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Inspection on 23/04/07 for The Grove Residential Home

Also see our care home review for The Grove Residential Home for more information

This inspection was carried out on 23rd April 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

This is a generally well maintained home, providing clean and comfortable accommodation for residents. People living in this home are well cared for by care staff and the service is well managed. Residents spoke highly of the staff with specific comments of `the staff are all good` and `they will do anything for you`. Staff members were observed carrying out their duties with kindness and sensitivity towards the residents.

What has improved since the last inspection?

The providers have appointed a new manager and an application for her registration has been forwarded to the Commission. The kitchen has been completely re-furbished and a new dishwasher has been purchased. Part of the roof has been repaired and two bedrooms have been re-decorated and re-carpeted. Activities have improved providing stimulation for residents and menus have been reviewed. Staff have regular supervision with the manager and are able to discuss care practices and any issues of concern.

What the care home could do better:

The statement of purpose and service user guide must contain full details for dealing with complaints, including the Commissions procedure. This service should also follow its Statement of Purpose. Pre-admission assessments should be in enough detail to ensure service users coming into the home will have their needs met. Information should be gathered from all people involved in caring for the service user and should always be used in care planning. Care plans must be in more detail and show that all risks are identified and clear actions are documented to minimise the risk. They should also include information on medication to allow appropriate management of individuals conditions and clearly record service users choice regarding intimate care including gender preference. . Reviews of care plans must be improved to include details of any changes required to the current care given and these should show that service users and/or their representatives have the opportunity to be involved, (this was also raised during previous key inspection). Medication management systems must continue to improve to ensure service users are not at risk. Safeguarding adult procedures must be in more detail and must be followed to ensure service users are not at risk. All staff should undertake relevant training to ensure they have the necessary knowledge and skills to provide service users with the care they need.

CARE HOMES FOR OLDER PEOPLE The Grove Residential Home West Ashby Horncastle Lincolnshire LN9 5PR Lead Inspector Elisabeth Pinder Key Unannounced Inspection 23 April 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Grove Residential Home DS0000057752.V334866.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Grove Residential Home DS0000057752.V334866.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Grove Residential Home Address West Ashby Horncastle Lincolnshire LN9 5PR 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) 01507 522507 Highgrove Care Ltd ** Post Vacant *** Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places The Grove Residential Home DS0000057752.V334866.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st August 2006 Brief Description of the Service: The Grove cares for older people in a non-smoking environment in a large detached property situated in the village of West Ashby, which is two miles from the market town of Horncastle. The home used to be a country house and is set in its own mature grounds and walled gardens with car parking facilities to the front and rear. The house is a listed building and therefore any changes to the facade must involve a planning process. The home has three floors and there is a passenger lift to the bedrooms on the first floor and a stair lift to the second floor. The rooms on the second floor have been created from attic accommodation and all four have traditional sloping ceilings. On the first floor there are four stairs to negotiate to access three of the single bedrooms. Thirteen of the bedrooms are single, two of them have an en-suite toilet. There are two toilets on the ground floor, two bathrooms with toilets and one single toilet on the first floor and a shower room on the second floor. The current fee range is £348 - 431 per week. Additional charges are made for hairdressing, chiropody and newspapers. The Grove Residential Home DS0000057752.V334866.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit to the home was undertaken by one inspector and formed part of a key inspection. The visit lasted six hours and took into account previous information held by The Commission for Social Care Inspection (CSCI) including previous inspection reports, their service history, monthly reports written by the provider and records of any incidents that had been notified to the CSCI since the last inspection. Prior to the visit four residents ‘Have your say about’ questionnaires were received and comments from these will be mentioned throughout this report. The homes pre-inspection questionnaire was not returned in time to be used to plan the visit but was handed to the inspector and information from this document will be used in this report. The site visit consisted of case tracking a sample of three people’s records, talking to them, observing staff interaction and assessing their care. A general conversation was held with some people whilst they were sitting in the lounge and a period of observation was undertaken during lunch. Two members of staff and the acting manager, who is in the process of applying to the Commission for registration, were interviewed and one visitor was spoken to. A random inspection was carried out on 1st August 2006 to assess the action taken to meet outstanding requirements and improvements were being made to meet some of these. However, two outstanding requirements remained, one regarding the registration of a manager and the second regarding assessing the quality of care provided in the home. This site visit focussed on all the key standards. What the service does well: This is a generally well maintained home, providing clean and comfortable accommodation for residents. People living in this home are well cared for by care staff and the service is well managed. Residents spoke highly of the staff with specific comments of ‘the staff are all good’ and ‘they will do anything for you’. Staff members were observed carrying out their duties with kindness and sensitivity towards the residents. The Grove Residential Home DS0000057752.V334866.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The statement of purpose and service user guide must contain full details for dealing with complaints, including the Commissions procedure. This service should also follow its Statement of Purpose. Pre-admission assessments should be in enough detail to ensure service users coming into the home will have their needs met. Information should be gathered from all people involved in caring for the service user and should always be used in care planning. Care plans must be in more detail and show that all risks are identified and clear actions are documented to minimise the risk. They should also include information on medication to allow appropriate management of individuals conditions and clearly record service users choice regarding intimate care including gender preference. . Reviews of care plans must be improved to include details of any changes required to the current care given and these should show that service users and/or their representatives have the opportunity to be involved, (this was also raised during previous key inspection). Medication management systems must continue to improve to ensure service users are not at risk. Safeguarding adult procedures must be in more detail and must be followed to ensure service users are not at risk. All staff should undertake relevant training to ensure they have the necessary knowledge and skills to provide service users with the care they need. The Grove Residential Home DS0000057752.V334866.R01.S.doc Version 5.2 Page 7 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 Residential Home DS0000057752.V334866.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Grove Residential Home DS0000057752.V334866.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 3 standard 6 is not applicable Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People coming into this service may be placed at risk as they do not have up to date information to help them make a decision about moving into the home and information gathered prior to admission is limited so their needs may not be assessed and planned for. EVIDENCE: All ‘have your say about’ questionnaires identified that enough information was given about the home to help them decide if it was the right place for them, however, the statement of purpose and service user guide are not up to date and do not meet with requirements. For example, the statement of purpose makes reference to the National Care Standards instead of The Commission for Social Care Inspection and staff information refers to the previous manager and senior care staff who have since left the home. The service user guide The Grove Residential Home DS0000057752.V334866.R01.S.doc Version 5.2 Page 10 does not give details of how to make a complaint or information relating to fees payable, paying for additional services and the arrangements for the payment of fees. The pre-admission assessments for two new residents were examined, one only contained basic information and did not give a clear indication of the resident’s needs. A letter confirming that after assessment the service can or cannot meet their care needs had not been sent. People spoken to were very complimentary about the home but were unable to remember how their admission was arranged. One ‘have your say about’ questionnaire identified that a contract had not been received, however, a copy of this was on the residents file and the manager agreed to give them a copy. The Grove Residential Home DS0000057752.V334866.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is lack of detail written in some care plans and risk assessments putting people at risk if their care needs have not been identified. EVIDENCE: Care plans examined have improved in content, however they gave no indication that residents have been involved in the development of these or their reviews. Risk assessments have not been written in respect of the use of bed rails and not all residents have manual handling assessments or nutritional assessments. On examining residents files it was noted that information gathered prior to admission is not always used in the current plan of care. For example, two pre-admission assessments identified that residents take ‘Warfarin’ medication and have to have monthly blood tests, but there was no information about this written in their care plans. Care plans included information regarding social and spiritual needs identified prior to admission but not all had been reviewed to reflect changes. A The Grove Residential Home DS0000057752.V334866.R01.S.doc Version 5.2 Page 12 comment written in one of the ‘have your say about’ questionnaires read ‘I don’t like to be woken up at 6am, 7am would be preferable’. This had not been written in this persons care plan and the manager said it had not been raised before but she would take action to ensure the care plan reflected this choice. Two ‘have your say about’ questionnaires identified that residents ‘always’ receive the care and support they need and two identified ‘usually’. Three identified that they ‘usually’ received the medical support needed and one ‘always’. The care records of one resident who had been admitted with a pressure sore clearly showed that the district nurse is involved and appropriate equipment has been provided. Hospital appointments to see consultants are also recorded. Accident records examined had been completed and where necessary appropriate action had been taken. A key worker system is used but one resident spoken to was unaware of this and who this person was. The key worker for this resident was not on duty, however, staff on shift had a clear knowledge of the resident’s needs and the action needed to meet these. Residents spoken to in a general conversation said they felt their privacy and dignity are always respected and staff members were observed carrying out their duties with kindness and sensitivity towards the residents. Medication records of the residents traced had been signed appropriately, however, care records examined did not give any indication to show that residents had consented to care workers giving them medication and did not include information on medication to allow appropriate management of individual conditions. For example, one pre-admission assessment identified that a resident did not sleep well at night and was prescribed night sedation, however, no reference was made to this in their care plan. Policies and procedures for medication are available and staff administering medicines have received training from their local pharmacist. However, further medication training is being planned to ensure staff competency. The manager was unaware of any pharmacist visiting the service on a regular basis but will look into this. Currently there are no residents who self-administer their medication. The Grove Residential Home DS0000057752.V334866.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service are able to enjoy a lifestyle which is flexible and they are able to make choices and activities are resident focused. EVIDENCE: Although no specific resident meetings are held the manager said she speaks with residents individually and considers their varied interests when planning the daily routines. Residents spoken to confirmed this, one said how much he enjoyed going out daily to his family and another said she enjoys walking to the shop every morning to collect the newspapers and at other times appreciates being able to spend time on her own in her room. Questionnaires received prior to the visit varied as to whether activities are arranged that they can take part in. One specific comment read “I believe that it would be beneficial for the residents to have more activities/outings.” This was discussed with the manager who agreed to look into this. During the visit residents were observed playing ‘catch’ ball with a large soft ball and residents artwork was on display. Activity records also showed that games, sing a longs and frequent walks take place. The Grove Residential Home DS0000057752.V334866.R01.S.doc Version 5.2 Page 14 Regular in house church services are held and one resident said she looked forward to communion. Residents confirmed that visitors are always welcomed and they are able to see them privately if desired. One visitor spoken to said she is pleased with the home, her relative has lived in the home for eleven years and although she lives away she is satisfied with the care provided and said that she is confident she would be informed of any concerns or incidents relating to her relative. Questionnaires received identified that residents ‘sometimes’ like the meals, one ‘always’ and one ‘usually’. One specific comment read ‘often the food is bland, cooked out and lacks imagination’. This was discussed with the manager who said she was aware of this and is currently taking action to review all menus and include a choice of spicy food. She also said she would speak with residents on a regular basis to review this. A comment was also made regarding condiments not being available on each table, for example, appropriate sauces to accompany meat. During the visit the main meal was lamb and observation noted mint sauce on each table. Residents were observed to be chatting with each other during their meal and staff were on hand to help residents when required. Menus supplied on the day showed that a balanced nutritional diet is offered. During the previous key inspection it had been recommended by a dietician that nutrition training should be provided for the cook. To date this has not been addressed and the manager said she would look into this. The Grove Residential Home DS0000057752.V334866.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents may be at risk due to inadequate procedures for dealing with complaints and inconsistent knowledge about safeguarding adults. EVIDENCE: The service user guide states ‘our home welcomes any comments, concerns or complaints’ but does not give details of the procedure to take to make a complaint. The summary of the statement of purpose does not mention complaints. These documents must be amended and made available to anyone coming into the home to ensure people know how to make a complaint and be assured their complaint will be acted upon promptly. The manager was given information about the Commission’s procedure for reporting complaints and the address and telephone number was given for the Central Registration and Compliance team (CRCT). The manager did not know of any complaint records but she agreed to ensure any future complaints are fully recorded and include timescales, action taken and the outcome. No complaints have been made since the previous inspection and people spoken to during the visit said that they felt confident to raise any concerns The Grove Residential Home DS0000057752.V334866.R01.S.doc Version 5.2 Page 16 with the manager or any member of staff. Four questionnaires received prior to the visit identified people knew who to speak to if they are not happy. No safeguarding adults referrals have been made in the last twelve months. There is a safeguarding adults procedure and the Lincolnshire County Council policy is available. However, the manager and the new member of staff have not had specific training and the manager was unclear of the correct reporting procedure. The Grove Residential Home DS0000057752.V334866.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in this home live in a clean, pleasant and hygienic environment and they are able to personalise their rooms. EVIDENCE: Since the previous inspection the kitchen has been completely re-furbished and both the Fire officer and the Environmental Health Officer have visited the home and are satisfied with their specific standards. The bedrooms of three people were seen and these were comfortable, clean and furnished with their own personal items. Residents commented that their rooms are always kept very clean. The radiator in one of the bedrooms was not working but a portable radiator had been provided and the manager confirmed that action is being taken to address this. Some bedroom radiators do not have protective guards fitted and the manager agreed to carry out risk The Grove Residential Home DS0000057752.V334866.R01.S.doc Version 5.2 Page 18 assessments for any uncovered radiators which may present a risk to residents. There is a programme to improve the decoration and fittings and two bedrooms have been re-decorated and re-carpeted. However, timescales are not always met. For example, part of the roof has been repaired but there remains a large section still needing attention and some exterior wood work has been repaired and repainted but attention is still required to the exterior of the building. It was also noted that a chair in bedroom 7 was ripped and the light above the sink in another bedroom did not work. Bedrooms have not been fitted with locks promoting privacy and a discussion was held with the manager with regards to including this in the home’s statement of purpose. The majority of ‘have your say about’ questionnaires identified that the home is usually fresh and clean and during the visit the home was clean and tidy and no unpleasant odours were noted. However, there were areas in need of attention and re-decoration and these include bedroom number 7, bathrooms and corridors where wallpaper and paint work is damaged. One specific comment read ‘the sink in my room needs unblocking as the water takes too long to flow away’. This was discussed with the manager who confirmed that she is aware of this issue and a plumber has been out but unsuccessfully. The Grove Residential Home DS0000057752.V334866.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff numbers are in sufficient quantity for them to be able to care for people living in this home. The service recognises the importance of training to ensure staff are knowledgeable and equipped to meet the needs of residents. EVIDENCE: Staffing rotas showed that two staff are available between the hours of 07:00 and 21:00hrs. One member of staff is available between 21:00 and 07:00hrs with another member of staff sleeping in. The manager’s hours are in addition to these and she also covers any shortfalls. Risk assessments have been carried out assessing the needs of residents during the night to establish if two awake night staff are needed and the providers are satisfied that residents needs are currently being met. Staff spoken to said they felt that there are enough staff on duty to meet the needs of the residents currently living in the home, they always have time to complete their tasks without rushing and have time to sit and talk to residents although some days are busier than others. However, should occupancy levels increase or residents needs change staffing levels must be increased accordingly. Residents spoke highly of the staff with specific comments of ‘the staff are all good’ and ‘they will do anything for you’. The Grove Residential Home DS0000057752.V334866.R01.S.doc Version 5.2 Page 20 Three questionnaires identified that staff are ‘usually’ available when needed and one ‘always’. All identified that residents feel staff listen and act on what they say. Information in the pre-inspection questionnaire given to the inspector showed that 70 of care staff have achieved, or are working towards, achieving the National Vocational Qualification (NVQ), which is a recognised training award in care. Training undertaken within the last twelve months included health and safety, food hygiene, fire training, Parkinson’s disease and NVQ training. Training planned includes manual handling, medication abuse and infection control. A discussion was held regarding equality and diversity issues and although no identified needs have been made for residents currently living in the home the manager agreed to look into providing training for staff. Staff spoken to confirmed that they are given opportunities to attend training and feel confident to carry out their roles. Since the previous visit one new member of staff has been recruited from overseas through an agency. Copies of relevant documents were held on file and the procedure for recruiting staff was discussed with the manager. Staff spoken to confirmed that they have been given a copy of the General Social Care Council (GSCC) code of conduct. The Grove Residential Home DS0000057752.V334866.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This service is being well managed and procedures are in place to ensure the health and safety needs of residents are met. However, there is a potential risk to residents as there are inadequate systems in place to monitor the quality of care provided. EVIDENCE: The providers have recently appointed a new manager and an application for registration has been forwarded to the Commission. Since the manager has been in post she has made several improvements, for example, ensuring all staff have regular supervision where they can discuss care practices and raise The Grove Residential Home DS0000057752.V334866.R01.S.doc Version 5.2 Page 22 any issues, planning a training programme and introducing more activities for residents. Staff said they have found the manager to be available when needed and approachable, a specific comment being “she will listen and take action and improvements are being made”. Residents spoken to said they really like the new manager and her husband and find her very kind and supportive. However, there is no system in place for residents to be involved in the day to day running of the home. During the previous two inspections the provider was asked to develop a system for reviewing and improving the quality of care provided in the home and to date this has not been put into place. Quality assurance systems should seek the views of all people involved in the service, for example; service users, relatives/representatives, General Practitioners (GP’s), district nurses and social workers. The providers visit monthly and reports of the visits are sent to the Commission, a discussion took place with the manager regarding using initials of residents on these reports to ensure data protection is not breeched. The manager maintains records of any monies held on behalf of residents and these are kept in the safe. The pre-inspection questionnaire identified that there are a range of policies and procedures available in the home relating to the health and safety of residents and since the previous visit one member of staff has completed health and safety training and further training is planned for new staff. This document also showed dates when equipment was serviced and fire alarm checked. The Grove Residential Home DS0000057752.V334866.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 1 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 The Grove Residential Home DS0000057752.V334866.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 [1][2] Requirement Timescale for action 30/06/07 2 OP1 5 & 5A 3 OP3 14[1][c] The statement of purpose must contain all information required by regulation to ensure up to date information is available to everyone using this service. A copy should be forwarded to the Commission. People using this service must 30/06/07 have access to an up to date service user guide which contains all information required by regulation including information about fees. Pre-admission assessments 30/06/07 should be in enough detail to ensure residents coming into the home will have their needs met. Information should be gathered from all people involved in caring for the resident. Information gathered prior to admission should always be used in the current care plan 4 OP7 15 Care plans must be in more detail and show that all risks are identified and clear actions are documented to minimise the DS0000057752.V334866.R01.S.doc 30/06/07 The Grove Residential Home Version 5.2 Page 25 5 OP16 22[5] [7a & b] 6 7 OP18 OP33 13[6] 24 [1][2] risk. Reviews of care plans must be improved to include details of any changes required to the current care given and these should show that residents and/or their representatives have the opportunity to be involved. The complaints procedure must be up to date and included in the statement of purpose to ensure people coming into this home must know how to raise any concerns and make a complaint when they need to. All staff must know the correct procedures for reporting any safeguarding adults referrals A system must be in place to assess and review the quality of care provided at the home. This requirement is outstanding from 24/04/06 30/06/07 30/06/07 31/08/07 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 OP30 Good Practice Recommendations All staff should receive training regarding equality and diversity. The Grove Residential Home DS0000057752.V334866.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Lincolnshire Area Office Unity House, The Point Weaver Road Lincoln LN6 3QN 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 Residential Home DS0000057752.V334866.R01.S.doc Version 5.2 Page 27 - 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!