Care Home: Grosvenor Terrace, 100

Similar services:

• Ashlong House
• Norbury Crescent (30)
• Edenvale
• Wadham Avenue
• Chatsworth Care - Dawson House
• Cowden Road, 52 - 54
• Chatsworth Care - Tudor Lodge
• Foxley Lane (121a)

What the care home does well The residents have lived at the home for many years. They are familiar with the environment, the community and most of the staff team. The home strives to achieve its aims by providing a service tailored to meet individual residents needs and works with outside agencies to do this. The manager and staff support the residents’ right to make choices for themselves by holding best interest meetings when necessary, to have a say in the service they receive and to develop social and daily living skills as well as emotionally as members of the local community. They use local shops and markets and go out locally when possible. They are supported by staff to become involved in a variety of activities as well as being supported in maintaining relationships with family and friends. Residents are encouraged to choose and to go on holidays of their choice. The home makes sure that the health care needs of residents met. Making sure if they are unwell, they are able see the doctor.Grosvenor Terrace, 100DS0000060231.V378507.R01.S.docVersion 5.3The organisation follows its recruitment procedures to make sure the residents are safeguarded and protected from abuse. What has improved since the last inspection? Care and support plans are reviewed regularly with the residents at the service and family, appropriate professionals and the advocate are invited to these. The manager and staff have worked to comply with the last requirements where they could but have been hampered from complying with them all because of restrictions within the organisation and with the Southwark who own and manage the property. They have employed a new member of staff. Staff are having more regular supervision and have the support of a manager who is enthusiastic. What the care home could do better: The manager would benefit from having more organisational support to help her develop her role as manager of the team. We found there has been a lapse in the training and development programme and a number of staff are overdue mandatory training. Staff seem to lack motivation. They need to be motivated and have clear goals to develop into a positive work force that will support the residents to lead a fulfilling life. Staff who dispense medication should be trained to give rectal diazepam when necessary as prescribed by the residents GP. This needs to be given within specific times that could cause untold harm f not administered soon enough. A number of records were not being kept up to date and were not available for inspection. The requirement relating to the envirionment remains out standing. This needs to be addressed. The service is not dedicating sufficient resources in maintaining the premises to a comfortable state. We were told that budgetary constraints in 2009 have resulted in a lack of progress in this area. The organisation needs to make provision to keep the premises clean and in a good state of décor. It looks much run down and dirty in places. The boiler has been replaced but they still need to use electric fires to maintain a good temperature suitable for people with disabilities. A warning letter is issued to the organisation. Key inspection report CARE HOME ADULTS 18-65 Grosvenor Terrace, 100 London SE5 0NL Lead Inspector Lynne Field Key Unannounced Inspection 1st December 2009 10:00 Grosvenor Terrace, 100 DS0000060231.V378507.R01.S.doc Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Grosvenor Terrace, 100 DS0000060231.V378507.R01.S.doc Version 5.3 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Grosvenor Terrace, 100 DS0000060231.V378507.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Grosvenor Terrace, 100 Address London SE5 0NL 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) 020 7701 5622 0207 703 8395 catalina@odyssey-csft.org www.odyssey-csft.org Odyssey Care Solutions for Today Manager not registered. Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Grosvenor Terrace, 100 DS0000060231.V378507.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 4 Date of last inspection Brief Description of the Service: 100, Grosvenor Terrace is a registered care for up to four adults with learning disabilities. Four women currently live there. The service is managed by Odyssey Care Solutions for Today, who have other similar homes in South London. The home is a two storey house in a residential road in Southwark. People have access to a lounge, kitchen/dining room, laundry room, toilet and bathroom on the ground floor with one single bedroom. Three single bedrooms, a bathroom and toilet are on the first floor. People have good access to local shops, leisure facilities, churches of different denominations, pubs, restaurants and public transport systems. The weekly fees vary depending on the individuals needs. Information is available in the Statement of Purpose and Service Users Guide. Grosvenor Terrace, 100 DS0000060231.V378507.R01.S.doc Version 5.3 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 stars. This means the people who use this service experience adequate quality outcomes. The unannounced inspection was carried out over one day in December 2009. The manager facilitated the second part of the inspection with the deputy manager. The inspection included a tour of the home and examination of records on care plans, medication records and the complaints book. The home had no vacancies at the time of the inspection. We met all the residents who live at the home and spoke to three care staff during the course of the inspection. We checked relevant policies and procedures as well as the resident’s files, the care plans and building maintenance records. During the visit we were able to observe how staff interacted with residents and how residents responded to staff. The manager returned a standard form, the Annual Quality Assurance Assessment (AQAA), to CQC. This was taken into consideration and used as part of the inspection process. The information we received from the above sources was used to inform the judgments made in this report. Fees are £1880-00 to £1944-00 per week depending on the needs of the resident. What the service does well: The residents have lived at the home for many years. They are familiar with the environment, the community and most of the staff team. The home strives to achieve its aims by providing a service tailored to meet individual residents needs and works with outside agencies to do this. The manager and staff support the residents’ right to make choices for themselves by holding best interest meetings when necessary, to have a say in the service they receive and to develop social and daily living skills as well as emotionally as members of the local community. They use local shops and markets and go out locally when possible. They are supported by staff to become involved in a variety of activities as well as being supported in maintaining relationships with family and friends. Residents are encouraged to choose and to go on holidays of their choice. The home makes sure that the health care needs of residents met. Making sure if they are unwell, they are able see the doctor. Grosvenor Terrace, 100 DS0000060231.V378507.R01.S.doc Version 5.3 Page 6 The organisation follows its recruitment procedures to make sure the residents are safeguarded and protected from abuse. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our Grosvenor Terrace, 100 DS0000060231.V378507.R01.S.doc Version 5.3 Page 7 order line – 0870 240 7535. Grosvenor Terrace, 100 DS0000060231.V378507.R01.S.doc Version 5.3 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 Grosvenor Terrace, 100 DS0000060231.V378507.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides important information to prospective residents, families and health professional so that they are informed on services available. No resident is admitted to the home unless they have had their needs fully assessed first and the home is confident that they can meet their needs. Prospective residents and their relatives can come and look around the home and meet staff before they decide to move there. EVIDENCE: The home has a statement of purpose and service user guide. We were told all the residents have lived in the home for some years. There are no vacancies at the present time. We were told the Statement of Purpose and Service User Guide would be given to prospective residents and their families and this explains what the service offers. This is written in easy to read format. We were told as part of the assessment process, the manager would follow the organisations admissions process and go to assessed them. If the home felt Grosvenor Terrace, 100 DS0000060231.V378507.R01.S.doc Version 5.3 Page 10 they could meet the prospective resident’s needs they would be invited to visit the home and be encouraged to make several visits to see if they liked it and meet the residents and staff. Grosvenor Terrace, 100 DS0000060231.V378507.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are consulted and supported to make decisions about their lives by staff and appropriate independent professionals. Potential risks are identified and residents are supported to take risks within a risk management framework. EVIDENCE: On the day of the inspection there were four residents living in the home. Three were out at their daycentres and activities and one was at home for the day. Staff said all residents have a named key worker and they have monthly key worker meetings with residents that are recorded in easy read format to ensure inclusion of the residents. We were told the home had implemented Odyssey’s new support plan system called ISA for all residents. Residents have comprehensive communication passports, individual support guidelines and Grosvenor Terrace, 100 DS0000060231.V378507.R01.S.doc Version 5.3 Page 12 plans as well as risk assessments on file. The manager said they have developed using objects of reference in relation to some residents in order to improve communication and support their needs and aspirations better. This helps in the monitoring individuals responses. We checked the residents’ files and found them more organised and have been continued to be developed since the previous inspection but still need to have some work. We found a number of these had not been reviewed or appeared not to have been reviewed because they have not been written up and put in the resident’s records. We spoke to the manager about this who has since confirmed the staff are in the process of doing this. Support plans and risk assessments should be reviewed regularly with residents and their families every six months or sooner if necessary and copies of these need to be available at all times. We were told the home has internal reviews and invites the family and other professionals involved. There were copies of best interest meetings on file. These are planning meetings for individual needs and then they review the plan after six months. Family are involved in these where there are family and we were told there is very good advocate supporting the residents of the home. We were told the social workers do not always hold annual reviews for the residents care or attend the reviews the home holds even when they are invited. Grosvenor Terrace, 100 DS0000060231.V378507.R01.S.doc Version 5.3 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): This is what people staying in this care home experience: 12,13,15,16,17 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are encouraged to access the community with the support of staff and engage in appropriate, enjoyable and fulfilling activities. Families and friends are encouraged to keep in touch with the residents and participate in social activities. Residents enjoy a healthy, varied diet. EVIDENCE: There is a timetable of weekly activities for each resident kept in their file. This has been written on picture format for in easy reading. Residents go to different activities depending on their needs. We were told residents are encouraged to go out as much as possible during the day and at weekends. Grosvenor Terrace, 100 DS0000060231.V378507.R01.S.doc Version 5.3 Page 14 They have regular access to the community and activities programmes are developed to meet each resident’s individual needs. In this way residents are supported and encouraged to take part in activities that are enjoyable, beneficial to their mental and physical health. Residents go to different activities depending on their needs. Three residents were out at various activities during the time of the inspection. Records are kept of the activities residents participate in. We saw residents go to a social club on a regular basis and other regular outings on the bus, for lunch, walks or to the cinema. They also plan special trips to local museums and have recently been on a river cruise. The manager said they had organised holidays on a one to one basis which the residents enjoyed. Residents are encouraged and supported to make choices regarding holidays and we were shown a number of photos of these outings and holidays. The residents are supported to make their own choices in regards to clothes, hair style, makeup, toiletries, bathing or showering. Residents are supported to the shops to purchase clothes that are age and peer appropriate. We observed that residents were dressed in comfortable clothes that was clean and warm. The manager said they thought it was important for residents to be well dressed and wear good quality clothes. Staff also support residents to shop for toiletries and presents for their families for birthdays and Christmas. The manager said they try to have more staff on duty if there is a special outing planned. The staff encourages residents to keep in contact with family and friends and key workers supporttheir key residents to remember family birthdays, special religious events that are relevant to them, Mothers Day and Fathers Day. Individual residents make choices around when they retire to bed, when they rise and are encouraged to get up on the days that they have a planned activity within plenty of time. Residents attended the organisations “Values” day where they had a stand. They also attended the AGM the organisation has. When we arrived there were two staff on duty. One resident was in the lounge. Other residents came back from various activities they were taking part in later in the day and they spend time in the lounge with the television and music on or in their rooms listening to music. As at the last inspection we did not observe a lot of staff interaction with residents and had the impression some staff lacked motivation. The organisation needs to look at ways they could help consolidate the team development and motivate them. The staff said they encouraged the resident’s to eat a healthy diet. They are supported to choose food items of their choice using photos of different dished the home has taken for this purpose. The staff said the residents had lived at the home for a number of years and they are able to tell by their reaction whether they like the food they are given. There was a good range of different food with healthy options, such as low fat food and fresh fruit recorded on the menu. Grosvenor Terrace, 100 DS0000060231.V378507.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents receive personal support, in the way they prefer and their physical and emotional needs are met. Residents are not able to take control of their medication and need assistance to take it. Staff need additional training in the administration of rectal diazepam. EVIDENCE: We were told all support plans and risk assessments are in the process of being redone but these were not in the resident’s files for us to see. The manager has since contacted us to say they are now on file. Staff need to keep written files up to date and available to be seen at all times. This is not just important as evidence but for new or bank staff who may not have been at the home for sometime and need up to date information about residents and how they prefer to be supported with their care. Staff spoke to residents with respect and addressed residents by the name they preferred to be called by. Grosvenor Terrace, 100 DS0000060231.V378507.R01.S.doc Version 5.3 Page 16 Each resident has health file. This records all the residents health needs. It includes a health action plan that has recently been implemented by the organisation and their medical profile. There are records of health appointments attended. This indicates each resident is supported by care staff to attend an appropriate range of healthcare appointments in line with their individual healthcare needs. None of the residents are able to take control of their medication and need assistance to take it. Medication is kept in locked cabinet in the kitchen area and key is kept by staff at all times. The home has a number of controlled drugs that are locked in a separate box in the cupboard. We checked the MAR charts and the medication of three residents and found it all correct. We were told that monthly audits and spot checks are done of medication procedures to highlight any shortfalls in procedures. Each chart had a photo of the resident and a list of the medications prescribed for the resident. Homely remedies list was signed by the GP. There were a number of medications that could not be put in the dosset boxes. It would be good practice to keep a running total of these medications on the MAR charts. The manager said the home receives regular pharmacy inspection visit, which provides them with further recommendations if necessary. Staff team had also received a feedback and training from the last visit done by pharmacist. We were told one resident is prescribed rectal diazepam. It needs to be administered immediately following the specified guidelines that are given to the home by the GP if it is needed by staff trained in this procedure. It is an invasive procedure and if wrongly administered it could cause damage to the rectum. The manager said only one staff had been trained in this procedure and if that member of staff was not on when it was needed they had to call an ambulance, which causes a delay and puts the resident at risk. All staff need to be trained in this procedure as it is essential to the resident’s health and welfare. Best interest meetings are held if a medical procedure is deemed necessary, and if the individual is unable to consent. The meeting consists of all relevant professionals in order for a collective decision can be made, that clearly has that persons best interest at the forefront. The advocate is also invited and attends to support residents. Grosvenor Terrace, 100 DS0000060231.V378507.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22.23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service has an accessible complaints procedure that has been developed in the last year. There are safeguards in place to protect the resident from abuse, neglect and self-harm. EVIDENCE: We saw a copy of the complaints procedure in pictorial format. An accessible format for the complaint policy and procedure has been developed since the last inspection. The complaints procedure is included in the Statement of Purpose, Service Users Guide and displayed at the service so relatives, representatives and other stakeholders are able to raise issues if and when required. We checked the complaints book. The manager told us they had not received any complaints. No complaints were recorded. The manager said all complaints are taken seriously and appropriate action would be taken to ensure a residents’ or a family member’s complaint was addressed immediately. There is a record of each residents petty cash, which shows all transaction. Two staff sign all transactions. Receipts are kept for all transactions and they are audited by the manager or deputy manager each month. We checked the resident’s money with a member of staff who went through the homes Grosvenor Terrace, 100 DS0000060231.V378507.R01.S.doc Version 5.3 Page 18 procedure with us and explained the money was checked at each handover. All money checked was correct. Staff told us they completed training in the protection of vulnerable adults as a part of their induction and through the organisation and were aware of their responsibility to report concerns or issues. We saw copies of records that confirmed they had all recently had SoVA which enables them to recognize and act on suspected case of abuse. We spoke to care staff during the inspection and who said there were different types of abuse, not just physical abuse, such as verbal abuse and financial abuse. They said if they suspected abuse was happening they would reassure the resident and report what they suspected to the manager or the deputy manager. Grosvenor Terrace, 100 DS0000060231.V378507.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is not being maintained to a good standard and is in places, dirty and shabby. Carpets and the kitchen are particularly dirty and should be replaced. The refurbishment program is not being routinely followed and is affected by budgetary constraints. EVIDENCE: There is a large lounge, kitchen/dining room, toilet and bathroom on the ground floor for the residents use. Next to the lounge is a large office that the manager and staff use and is large enough to be used as a meeting / training room if necessary. There is one single accessible bedroom on the ground floor and three single bedrooms and a bathroom with toilet on the first floor accessed by a flight of stairs. Grosvenor Terrace, 100 DS0000060231.V378507.R01.S.doc Version 5.3 Page 20 We found the communal areas of the home were in a poor state of repair and are in need of redecoration. Carpets, particularly in the office, need replacing. The kitchen was dirty, with some walls at high level covered in grease and the kitchen units looked shabby. The kitchen would benefit from being completely refurbished and redecorated. We were told they had quotes for work on the decoration to be done but that Odyssey Care Solutions, the provider has had to impose a temporary budget freeze since the last key inspection, which has had some effect on the refurbishment of the house. Southwark Council have also imposed a temporary budget freeze, which has resulted in the carpets not being replaced, which was a requirement made in the 2008 inspection that has not been met. The heating system has been replaced but it still is not working properly and they need the extra heaters to keep the house warm. The manager said the heating system checked by the engineers but it still did not heat the home adequately and they needed to use electric heaters to keep the home heated to a comfortable acceptable temperature. This needs to be addressed. We were given copies of the risk assessments that have been done to cover the portable heaters. Bedrooms are single and have been decorated and personalised to the individuals taste with pictures, photographs and articles that reflect peoples religious and cultural identity. We saw people to be comfortable and have the things they want and need in their rooms. We saw the hoist that staff told us give residents appropriate support safely. We saw people using wheelchairs and armchairs that meet their assessed needs. We were told they hoped to be able to buy another specialist chair for one resident when the budget was available. Grosvenor Terrace, 100 DS0000060231.V378507.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,34,35,36 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Recruitment arrangements are robust and residents are safeguarded by staff that are thoroughly vetted. Resident’s individual and joint needs are met by appropriately trained staff who have regular supervision and are supported in their work. EVIDENCE: We checked the staff rota and this reflected the staff members that were on duty. We were told by the manager that sometimes residents needed one to one support and this would be reflected in the rota. We were told it was not always possible to go out on the spur of the moment because staffing needs to be planned but where possible they would try to do this. We were told by staff if there was an event planned they would get more staff but there are still staffing issues because of the high support needs of the residents. Most of the care staff in the home had worked at the home for a number of Grosvenor Terrace, 100 DS0000060231.V378507.R01.S.doc Version 5.3 Page 22 years including locum workers, so they know the residents well. They have recently recruited a new member of staff. We were told the organisation follows its recruitment prossess and prior to starting prospective staff will receive a POVA check and full enhanced CRB check. Staff recruitment personnel files are held at head office. Copies of the requirements in Schedule 2 records of recruitment are held in the home. The manager said all staff are given comprehensive job descriptions, staff handbook, personal development diary and social care codes of practice when they join the organisation. They have a six month probationary period during which time they must complete the orgnisations induction program as well as completing the homes induction program. They are enroled into the LDQ programme. We were sent a copy of the staff training records and saw the new member of staff had completed their manadatory induction within the time scale specified. We saw a copy of the training record held at the organisations head office and training dates are marked on the rota. Most of the annual manadatory training was up to date but there was that some needed to be completed. The manager should audit this an ensure all training is kept up to date. Both the manager and deputy manager have NVQ level4 and three care staff have NVQ level 3. We were told the home has regular team meetings, staff supervision and annual appraisals. Staff seem to lack self motivation and direction. For example staff have not kept residents files up to date and care plans had not been written up even though they have been reviewed and reminded to do this. They need to take ownership of this and do this aspect of the work without being reminded. This could be looked at as part of their appraisal and job competencies. . Grosvenor Terrace, 100 DS0000060231.V378507.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42,43 People using the service experience Adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff and residents would benefit from having the stability of a registered manager. The manager is qualified and experienced and runs the home well. EVIDENCE: The homes management team consists of a manager and a deputy who are both experienced in the care sector. The manager needs to apply to become the registered manager and this would give more stability to the team. The manager is also a qualified nurse and has NVQ leve 4. The manager is relativley new to the service but they have good knowledge of the complex Grosvenor Terrace, 100 DS0000060231.V378507.R01.S.doc Version 5.3 Page 24 health needs of the residents who live in the home. They just returned to work and is still establishing her role as manager of the team. They would benefit from more personal and profesional support to develop the team that has been together for sometime and needs to move forward. We found she was knowledgable about the needs of the residents and is enthusiastic to provide a good service. Although she had only returned to work recently she was working towards ensuring the requirements in the last report were followed up and met. The AQAA was completed at short notice and contained information to help with the inspection. We noted in the August Action Plan for the service, there was a team development day planned to happen in October. This needs to happen and will be to the of benefit to staff and residents from the consolodation of the staff team. Monthly monitoring visits have been conducted but actions need to be monitored and followed up at the next monitoring visit. We found this did not always happen. We were told a Values day to get the views of people using services was introduced recently. This is planned to take place annually. An independent advocate familiar with each resident attends all the annual reviews. Despite these various methods for seeking views of residents and families within the organisation we found information is not collated and analysed to get a view overall of the outcome of individual processes or of the service performance. The home has policies and procedures in place around health and safety. The records we saw indicated the homes health and safety services and equipment have been checked, serviced and maintained at the appropriate intervals. We saw there was a copy of the fire certificate floor plan and risk assessment on file. There is a fire procedure in place. The break alarms are being tested weekly and fire-fighting equipment has been checked regularly. Fire drills have been carried out with residents at various times of day on different days. We discussed fire evacuation process. Because of the nature of the resident’s disabilities, the home could get specific advice about what to do in the event of a fire occurring because it could be difficult for two staff to get four residents out safely without having to go back into a burning building. Copies of the reports and records of the health and safety checks are kept at the home and were up to date. Grosvenor Terrace, 100 DS0000060231.V378507.R01.S.doc Version 5.3 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 x 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 3 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 2 3 X 3 x LIFESTYLES Standard No Score 11 X 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 x 3 3 3 x 2 3 2 Version 5.3 Page 26 Grosvenor Terrace, 100 DS0000060231.V378507.R01.S.doc Yes 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 YA6 Regulation 15 Sch 3 Requirement The registered person must ensure records of residents assessed needs are kept up to date at all times and are available in the resident’s files. The registered person needs to ensure there are sufficient staff trained in the administration of rectal diazepam so there is always a member of staff on duty to administer it if necessary without delay. The registered person must ensure the stained carpets in the lounge, entrance and hallway are replaced to provide a good environment for the people who live there. The registered person needs to ensure the homes kitchen is deep cleaned or replaced and refurbished. The registered person must audit the homes staff training records to ensure staff have completed the annual mandatory training and this training is kept up to date each year. The registered person shall keep records up to date at all times. DS0000060231.V378507.R01.S.doc Timescale for action 13/02/10 2. YA20 13(2) (c) 13/03/10 3. YA24 YA30 23 (2) d 31/03/10 4. YA30 16(j) 31/03/10 5. YA35 18( c)(i) 13/02/10 6 YA41 17 Sch 3 &4 13/02/10 Grosvenor Terrace, 100 Version 5.3 Page 27 7 YA43 24(1)(b) The registered person must ensure the manager is supported to develop the service and establish her role in the staff team. 31/03/10 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA39 Good Practice Recommendations After the monthly monitoring visit, any actions to improve the services provided should be monitored and progress checked at the next visit. Grosvenor Terrace, 100 DS0000060231.V378507.R01.S.doc Version 5.3 Page 28 Care Quality Commission London Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Grosvenor Terrace, 100 DS0000060231.V378507.R01.S.doc Version 5.3 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. 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!