Inspection on 27/09/06 for The Grove

This inspection was carried out on 27th September 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Grove 22/08/07

The Grove 30/12/05

The Grove 09/03/05

The Grove 19/07/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Grove, The 235 Stradbroke Road Lowestoft Suffolk NR33 7HS Lead Inspector John Goodship Key Unannounced Inspection 27th September 2006 10:00 Grove, The DS0000029259.V312360.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 Grove, The DS0000029259.V312360.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. Grove, The DS0000029259.V312360.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grove, The Address 235 Stradbroke Road Lowestoft Suffolk NR33 7HS 01502 569119 01502 537919 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) Amber Care (East Anglia) Ltd Mrs Naomi Johann Woodley Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Grove, The DS0000029259.V312360.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th December 2005 Brief Description of the Service: Situated on the outskirts of Lowestoft, The Grove offers registered care to five younger adults aged under 65 who have learning difficulties, autism and behaviours that may be challenging. The home is a large bungalow dwelling, which has been extended to provide five- bed roomed accommodation, two lounges, a large kitchen, an enclosed rear garden and is set back from a busy road. There are local shops and services within a close proximity. Residents of The Grove attend a day service also run by Amber Care during the week. At the time of inspection, the fees ranged from £500 to £2500 per week. Grove, The DS0000029259.V312360.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection under the Commission’s “Inspecting for Better Lives” policy. Its purpose was to assess all the key standards listed overleaf under each Outcome Group. The Commission had issued a questionnaire survey for residents and relatives. Three were returned by relatives, and three by residents, who had completed them with help from relatives and staff. Their comments have been incorporated into the relevant Outcome Group evidence section. The manager was present throughout the visit, together with the newest resident with their support worker. The inspector toured the home, examined staff records and care plans, and spoke to the resident and the support worker. What the service does well: What has improved since the last inspection? The admission of a new resident was handled well. A full fire assessment has been undertaken and meets the fire protection legislation. Grove, The DS0000029259.V312360.R01.S.doc Version 5.2 Page 6 An additional bedroom has been created from an activity room and has been approved by the Commission. Medication documentation now incorporated all non-prescribed medicines. What they could do better: 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. Grove, The DS0000029259.V312360.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 Grove, The DS0000029259.V312360.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s and relatives can expect that the home will identify the individual needs and preferences of residents, and will offer the opportunity to visit the home before any admission is agreed. EVIDENCE: A Statement of Purpose that had been written for the home contained all the items of information required. A Residents’ Handbook had been compiled and included a Statement of Terms and Conditions of Residence. This was used as a service users’ guide and had been compiled using photographs of the home, staff and residents. Symbols had been used to promote understanding. The Statement of Purpose had been updated to incorporate reference to the extra room. The Service Users’ Guide was still waiting to be revised and produced in a user-friendly version. The manager stated that she was proposing to ask the newly appointed senior support worker to do this work. A requirement has been made to ensure this happens. A relative commented that they had received “ample information, consultations and visits to make the decision for my relative.” Grove, The DS0000029259.V312360.R01.S.doc Version 5.2 Page 9 The resident who had been admitted most recently was case-tracked. This person was to be an additional resident for the extra room recently approved by the Commission for Social Care Inspection. Their pre-admission process was recorded in detail. They had been visited by the manager in their day centre service, and they had been to visit the home. Their diagnosis was covered by the home’s admission criteria. There was a full medical history and medication profile in the assessment. Grove, The DS0000029259.V312360.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be assured that their care needs will be reviewed regularly to make sure that their current needs are being met. The home provides as much support as necessary to help residents decide about aspects of their daily lives. Residents can be assured that they will be encouraged and supported by the home in taking risks as part of developing an individual life style. EVIDENCE: Very detailed care plans were in place at the home. They contained the required information, photos, information about the individual, their relatives and families and great detail regarding their care needs, risk assessments and gave very clear instructions to staff regarding the likes and dislikes, needs and behaviours of each individual. Staff signed to say that they had read the care plans. A relative commented that: “I understand my relative is constantly consulted about food and clothes and play decisions.” The care plan of the newest resident set out the aims and objectives of their move. These included the need for a settled placement after being moved Grove, The DS0000029259.V312360.R01.S.doc Version 5.2 Page 11 through various respite services after the relatives were no longer able to continue caring. Before admission, they visited The Grove to see the room they would occupy. Eventually they chose the colours of the walls, although initially only one wall was painted the bright red chosen by the resident. Since coming to live in the home, the care plan review showed that a normal routine had been developed. They got up with the other residents, joined in with activities, helped cook, and liked to watch football. This latter theme was evident from the design on the bed covers. Aspects of their medical problems had been noted in the care plan as improved. The inspector observed the resident in the lounge interacting with members of staff, who were clearly able to communicate and translate the verbal and non-verbal signals to find out their wishes. Several risk assessments had been developed, identifying the risk, and how staff should support the resident to minimise the risk while retaining a certain amount of choice and independence. Examples of the assessment areas included: using a wheelchair outside the home, using the kitchen, choking on food, slipping in the shower. The latter assessment had been revised after the resident had fallen in the shower. An incident report was in the file. Two mats were now to be used on the floor, and the resident is transferred to and from a wheelchair for access to and exit from the en-suite shower room. During the inspection, an assessor from the hospital wheelchair service arrived to check the most appropriate chair for this resident. A purpose fitted chair was needed because of this person’s difficulty in sitting without pain. The home was promised that the new chair should arrive in three weeks. The staff were seen to be explaining what was happening, and the outcome, to the resident. A report covering each twenty four hour period was written by each shift, on a proforma covering activities, daily routine, appointments, incidents, medication given, personal care, food and drink, and the staff working with the resident on each shift. These records were read each morning by the manager to check on each resident. A similar format was in place for all other residents. Examples were given of choices which residents were offered and how they made those choices. One resident was offered several sets of clothes in the morning to choose which to wear. Both staff and a relative said that this resident had very explicit facial expressions which showed their wishes and feelings. A choice of cereals was available at breakfast time. Some could indicate choice by touching the boxes. Grove, The DS0000029259.V312360.R01.S.doc Version 5.2 Page 12 Grove, The DS0000029259.V312360.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): 11,12,13,14,15,16,17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives can be assured that the home will encourage residents to join in appropriate activities both in the home and in the community. Residents and relatives can be assured that the home will respect residents’ rights in their daily lives. Residents can expect that they will be provided with a healthy diet with proper surveillance of their nutritional needs. EVIDENCE: A daily Independent Living report was completed for each resident, matching planned skill areas identified in their annual plan with actual activities and progress. Examples of skills being encouraged were: making the bed, putting their own laundry away in drawers, loading the dishwasher, sweeping the floor, polishing their shoes, cleaning their room, making cakes. The reports listed the level of support given by staff on each activity. These reports were good practice and showed that a pro-active programme of support was given by staff. Grove, The DS0000029259.V312360.R01.S.doc Version 5.2 Page 14 The residents had been on holiday together this year, to a caravan site in Norfolk. There were five staff for four residents in two caravans. Staff reported that the residents seemed to enjoy the change of surroundings. A visit to the pantomime had been booked for the Christmas outing. Several residents helped to cook as far as they were able, and with staff support. Cakes were apparently popular. There were generic and individual risk assessments around eating support. There were fresh vegetables in the kitchen, and a varied menu which residents helped to select. The temperature of the fridge and freezer were taken and recorded. All items in the fridge at the time of the inspection were covered and dated. One resident was on a gluten free and lactose free diet. There was evidence that this had improved their health. Service users accessed different daytime activities according to their needs. During the week, they all attended the Ambercare day centre. At weekends there were records of outings. To provide continuity of staffing and to enable residents to be out for as long as was necessary, weekend shifts lasted for twelve hours. There was a large staff noticeboard in the kitchen covered with directives from the owners and instructions to staff from the manager. This detracted from the otherwise homely feel of the home, and a recommendation has been made to find an alternative site for this noticeboard. Grove, The DS0000029259.V312360.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): 18,19,20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be assured that staff are very aware of the physical and emotional needs of residents to enable them to live a healthy and social lifestyle. Residents will be better protected with their medication when the home complies with the dating of opened creams and liquids. EVIDENCE: The inspector noted that details of care plans specified the way and manner in which residents indicated they wished their care to be provided. Daily record sheets gave an account of staff actions and interventions with residents. One resident had been moved to a specialist assessment unit in Ipswich because of a marked worsening in their challenging behaviour. The referral was to determine the causes of this and to develop a programme of rehabilitation which could be continued at The Grove. The manager said that the home would be discussing with the unit an appropriate date for the resident’s return. The deputy Manager was visiting the person in the unit at regular intervals to maintain contact. The original agreement with the funder had been that increased staffing would be funded on the resident’s return to support their treatment programme. Grove, The DS0000029259.V312360.R01.S.doc Version 5.2 Page 16 The care plan of one newest resident identified their social and medical needs drawn initially from the pre-admission assessment. It identified their several medical conditions, including right-sided hemiplaegia and the wearing of a pacemaker. For this they were under the supervision of the local cardiology clinic. The result of blood tests was awaited. Other health checks had been arranged since admission particularly for cataracts. A list of allergies was included in the plan. There was evidence in the care plans that GPs do regular medication reviews. The drug cupboard was in the lobby of the back door. The blister packs were checked and the numbers given were correct against the time and date. The MAR sheets were inspected and showed that all administrations had been signed as given. All the staff had done the course run by the pharmacy supplier, and the deputy manager had done their advanced course. Some of the creams and bottles in the cupboard had not been dated on being opened. This was made an immediate requirement. Grove, The DS0000029259.V312360.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): 22,23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Relatives and residents can be assured that their complaints will be dealt with appropriately. Residents can be assured that action will be taken on any allegation of abuse. However, the home must report serious incidents to the Commission in order to fully protect residents. EVIDENCE: The survey questionnaires from relatives all indicated that they would know how to complain, although none had ever done so. The behaviours of some of the residents was at times challenging to both staff and other residents. The inspector had witnessed on a previous visit several instances of such behaviour when the residents returned from the day centre. These were handled appropriately by the staff, using diversion and deescalation. These incidents were always logged on incident or accident forms. A summary of all incidents was kept for regular review to identify if changes were needed to care plans, and for staff training discussions. Staff were trained on the Unisafe programme for handling challenging behaviour.. There had been an allegation in April 2006 by staff that a colleague had used inappropriate techniques to move a resident. This had been correctly reported according to the County Adult Protection policy by the home, with the police being involved and the home making referral to the POVA (Protection of vulnerable adults) list. Grove, The DS0000029259.V312360.R01.S.doc Version 5.2 Page 18 Another POVA allegation arose in August 2006 when bruises were seen on the same resident when they returned to The Grove from their day service. Again appropriate action was taken by the home to activate the POVA reporting policy. The police took no action after investigation. The records of the home were comprehensive which assisted the investigation in separating this incident from other occasions of challenging behaviour. However although on the first occasion, the manager phoned the information to the Commission for Social Care Inspection, this did not happen with the second referral. In both cases, no formal written notification was received by the Commission under Regulation 37. An immediate requirement was made at the inspection that such notices must be sent to the Commission as soon as possible after the incident. This is in addition to any referral through Customer First. The home’s adult protection policy was up-to-date with the latest County policy, except that it did not specify that all POVA allegations must be reported in the first instance to Customer First, as Social Care Services take the lead in these cases. Staff training in adult protection was covered initially in the abuse section of the Skills For Care induction syllabus, then in the unit in NVQ Level 2, and also through the use of the video “No Secrets”. When questioned, a member of staff was able to demonstrate an understanding of the definition of abuse. They were able to describe examples, including actual instances from a previous care post. They were clear that the route for reporting was to the manager or the person in charge of the shift. The manager was the appointed person for handling the financial affairs of all residents. All bankbooks were inspected and withdrawals explained and reconciled with receipt books and cash. Grove, The DS0000029259.V312360.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): 24,25,28,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be assured that the home is comfortable, clean and safe, with opportunities to decorate and furnish their own rooms. EVIDENCE: The additional room was inspected. This was now occupied by the new resident and had already been personalised with photos and football related items. The manager said that an armchair was on order for the new room. The fire officer had required smoke stop seals to be fitted to the door and this had been done. The door was wedged open with a rubber wedge. The inspector asked the manager to remove this, as it was a fire protection hazard. This was done. It had been wedged because of the need to move the resident in a wheelchair. The inspector required the manager to investigate an alternative method of keeping the door open, which would be responsive to the fire alarm. The owner was informed and a maintenance man arrived during the inspection to check out the best solution. The communal space including the conservatory remained in excess of the minimum required by the Standards. The manager said that some of the furniture in the main lounge was to be replaced. Grove, The DS0000029259.V312360.R01.S.doc Version 5.2 Page 20 The manager believed that the drainage in the en-suite wet room was not quick enough for the safe moving of the resident. After one fall, which was recorded, two mats were now used to reduce slipping and the resident had to be moved in and out of the wet room in a wheelchair. The manager thought that this might not be necessary with better drainage. One resident had a red flashing light installed which was linked to the fire alarm. This was to help them understand the need to get up and start moving out of the room when the alarm went off. The inspector noted that a small section of smoke seal was missing from the top of a resident’s door. The manager reported it at once to the maintenance man who took action to organise its replacement. A relative wrote that: “The home is always fresh and clean, yet still homely.” This was borne out by the inspection. Grove, The DS0000029259.V312360.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): 32,33,34,35,36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are cared for by competent and safe staff in appropriate numbers to support their daily needs. Residents cannot be assured that they are fully protected by the home’s recruitment procedures. EVIDENCE: The normal staffing ratio was one carer to one service user. All service users either went out to an external day service or spent the day with home staff. One service user was funded for an additional carer for community activities on some days or at certain times. Three staff were about to leave after their notice period expired. Two of these were resigning for health reasons. Three new staff had been recruited and were on their probationary periods. A new senior support worker was due to start in November. No agency staff were used as, according to the manager, they would not have the skills required and it would be difficult for residents to relate to them. The provider, however, had a number of services which operated a bank system for filling gaps in the rota. Induction training records for the new staff were examined. In-house induction included supervised periods working with each service user in turn, with particular recording of their knowledge of the service user’s mobility, diet, Grove, The DS0000029259.V312360.R01.S.doc Version 5.2 Page 22 general activities, and personal care needs and preferences. Items of the syllabus which could not be covered in-house, such as moving and handling training, were accessed through the training provision of the County Social Care Services. Some staff were trained in the use of signing, either Makaton or British Sign Language, which were used by one resident, who was able to help in the training as was their relative. Only five staff below the manager had passed NVQ Level 2 or above, out of 11 care staff. The deputy manager would shortly complete NVQ Level 4. The files of three recently appointed staff were examined. Two of them did not have the references in the file although the manager said they were still at Head Office. The application form for one person was also said to be at Head Office. Although Criminal Record Bureau Disclosure Certificates were in all the files, only one had the POVA list reply. Again it was stated that these were at Head Office. The records showed that there were regular supervision sessions for staff and annual appraisals. Monthly staff meetings were held and there was a list on the noticeboard for staff to sign that they had read the minutes of each meeting. A relative commented that because of the time they spent at the home and the relationship they had formed with staff, they saw that staff always treated their relative well. One resident had said on their questionnaire, through the manager, that the staff always treated them well. When asked if the carers listened and acted on what they said, one resident said: “Yes thank you.” Grove, The DS0000029259.V312360.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): 37,39,40,41,42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a well managed home with supportive staff, protected by safe procedure. However, the policy review system cannot yet give residents sufficient confidence that the running of the home is under regular review. Residents’ fire safety cannot be assured while a door wedge is in use. EVIDENCE: The manager was approved as a fit person by the Commission in 2004, and the deputy manager was studying for NVQ Level 4. Although regular monthly visits were made by the owners and reports written to meet Regulation 26 and forwarded to the Commission, the reports were not retained on site. The owner agreed to action that. All the relatives who responded to the questionnaire said that they were welcome in the home, were kept informed of important matters, and were consulted about care. There was a comprehensive fire risk assessment, which had been approved by the Fire Officer when they inspected the additional room. Grove, The DS0000029259.V312360.R01.S.doc Version 5.2 Page 24 The policy file kept in the manager’s office contained all the required policies. Some had been reviewed and revised with the dates of the reviews. Others did not have a date when written, nor a date for a review. The accident book was properly completed, whilst retaining the requirements of data protection. The incident file kept a record of all incidents. A copy of each form was also filed in the appropriate resident’s care plan and a third copy went to the head office. The insurance certificate was current, and the certificate of registration was displayed in the hall. As part of the process of creating an additional room, the home had consulted with relatives of existing residents. The manager reported that some had been concerned that a new resident would disrupt the others. This had not happened according to the manager. The finances of two residents were managed by the home, with the manager and deputy manager as appointees. The finances of the others were managed by relatives who gave regular amounts to the manager for everyday expenses. All monies handed over, as well as the funds of the first two residents, were kept in separate building society accounts and withdrawn by the appointees. All the books were examined. All showed regular income and expenditure, with a receipts file to match the transactions. Cashbooks and receipts were kept in a safe attached to the office wall. The cash held for one resident was checked and tallied with the cashbook and receipts. A relative wrote in the survey questionnaire that: “I am extremely happy with The Grove. I would prefer some contact with the owners but this does not affect the care. I am satisfied my relative is happy and safe at the home.” Grove, The DS0000029259.V312360.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 3 4 3 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 3 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 3 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 3 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 3 X 3 X 2 2 3 2 X Grove, The DS0000029259.V312360.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 YA20 Regulation 13(2) Requirement The registered person must ensure that all medicinal creams and bottles are dated when they are first opened. The registered person must give notice to the Commission without delay of the occurrence of any of the matters listed under this Regulation. The registered person must not employ a person to work at the home unless they have obtained all the information specified in Schedule 2 of this Regulation, and those records are kept in the home. The manager must confirm to the Commission that all required documents for the staff appointed since May 2006 have been moved into the home, by 31/10/06. The registered person must ensure that copies of the monthly reports specified under this Regulation are kept in the home. The registered person must ensure that no doors are held open except with an approved device which responds to the fire DS0000029259.V312360.R01.S.doc Timescale for action 27/09/06 2. YA23 YA41 37 27/09/06 3. YA34 19 27/09/06 4. YA39 26 27/09/06 5. YA42 4(c) 27/09/06 Grove, The Version 5.2 Page 27 alarm. Confirmation that this has been done must be sent to the Commission by 31/10/06. 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 YA24 Good Practice Recommendations The registered person should find an alternative site for the staff noticeboard. Grove, The DS0000029259.V312360.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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. Extracts may not be used or reproduced without the express permission of CSCI Grove, The DS0000029259.V312360.R01.S.doc Version 5.2 Page 29 - 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. 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