Care Home: 2 The Grove

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What the care home does well People have good information so that they can make decisions about whether they would like to live in this home. The service makes sure that they have the right information so that they can look after people properly. People who want to live in the home are able to visit and see what it is like to live there. Each resident has their own care plan; these contain all the information that the staff need to know so that they can care for people properly. The care plans are written in a user-friendly style and residents can be involved in the care planning process. The staff help residents to make choices and to maximise their independence and maintain their safety. The residents are able to lead interesting lives and can make decisions about how they send their time, including going to local churches, other community activities and keep in touch with family and friends. The staff help residents to plan the menu`s, shop and cook. They are able to balance the resident`s food choices and ensure a healthy balanced diet. The staff relate well to residents and have a good understanding of their needs. Residents were relaxed, content and well cared for. All aspects of care are managed well. Residents are supported to access doctors and specialist services. Staff make sure that residents are supported to take their medication safely. The home makes sure that people have the right information about how to complain if they are unhappy. Residents have individual complaints information that is suitable for their communication abilities. Staff have the right training and skills to ensure that residents are safe. Residents are supported to manage their money. The home is a safe and comfortable place for people to live. Residents have their own bedrooms and able to make choices about how the room is decorated and furnished. The home is clean and the management make sure that it is a nice place to live. The manager makes sure that there are enough staff to care for the residents properly and that they have the right checks and training.The manager has the right skills to run the home properly. The service does the right checks to make sure that the home runs smoothly and is safe. What has improved since the last inspection? The staff have worked hard to assist residents in making choices by the development of visual aids. Examples of this include pictorial menu boards, individual complaints procedures and life development plans. The service plans to develop the environment; one initiative is the conversion of the garage into a games room, which will increase the communal area of the home. The service is working with an Occupational Therapist to make sure that residents have all the right equipment, such as handrails and other aids. Since the last inspection the home has had a new kitchen, which has been designed to make sure that residents are able to use it easily. Since the last inspection the manager has become registered with the Commission for Social Care Inspection. What the care home could do better: The management know that they need to give people new contracts when things change. The manager has agreed to make sure that guidance about the management of resident`s continence is sought. The manager has agreed to make sure that the keys to the medication cupboard are stored safely at all times. The manager has agreed to ensure that information about resident`s bank accounts is stored safely. CARE HOME ADULTS 18-65 2 The Grove Westoning Bedfordshire MK45 5JW Lead Inspector Stephanie Vaughan Unannounced Inspection 22nd April 2008 09:15 2 The Grove DS0000014906.V362926.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 2 The Grove DS0000014906.V362926.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. 2 The Grove DS0000014906.V362926.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 2 The Grove Address Westoning Bedfordshire MK45 5JW 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) 01525 717098 no email as at 28.6.7 www.macintyrecharity.org MacIntyre Care Debora Helen Ibbetson Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 2 The Grove DS0000014906.V362926.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th May 2006 Brief Description of the Service: 2 The Grove provides a home for up to six service users with learning disabilities. It is a purpose-built house on a small, enclosed estate of three registered homes, all belonging to Macintyre. The home is situated in the village of Westoning and is walking distance of local shops, a church, and public houses. The house is divided into two sections accommodating two and four service users. Each section has a separate kitchen and lounge as well as a utility room. The larger section has two bathing facilities with toilets and also a separate toilet. The smaller unit is able to provide accommodation for two people with physical disabilities. One of the bedrooms downstairs was turned into an office and this provided more space for staff. The office room upstairs was turned into an activity/quiet room for service users and has an en-suite shower and toilet. There is a large rear garden with three swings, a slide, football net, a hammock, and a patio area, and a garden shed. The garden was well used by service users, and meet their needs. The Commission for Social Care Inspection reports are available to people via the service on request. Current fee’s range from £4,000 to £8,000 per month. Additional charges are made at varying rates for holidays, outings, toiletries, hairdressing and other personal items. 2 The Grove DS0000014906.V362926.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 2 star. This means the people who use this service experience good quality outcomes. Prior to this statutory inspection, a period of four hours was spent in preparation. This comprised reviewing the previous inspection reports and associated documentation. Both the Annual Quality Assurance Assessment and comment cards were submitted by the provider within the appropriate time scale, however due to unforeseen circumstances these were not available for inspection purposes at the time of the inspection. The Commission have received no complaints or concerns about the service. However there has been one safe guarding allegation since the last inspection. This has been investigated by the appropriate authorities and is now closed. The Commission have a focus on Equality and Diversity and issues relating to this are included in the main body of the report. This site visit to the home was conducted over a period of five and a half hours during which the inspectors made observations and spoke to management and staff. The homes specialises in providing care to people with learning difficulties, as such their communication abilities are limited. In these circumstances observations made during the inspection are used to inform the inspection process. A limited tour of the premises was conducted which involved viewing the communal areas and a selection of the private accommodation. Case tracking is the method used during inspection where of a sample of two residents were selected and all aspects of their care and experiences reviewed, including individual plans of care and associated documentation. The Registered Manager was present throughout this visit. 2 The Grove DS0000014906.V362926.R01.S.doc Version 5.2 Page 6 What the service does well: People have good information so that they can make decisions about whether they would like to live in this home. The service makes sure that they have the right information so that they can look after people properly. People who want to live in the home are able to visit and see what it is like to live there. Each resident has their own care plan; these contain all the information that the staff need to know so that they can care for people properly. The care plans are written in a user-friendly style and residents can be involved in the care planning process. The staff help residents to make choices and to maximise their independence and maintain their safety. The residents are able to lead interesting lives and can make decisions about how they send their time, including going to local churches, other community activities and keep in touch with family and friends. The staff help residents to plan the menu’s, shop and cook. They are able to balance the resident’s food choices and ensure a healthy balanced diet. The staff relate well to residents and have a good understanding of their needs. Residents were relaxed, content and well cared for. All aspects of care are managed well. Residents are supported to access doctors and specialist services. Staff make sure that residents are supported to take their medication safely. The home makes sure that people have the right information about how to complain if they are unhappy. Residents have individual complaints information that is suitable for their communication abilities. Staff have the right training and skills to ensure that residents are safe. Residents are supported to manage their money. The home is a safe and comfortable place for people to live. Residents have their own bedrooms and able to make choices about how the room is decorated and furnished. The home is clean and the management make sure that it is a nice place to live. The manager makes sure that there are enough staff to care for the residents properly and that they have the right checks and training. 2 The Grove DS0000014906.V362926.R01.S.doc Version 5.2 Page 7 The manager has the right skills to run the home properly. The service does the right checks to make sure that the home runs smoothly and is safe. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. 2 The Grove DS0000014906.V362926.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 2 The Grove DS0000014906.V362926.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 & 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admission procedures are robust and ensure that residents and their representatives have the right information to enable them to decide if they would like to live there and that the service is able to meet their needs. EVIDENCE: The service has a Statement of Purpose with complies with the criteria set out in schedule 1 of the National Minimum Standards. There is also a comprehensive Service Users Guide, which is produced, in an easy read format with pictorial information. This information is made available to existing and prospective residents and their representatives. The service ensure that the Commission for Social Care Inspection reports are available in the home and are accessible to all. There have been no recent admissions to the service, however individual plans of care evidenced that the service has robust admission procedures in place, including comprehensive assessments conducted by the service to ensure that 2 The Grove DS0000014906.V362926.R01.S.doc Version 5.2 Page 10 they are able to meet the needs of prospective residents. Assessments from funding authorities are also obtained and held on file. The home has two vacancies at present and the management are highly sensitive to the impact that a new resident may have on the existing residents and admissions are arranged with sensitivity to the needs of all residents. Prospective residents have the opportunity to visit the home on a number of occasions before deciding whether they would like to live there. Each resident has an individual service agreement in place which specifies the terms and conditions. These are currently being updated to reflect the changes in the fees. However it was noted that where residents or their representatives were unable to sign the agreement that two managers signed the agreement on behalf of the resident. This was discussed with the Registered Manager who has agreed to seek support from the Advocacy Services on behalf of the resident. 2 The Grove DS0000014906.V362926.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. 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. The residents have a detailed plan of care, which indicates that they are treated as individuals and their personal and social care needs are fully met. EVIDENCE: Each resident has a comprehensive individual plans of care which is based on the information obtained thorough the assessments. These are written from the residents perspective and are highly person centred. The service involves residents in the care planning process according to their individual abilities. The individual plans of care are person centred and developed in a userfriendly format, contain comprehensive information about the health, personal and social care of the residents. In addition they set out detailed and specific instruction to staff about the management of challenging behaviour. 2 The Grove DS0000014906.V362926.R01.S.doc Version 5.2 Page 12 There is evidence that the individual plans of care are reviewed on a regular basis and that residents are involved in this process. However there were three large ring binders that comprised the individual plans of care. Some of the information was duplicated and out of date. This was discussed with the Registered Manager who has agreed to archive outdated material in order to avoid confusion. There was clear evidence within the individual plans of care that residents are supported to make decisions for themselves within all aspects of their daily lives, any limitations on choice were seen to be in the best interests of residents and supported risk assessments. Each resident has an individualised and comprehensive set of risk assessments which have appropriate controls to reduce and manage the risks identified, whilst enabling the resident to achieve maximum control of their lives. 2 The Grove DS0000014906.V362926.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have control over their lives, which enable them to enjoy a lifestyle that promotes their choice and independence. EVIDENCE: There is clear evidence that staff use a range of methods to facilitate communication with residents within the service and the community enabling them to fully participate in daily living activities. Individual plans of care evidenced that residents have an individualised programme of activities throughout the week. These identify that residents have educational opportunities are able to attend day centres and participate in activities of their choice. Residents are also able to opt out of activities should they wish to do so. 2 The Grove DS0000014906.V362926.R01.S.doc Version 5.2 Page 14 The service has dedicated transport and there is clear evidence that residents are supported to access their local community. There are regular outings provided and staff support residents on an individual basis with activities such as shopping and swimming. Residents are supported to maintain their faith and are able to attend local churches and associated activities. There is clear evidence that residents are supported to maintain links with family and friends through a variety of methods such as home visits, letters and telephone calls. The staff also maintain a list of family events such as birthdays and anniversaries to support the residents to maintain family links. The individual plans of care demonstrate that routines are flexible in the home residents are able to choose what time they rise and retire to bed within the constraints of their programme of organised activities. They are also able to participate in a range of household activities, which promote their independent living skills such as meal preparation, shopping and general household chores. Residents are supported to express their individuality through their personal appearance in choice of clothing and hairstyles. Individual plans of care contain evidence that the staff are mindful of the gender and sexuality of residents and they are provided with sensitive support. Individual plans of care evidenced that resident’s preferences were recorded, which includes their food preferences. All of the existing residents are white European and staff confirmed that their preferences were for traditional foods as specified. The staff have developed visual aids to enable residents to participate in the planning of the menus. The service is able to balance the preferences of individuals whilst maintaining a healthy balanced diet. During the inspection residents were seen to be making choices about what to eat and during at lunchtime and were assisted in the preparation of this. 2 The Grove DS0000014906.V362926.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of health and personal care is sensitive and responsive to the needs and wishes of the individual ensuring that residents are well cared for. EVIDENCE: Individual plans of care provide detailed instruction to staff about the individuals health personal and social care needs. Daily records were detailed and demonstrated that the care specified was being provided and that residents are able to exercise choice within their daily lives. There was evidence that the staff have a good understanding of the residents needs and that they related well to residents. There was also evidence that residents wishes regarding the gender of staff providing personal care and their privacy was respected. 2 The Grove DS0000014906.V362926.R01.S.doc Version 5.2 Page 16 Staff provide residents with support in their personal care as specified in the individual plans of care, in addition residents have pictorial information within their rooms to remind them of their personal care routines. Residents appeared well cared for and appropriately presented. There was evidence that residents have appropriate aids and adaptations to assist in their activities of daily living. Individual plans of care evidenced that residents are supported to accesses appropriate health care services, including routine health checks, medical treatment and hospital services. Health care specialist such as podiatrists, dieticians, Occupation Therapists, physiotherapists, opticians and audiologists are also accessed as required. However the individual plans of care indicated that two of the residents have continence problems and there was no evidence that guidance had been sought for either of these residents. This was discussed with the Registered Manager who agreed to ensure that the appropriate referrals were made. Residents have access to individual key workers who work with them on a regular basis. Medications systems were reviewed the service operates with a Monitored Dose System supplied by a local high street chemist. Medication systems were in good order, each resident had a Medication Administration Records which specified the prescribed medication. A spot check indicted that the medication had been given as prescribed and that it corresponded with the remaining stock. Systems were in place for the ordering, safe storage and disposal of medication. The keys to the medication cabinet are currently stored within an unlocked key cupboard within the office, the office is often unattended and unlocked which means that unauthorised access may be obtained. This was discussed with the Registered Manager who took immediate action to secure the keys. Management of terminal care and death was reviewed, and there was evidence that information is recorded within the individual plans of care, the management are mindful of the changing needs of the residents and the implications of ageing, terminal care and death. 2 The Grove DS0000014906.V362926.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a robust complaints procedure, which is highly sensitive to the needs of the individual residents, and there is good staff awareness about the Safeguarding Adults, which ensures that the residents are fully protected. EVIDENCE: There have been no concerns or complaints made about this service. There is a robust compliant procedure and that this is made available to residents through the Service Users Guide, individual plans of care and each resident has their own individualised complaints procedure, which is produced in a format most suitable for the individual. Through discussion with management and staff it was established that concerns are welcomed and that they are used to inform service development. The service has access to the current Local Authority Guidelines on the Safeguarding of Adults and staff have received training in this area, Staff spoken to were able to demonstrate a good level of understanding of protecting the vulnerable and the associated processes. 2 The Grove DS0000014906.V362926.R01.S.doc Version 5.2 Page 18 There has been one Safeguarding Adults incident since the last inspection; the service has fully cooperated with the investigating authorities. This investigation has now been closed due to insufficient evidence. Staff were seen to relate well to residents and residents appeared to be relaxed and to enjoy the company of staff. Staff were seen to be sensitive to the non verbal communication of residents and were able to interpret the residents wishes. The service holds small amounts of money for residents; these are stored within individual wallets and securely stored. A spot check was conducted and the balance found to corresponds with the associated records – appropriate receipts are retained to evidence appropriate expenditure and frequent audits are conducted to ensure ongoing accuracy. However the individual plans of care, which are accessible to all staff contained sensitive information regarding bank accounts. This was discussed with the Registered Manager who agreed to remove this information and to store securely to ensure that the residents are protected form identity fraud. 2 The Grove DS0000014906.V362926.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within the home is good, providing residents with a safe and comfortable place to live. EVIDENCE: The environment is comfortable, well maintained and homely, currently meets the needs of the existing residents. The management are currently reviewing the environment to allow for more communal multi purpose space. This includes the conversion of two garages into out door games rooms. The exterior of the premises is safe and provides residents with access to an enclosed rear garden and the management described scheduled improvements to enhance the enjoyment for residents. 2 The Grove DS0000014906.V362926.R01.S.doc Version 5.2 Page 20 The service currently provides communal and private space that promotes the privacy and dignity of the service users. All residents have single rooms and are encouraged to personalise their bedrooms. It was observed that the staff support the residents to make changes and to personalise their rooms to individual preferences. The bathroom and toilet facilities are appropriate to need and are in sufficient number and quality. The service provides specialist aids and adaptations to meet the resident’s needs. The management has also consulted an Occupation Therapist for guidance on the fitting of individualised aids and adaptations throughout the home. One resident requires the occasional use of a wheel chair and the environment laid out to accommodate the safe use of a wheel chair. Since the last inspection a new kitchen has been installed, with a lowered work surface to meet the needs of the existing residents. The management of the service provides robust infection control procedures and the home was clean and hygienic throughout. The staff were able to confirm that all of the equipment was in good working order. There are separate laundry facilities that support good infection control practices. There are adequate supplies of hot water and the home is heated by under floor heating. 2 The Grove DS0000014906.V362926.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service employs robust recruitment procedures and appropriate numbers of inducted and trained staff to ensure that the residents are in safe hands at all times. EVIDENCE: The service has an appropriate duty rota in place, which clearly demonstrates that there are sufficient staff on duty to meet the needs of the existing residents. There are always at least three staff on duty throughout the day and one waking and one sleeping staff on duty during the night. The existing residents are white European and the staff group are reflective of the ethnicity, culture, age and gender of the residents. There is evidence that staff are encouraged to pursue National Vocational Qualification in Care level 2 and 3. There is evidence to demonstrate that staff receive all mandatory training, including a comprehensive induction 2 The Grove DS0000014906.V362926.R01.S.doc Version 5.2 Page 22 programme, Moving and Handling, First Aid, Fire Safety, Safe Administration of Medication, Basic Food Hygiene, Infection Control. In addition staff all receive training specific to the needs of the individual residents, for example epilepsy awareness. Through discussion with staff it was established that they had a good understanding of the needs of the residents and were able to demonstrate competence in their roles. 2 The Grove DS0000014906.V362926.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 &42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate leadership, guidance and direction means that the service is managed in the best interests of the residents. EVIDENCE: Quality Assurance practices were reviewed and demonstrated that the service seeks the views of people who use the service such as the residents, their relatives, professional contacts and staff. The results of the professional survey have been returned and the analysis indicates a high level of satisfaction. The results of the other surveys are anticipated in the near future and the findings are to be used to inform service development. The Registered Manager has 2 The Grove DS0000014906.V362926.R01.S.doc Version 5.2 Page 24 identified improvements to the resident’s surveys to develop and easy read format. In addition the management systems are in place that ensure regular audit of processes within the home, for example the standard of the environment and residents money. A limited tour of the premises was conducted and no hazards were identified and safe working practices were evident. Kitchen records were viewed and evidenced safe food hygiene practices. Fire records were viewed which indicted appropriate maintenance and routine checks which also evidenced safe working practices. Staff are suitably trained to promote the Health & Safety of residents and staff. Polices and procedures are accessible to staff and are up to date. The current manager is experienced, well qualified and was registered with the Commission for Social Care Inspection in September 2007. The service has both a development and business plan in place to develop the service in enable the stated aims and the objectives to be met. Quality Assurance practices were reviewed and demonstrated that the service seeks the views of people who use the service such as the residents, their relatives, professional contacts and staff. The results of the professional survey have been returned and the analysis indicates a high level of satisfaction. The results of the other surveys are anticipated in the near future and the findings are to be used to inform service development. The Registered Manager has identified improvements to the resident’s surveys to develop and easy read format. In addition the management systems are in place that ensure regular audit of processes within the home, for example the standard of the environment and residents money. A limited tour of the premises was conducted and no hazards were identified and safe working practices were evident. Kitchen records were viewed and evidenced safe food hygiene practices. Fire records were viewed which indicted appropriate maintenance and routine checks which also evidenced safe working practices. Staff are suitably trained to promote the Health & Safety of residents and staff. Polices and procedures are accessible to staff and are up to date. 2 The Grove DS0000014906.V362926.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 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 3 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 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 4 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 X X 3 X 2 The Grove DS0000014906.V362926.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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 2 The Grove DS0000014906.V362926.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Eastern regional Contact Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 2 The Grove DS0000014906.V362926.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. 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