing and hand washing must be available and adhered to. The home must have an effective staff team with sufficient numbers to support service users’ assessed needs at all times and kept under review. A training needs assessment must be carried out for the whole team and a staff training and development plan developed. Each staff member must have an individual training and development assessment. Staff must receive an annual appraisal and formal supervision 6 times per year. An application to register the manager must be submitted to CSCI. An effective quality assurance system must be developed in addition to seeking the views of service users/relatives and significant others and results published. An annual development plan for the home must be developed. The registered person must ensure that all records required by regulation are well maintained, up to date, accurate, accessible to staff and available for inspection. All staff must receive mandatory training relating to safe working practices and these be updated at the required frequency. 14/08/06 08/08/06 31/08/06 30/09/06 30/09/06 01/09/06 30/09/06 30/09/06 31/08/06 30/09/06 The Grove DS0000066733.V296529.R01.S.doc Version 5.2 Page 30 25 YA42 13(4)(a) 23 26 YA42 12,13 27 YA42 37 The registered person must 09/08/06 ensure that all parts of the premises that service users have access to be well maintained and safe. Risk assessments must be 14/08/06 carried out for all safe working practices and staff made familiar with these. The manager must be made 09/08/06 aware of his responsibilities to notify CSCI of any events as stated under regulation 37. Any notification made in accordance with this regulation, which is given orally must also be confirmed in writing. 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 YA12 YA22 YA42 Good Practice Recommendations It is recommended that opportunities for service users to continue their education be explored. It is recommended that the current systems in place to monitor service user finances be improved. It is recommended that the monthly health and safety checklist be revised to provide space for identified action required. The Grove DS0000066733.V296529.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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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