Inspection on 22/04/08 for The Grove

This inspection was carried out on 22nd April 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 1 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 03/05/07

The Grove 27/09/06

The Grove 02/08/06

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 28/09/2008.

CARE HOME ADULTS 18-65 The Grove The Grove 74 King Street Dawley Telford Shropshire TF4 2AQ Lead Inspector Rebecca Harrison Unannounced Inspection 22nd April 2008 09:30 The Grove DS0000066733.V362788.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.V362788.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.V362788.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 david.king@dimension.uk.org www.dimensions-uk.org Dimensions (UK) Ltd Care Home 5 Category(ies) of Learning disability (5) registration, with number of places The Grove DS0000066733.V362788.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd May 2007 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. Dimensions (UK) Ltd is the registered service provider and the responsible individual is Mr David Nance. The service does not currently have a registered manager in place however interim managerial arrangements are in place. The Grove is a large detached property situated in the town of Dawley, Telford. The home offers access to local amenities and public transport and is in keeping with the local community. The accommodation is based over two floors providing five single bedrooms, a kitchen, lounge, dining room, conservatory and large enclosed gardens. People who use the service and their representatives are able to gain information about this service from the Statement of Purpose and Service User Guide. Inspection reports produced by CSCI can be obtained direct from the provider or are available on our website at www.csci.org.uk The current fee charged per person is £1554.00 per week. The reader may wish to obtain more up to date information about fees direct from the service provider. The Grove DS0000066733.V362788.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means that people who use this service experience adequate quality outcomes. The inspection was unannounced and took place on 22nd April 2008 by one inspector over 6.5 hours. A range of evidence was used to make judgements about this service to include discussions with staff on duty, the quality auditor, surveys we received from two relatives and a healthcare professional, a tour of the home, a review of quality assurance processes and observation of care experienced by people using the service. We also looked at a number of records to include care records held on behalf of two people, complaints and protection, staff training, recruitment and health and safety records. Prior to this inspection an Annual Quality Assurance Assessment (AQAA) document was posted to the provider for completion. The AQAA is a selfassessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for them to share with us areas that they believe they are doing well. By law they must complete this and return it to us within a given timescale. The Responsible Individual for the organisation completed this and some comments have been included within this inspection report. The purpose of the inspection was to assess ‘Key’ National Minimum Standards for Younger Adults and to review the four requirements made as a result of the previous inspection undertaken on 3rd May 2007. A quality rating is provided throughout the report based on each outcome area for the people who use the service. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. What the service does well: Most of the permanent staff employed hold a recognised care award known as a National Vocational Qualification, which exceeds National Minimum Standards. People are provided with varied opportunities to develop and maintain their social and recreational interests and are supported to keep in contact with their family and friends. We received surveys from two relatives who stated: The Grove DS0000066733.V362788.R01.S.doc Version 5.2 Page 6 ‘Just to say thank you to The Grove for their care and please may it continue’ ‘Our son is happy as is possible and look on The Grove as his home that he does not like being away from. He has good care…we trust the home and staff they are kind and efficient and caring’ What has improved since the last inspection? What they could do better: The Annual Quality Assurance Assessment (AQAA) forwarded to CSCI was very detailed and identified areas for improvement to include: ‘Each person supported within the service should hold their own person centred way forward. This will be developed through identifying the correct planning tool to enable the person to choose their own lifestyle preference’ The Grove DS0000066733.V362788.R01.S.doc Version 5.2 Page 7 One person stated ‘staff are very professional with service users and try to give more than 100 but team work and communication needs to be improved’ which was fully acknowledged in the provider’s self-assessment as an area for improvement. A survey from a relative stated the home could improve: ‘Only with more permanent staff to allow more outings’ Comments received from staff in relation to how the service could improve include: ‘We need more permanent staff, more drivers and less paperwork to allow us more time with the people we support’ ‘It has been a difficult few months but things are getter better and the people we support are safer than they were last year. Some days the lack of permanent staffing has had an impact on the lives of people who live here’ Staff should receive supervision at the required frequency given the current morale, high use of agency staff and lack of permanent staff within the team. The provider must ensure that following our agreement for staff personnel records to be centralised, that the necessary information required to be held in the home is readily available for inspection so we can assess the robustness of the provider’s practice in the recruitment, selection and retention of staff. The homes quality assurance processes require further development in order to regularly review the quality of care provided to people using the service. There has been a considerable period of instability within the team and although staff continue to work positively with the people they support the team now requires a period of stability to improve the overall service provided. 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 Grove DS0000066733.V362788.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.V362788.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 5 Quality in this outcome area is good People are provided with the necessary information needed to choose a home, their needs are assessed and they are given a contract, which tells them about the service they will receive. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home provides people with information about the service in its Statement of Purpose and Service User Handbook. Both documents require updating to reflect changes in management and staffing. There have been no new admissions to the service since the last inspection however assessment procedures were considered satisfactory at previous inspections. Individuals receiving a service are provided with a copy of their Terms and Conditions of residency, which have been produced in an easy read format and approved by an independent advocate. The Grove DS0000066733.V362788.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 and 9 Quality in this outcome area is good Staff are provided with detailed information to ensure peoples individual needs are met and regularly reviewed. People living at The Grove are supported to make decisions and enabled to take responsible risks to lead an independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All records held on behalf of two people were examined and contained detailed support plans, which had been developed using a person centred approach. Staff spoken with considered they are provided with sufficient information for the delivery of care and support. It was reported that both people had been formally reviewed in conjunction with the placing authority and significant others however minutes of reviews were not readily available. People have designated key workers who are responsible for completing monthly reports and continually updating records to reflect any change in need. Staff were advised to ensure monthly reports are more detailed. The Grove DS0000066733.V362788.R01.S.doc Version 5.2 Page 11 Individual reactive management plans were available with evidence of review these provide staff with detailed guidance on how to effectively manage any behaviours that may challenge using a positive and consistent approach. People using the service do have access to an independent advocacy service if desired. Records seen on the files examined clearly evidenced that relatives and designated key workers advocate in the best interests of individuals as necessary. The Annual Quality Assurance Assessment (AQAA) forwarded to CSCI identified areas for improvement to include: ‘Ensure people we support have their say and are listened to by arranging independent advocacy and self advocacy meetings’ People living at The Grove are encouraged to lead an independent lifestyle based on the management of risk. Detailed risk assessments to support community activities and daily living tasks were available on the files examined with evidence of review. The Grove DS0000066733.V362788.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17 Quality in this outcome area is good People continue to be provided with varied opportunities to develop and maintain their social and recreational interests and are enabled to keep in contact with family and friends. People receive a healthy, varied diet according to their dietary requirements and choice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two people access educational opportunities provided through the local college. None of the current service users access work opportunities due to the nature of their needs. Throughout the inspection people were supported to access a number of community and social activities for example hydrotherapy, a walk, a trip to Ironbridge and Shrewsbury and a pub lunch. Leisure time preferences were The Grove DS0000066733.V362788.R01.S.doc Version 5.2 Page 13 documented on the files examined and evidenced people continue to access local community facilities on a regular basis supported by permanent staff or experienced agency staff. Since the last inspection all of the people who live at the Grove have been supported to go on a holiday, which proved very beneficial. Observations made and records evidenced that people are supported to partake in daily tasks around their home as much as possible. Personal preferences in relation to housekeeping tasks were available on the records seen. Routines are flexible which was evidenced on arrival to the home when an individual chose to have a lie in. People living at The Grove are encouraged to maintain contact with their families and friends. Contact sheets were available on the files examined and indicate people have regular contact. Links with people living in other local services managed by the provider has been promoted which has developed peoples social networks are proved positive. Family and friends are also invited to social events organised by the home. Staff record all contact made with families and files examined contained details of important events such as relatives birthdays, anniversaries etc. One person was supported to purchase a card for his relative during the inspection. The home has received a number of compliments from visitors since the last inspection and comments received include: ‘Friendly welcome clean and fresh staff co-operative’ ‘A great party all our clients enjoyed themselves. A lot of hard work and effort has gone into making it a success’ ‘What a brilliant night great food great fireworks and great company’ Observations made and discussions held with permanent and an agency staff member evidenced that people living at The Grove are treated as individuals and given respect. All staff have developed positive working relationships with the people they support and those spoken with had an understanding of peoples rights. Menus seen indicate that people are provided with a balanced and nutritional diet taking into account their personal preferences. Staff spoken with reported that people are involved in menu planning through using pictorial aids, which promote choice. Support plans detailed peoples preferences in relation to meals and any support requirements. The Grove DS0000066733.V362788.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. People living at The Grove are safeguarded by the home’s improved systems for handling, storing and administering medication. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Health records examined were detailed and support plans evidenced personal preferences in relation to the delivery of personal care however staff were advised that plans should be more specific in relation to the level of assistance an individual requires. Records evidence that people access NHS healthcare facilities as required and details and outcomes of appointments attended were available. Since the last inspection Emergency ‘grab files’ have been developed for all individuals. These files are taken to all health appointments or hospital admissions and contain a valuable communication book which provide health staff with information to make sure people who have difficulties understanding and communicating get an equal service. The files were well The Grove DS0000066733.V362788.R01.S.doc Version 5.2 Page 15 presented and are an excellent tool to monitor peoples individual health needs. Since the last inspection a new medication policy and procedure is in place in addition to staff competency assessments as required by the previous inspection. Managers have liaised with our pharmacy inspector in order to improve how the service manages medication. Staff spoken to reported procedures are much improved and safeguard people. All staff have received in-house training or attended a distance-learning course in safe handling and administration of medications. Medication procedures were examined and appeared satisfactory at the time of the inspection. Records evidence that medication reviews are undertaken on a regular basis by the local team. The Grove DS0000066733.V362788.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate The home has is a complaints procedure in place and people using the service are provided with pictures and symbols if they wish to express their concerns. Procedures to safeguard people from potential abuse are in place although managers must ensure these are effective to ensure people are not placed at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who live at The Grove and their families have access to a complaints procedure, which was available on the service user files examined. The procedure has been developed in a format appropriate to the people living at the home. No complaints were found recorded in the complaints log and the Quality Auditor who assisted with the inspection confirmed that no complaints have been received by the home since the last inspection. We have not received any complaints, however we did receive a concern in September 2007. Due to the nature of this concern the information was shared with the Senior Practitioner for Adult Protection due to an ongoing investigation into adult protection issues relating to the service. The investigation has since closed following a meeting held in October 2007 where recommendations were made. The management have not effectively dealt with some adult protection incidents, which potentially put others at risk. Such incidents have been brought to the attention of ourselves and other agencies and meetings held. The Grove DS0000066733.V362788.R01.S.doc Version 5.2 Page 17 The provider has acknowledged all shortfalls within the service and appears committed to improvement. A new referral under safeguarding adults has recently been made and is awaiting investigation however we were promptly notified of this. Staff spoken with confirmed they have received training in adult protection. Both permanent staff and agency staff have received training in the management of actual and potential aggression. It was reported no person has been subject to physical intervention or restraint since the last inspection. The home has a policy in place for the management of service users finances and it was reported that all people now have their own bank accounts. Financial procedures were discussed with a member of staff and the manager who considered these to be robust and safeguard both people using the service and staff. Managers undertake regular audits. The Grove DS0000066733.V362788.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 and 30 Quality in this outcome area is adequate Although The Grove provides a comfortable, safe and well-maintained environment to live, the layout of the home is not suitable for meeting the individual needs of the current people accommodated, which impacts on their lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The self-assessment completed by the provider fully acknowledges that the current environment is not suitable to meet the individual needs of the people accommodated. It states ‘There is a lack of private space other than personal bedrooms an it is evident that this has a major negative impact on the lives of those who live there’. Therefore in consultation with people using the service, their representatives, staff and the placing authority, alternative placements are being sourced in order to move individuals on to more suitable services within the Telford area. The Grove DS0000066733.V362788.R01.S.doc Version 5.2 Page 19 A brief tour of the home was undertaken accompanied by a member of staff. Staff have supported people who use the service in purchasing pictures and soft furnishings in an attempt to make their home less clinical in appearance and more homely. People were happy to show the inspector their room, which were all very personalised. It was reported that maintenance issues have now been resolved following discussions with Telford and Wrekin’s Contracts Department and that repairs are now responded to much quicker. On arrival to the home contractors were on site dealing with blocked drains. An ‘Assistive Technology System’ is installed to provide staff with back up assistance if required to help monitor individuals however this was reported broken at the time of the inspection. Staff stated that they are waiting for the system to be repaired however alternative measures have been put in place to monitor individuals in the interim. Since the last inspection people have been supported to develop a sensory garden and plant out hanging baskets and pots. The garden was found overgrown and a quote to replace broken fencing panels has been obtained. It was reported works would be carried out shortly. The home was generally found clean during this unannounced inspection and a cleaning schedule is maintained and personal protective equipment was available. Staff are currently receiving training in the management of infection control procedures. An unpleasant odour was detected in two bedrooms and this was acknowledged by staff that reported that infection control procedures are in place however it has proved difficult to eliminate the problem. Substances hazardous to health are appropriately stored and new data sheets and assessments have been obtained. The Grove DS0000066733.V362788.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): 32,33,34,35 and 36 Quality in this outcome area is adequate There has been a considerable period of instability within the team, however staff continue to work positively with the people they support and are provided with good training opportunities to ensure they are fully equipped to meet the individual needs of the people accommodated. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Throughout the inspection staff were seen to interact well with the people they support. Discussions held with three staff evidenced that they had a good understanding of people’s individual needs. It was reported of the ten permanent support staff employed, eight hold a recognised care award known as a National Vocational Qualification and one member of staff is currently working towards their award. This exceeds National Minimum Standards. The team consists of a manager, two seniors and eight support workers. It was reported that since the last inspection four staff have left to include one who has transferred to a sister home. Three staff are currently off sick and one person in addition to the manager is currently suspended. It was reported two people have recently been offered positions pending all pre-recruitment The Grove DS0000066733.V362788.R01.S.doc Version 5.2 Page 21 checks. Two experienced staff from other local homes managed by the provider, have been seconded to The Grove on a temporary basis to assist with the current staffing situation. Records seen and discussions held evidence that the home continue to be over reliant on agency staff however the same agency staff are used on a regular basis to ensure continuity of care for people living at the home, which was confirmed in discussion with staff on duty. On arrival at the home there were five members of staff on duty. The usual ratio during the day is four staff to support the five individuals using the service however this is flexible to accommodate activities in the community to include hydrotherapy and college. Staff spoken with considered there is sufficient staff on duty to meet the needs of the people accommodated. Staff spoken with stated the following in relation to morale: ‘It is at its lowest’, ‘Low but improving’, ‘Definitely better than in 2006’ ‘Was getting better last year but going down again due to the lack of permanent staff, high use of agency staff and sickness levels. One person stated ‘staff are very professional with service users and try to give more than 100 but team work and communication needs to be improved’ which was fully acknowledged in the provider’s self-assessment as an area for improvement. It was reported that three staff have been recruited since the last inspection. The provider has obtained our agreement for the centralisation of staff records to be held at their Head Office and keep a pro-forma (basic details) of staff information in the home in line with the Commissions policy and guidance. Pro-forma’s were not readily available on two staff files examined and the third file was not accessible for inspection. It was reported that original documentation is held at the providers Head Office or local office and photocopied documents sent to the home. Two people who use the service have played an active role in staff recruitment and received payment for their work. One member of staff recruited since the last inspection considered that the providers recruitment procedures to be robust and confirmed all prerecruitment checks had been undertaken. We did not receive any surveys from staff however staff spoken with reported that training has much improved since the last inspection. The training matrix seen indicated that staff have received training in safe working practices in addition to service specific training. Such training includes Autism Awareness, Infection Control, the Management of Actual and Potential Aggression, Epilepsy and Midazolam. Some staff have recently attended training in Person Centred Planning, the Mental Capacity Act, Mental Health and Health Facilitator training. An agency member of staff spoken with also confirmed his training is up to date and service specific. The Grove DS0000066733.V362788.R01.S.doc Version 5.2 Page 22 A staff appraisal and supervision tracker form is in place, which identified that not all staff received supervision at the required frequency between November 2007 and April 2008. This was fully acknowledged at the time of the inspection and discussions held with staff and records seen evidence that formal staff supervision is now ‘back on track’. The Grove DS0000066733.V362788.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is adequate Senior managers have clear understanding of the current shortfalls and the improvements required to improve overall outcomes for people living at The Grove. Quality assurance requires further development to assess performance and evaluate outcomes for people using the service. The home is managed and maintained in a manner, which ensures the safety of people using the service and the staff team. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Grove DS0000066733.V362788.R01.S.doc Version 5.2 Page 24 A new manager was appointed in October 2007 however is currently suspended pending an investigation. Interim managerial arrangements have been made following discussion with us to ensure consistent support. The Annual Quality Assurance Assessment (AQAA) forwarded to CSCI was very detailed and reflects both the strengths and areas for identified for improvement of the service. Satisfaction surveys in order to gain peoples views about the service provided have yet to be distributed and an annual development plan completed. Monthly visits and reports required under Regulation 26 have been undertaken but not at the required frequency. The organisation has recently appointed a Quality Auditor who will take on the responsibility of Quality Assurance. Quality Monitoring Officer also undertakes regular visits for the local authority. Matters pertaining to health and safety appeared satisfactory at the time of the inspection. Risk assessments for the management and safe working practices in the home are in place with evidence of review. The service meets the requirements of the fire and environment health departments. Certificates for the servicing of equipment are maintained and safety checks are undertaken at the required frequency. Training records evidence that staff now receive training in safe working practices at the required frequency. Staff have access to policies and procedures, which are regularly reviewed and updated. The Grove DS0000066733.V362788.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 3 2 3 3 x 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 2 35 3 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 3 3 x 3 x 2 x x 3 x The Grove DS0000066733.V362788.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA34 Regulation 19 Requirement The provider must ensure that following our agreement for staff personnel records to be centralised, that the necessary information required to be held in the home is readily available for inspection so we can assess the robustness of the provider’s practice in the recruitment, selection and retention of staff. Timescale for action 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 Refer to Standard YA39 Good Practice Recommendations The homes quality assurance processes require further development in order to regularly review the quality of care provided to people using the service. The Grove DS0000066733.V362788.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Grove DS0000066733.V362788.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!