Care Home: Grove Cottage

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What the care home does well The home is well organised with structures and systems in place to facilitate smooth running. Policies are well written and clear. Documentation like support plans and risk assessments are of a good standard. Needs are reviewed regularly.All service user surveys received were positive and service users indicated they liked the home. At his review one service user told his social worker "I like it here". The ethos of the home is empowerment. The manager and staff seem to successfully tread a line between keeping service users safe, and allowing them to follow their own inclinations. The outcome is a good quality of life for service users, with autonomy and choice.The inspector felt that people were given as much choice in their lives, as possible.....but were still taken good care of. What has improved since the last inspection? The visitors book appeared to be properly kept up, and 50% of the staff now have NVQ qualifications.The visitors books is being properly used now. Staff working at the home are better qualified. What the care home could do better: The inspection resulted in four good practice recommendations. The manager should return to manage the service in January as expected. This should ensure that the service continues to offer the high quality of care which this inspection evidenced. All service users should have health action plans to ensure that their health needs are planned for and met. All unnecessary labels and paperwork should be cleared out of the medication folder to reduce the margin for error. Staff training should be brought up to an overall standard with all basic core topics up to date.All service users should have a plan about how to stay healthy.Everything to do with medication should be really clear and tidy with only up to date information and no old bits of paper.Staff need to have had all have the most important training courses. CARE HOME ADULTS 18-65 Grove Cottage 44 Grove Road Mile End London E3 5AX Lead Inspector Anne Chamberlain Unannounced Inspection 4th December 2007 9:40 Grove Cottage DS0000070243.V356122.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Grove Cottage DS0000070243.V356122.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Grove Cottage DS0000070243.V356122.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grove Cottage Address 44 Grove Road Mile End London E3 5AX 020 8981 6291 020 8980 5830 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) www.grooms-shaftesbury.org.uk Grooms-Shaftesbury Mr Gavin Alexander Page Hellis Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (5) of places Grove Cottage DS0000070243.V356122.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories 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 and LD(E) The maximum number of service users who can be accommodated is: 5 Date of last inspection First inspection Brief Description of the Service: Grove Road was owned and managed by the Shaftesbury Society (Christian care in action). Following a merger this year the home is now provided by Grooms-Shaftesbury. It is a registered care home for up to five people with mild or moderate learning disability. The home aims to enabling service users to develop their own lives through minimizing the effects of any disadvantages they have. The building is a four story Edwardian house with five single bedrooms, two bathrooms and a ground floor cloakroom. There is no lift but a garden at the back of the house. The home is conveniently situated close to public transport and other facilities, such as parks and the canals of East London. Fees at the care home are in the region of £900 per week. Grove Cottage DS0000070243.V356122.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector received completed survey forms from all five service users before the inspection. The Annual Quality Assurance Assessment was not to hand before the site visit but the inspector expects to receive it shortly after. The aim of the site visit was to conduct an unannounced inspection of key standards, and to monitor compliance with the two legal requirements issued at the last inspection. The inspector met and exchanged greetings with all the service users. She chatted to one service user and attended part of the placement review of another, which was held on the day. The deputy manager of the service was on duty on the day of the inspection as well as one carer. She assisted the inspector with the inspection, but was also occupied with reviews which were taking place on that day, and caring for service users. The inspector felt however, that she was able to find the greater part of the information and evidence she needed from the three service user and three keyworker files which she viewed as well as other key documentation and records. In addition to the above the inspector made a tour of the house. She inspected the arrangements for the administration of medication to the one service user who has prescribed medication. The inspector would like to take this opportunity to thank the service users, deputy manager and staff for their co-operation and assistance with the inspection. The inspector came to the service so she could see if people were well looked after there, and so that she could write a report about what she found. Grove Cottage DS0000070243.V356122.R01.S.doc Version 5.2 Page 6 She looked at lots of paperwork and some files. She sat in on someones placement review. What the service does well: The home is well organised with structures and systems in place to facilitate smooth running. Policies are well written and clear. Documentation like support plans and risk assessments are of a good standard. Needs are reviewed regularly. Grove Cottage DS0000070243.V356122.R01.S.doc Version 5.2 Page 7 All service user surveys received were positive and service users indicated they liked the home. At his review one service user told his social worker I like it here. The ethos of the home is empowerment. The manager and staff seem to successfully tread a line between keeping service users safe, and allowing them to follow their own inclinations. The outcome is a good quality of life for service users, with autonomy and choice. The inspector felt that people were given as much choice in their lives, as possible….. but were still taken good care of. What has improved since the last inspection? The visitors book appeared to be properly kept up, and 50 of the staff now have NVQ qualifications. The visitors books is being properly used now. Grove Cottage DS0000070243.V356122.R01.S.doc Version 5.2 Page 8 Staff working at the home are better qualified. What they could do better: The inspection resulted in four good practice recommendations. The manager should return to manage the service in January as expected. This should ensure that the service continues to offer the high quality of care which this inspection evidenced. All service users should have health action plans to ensure that their health needs are planned for and met. All unnecessary labels and paperwork should be cleared out of the medication folder to reduce the margin for error. Staff training should be brought up to an overall standard with all basic core topics up to date. All service users should have a plan about how to stay healthy. Grove Cottage DS0000070243.V356122.R01.S.doc Version 5.2 Page 9 Everything to do with medication should be really clear and tidy with only up to date information and no old bits of paper. Staff need to have had all have the most important training courses. 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. Grove Cottage DS0000070243.V356122.R01.S.doc Version 5.2 Page 10 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Grove Cottage DS0000070243.V356122.R01.S.doc Version 5.2 Page 11 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): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Any prospective service user would be well assessed before being offered a place in the home. EVIDENCE: The inspector viewed the files of three service users. They contained good personal profiles for the individuals, and evidence of adequate assessment by the home before a placement was offered. Grove Cottage DS0000070243.V356122.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual plans are good, risk assessment is thorough and service users are encouraged to take as many decisions as possible. EVIDENCE: Two of the service user files viewed contained broad and well written support plans for the individuals. There was less support information on the third file and the deputy manager explained that the individual is really quite independent. The inspector gathered the impression that a lot of work has been done with the individual since he has been at the home and his care needs have reduced. There was evidence that the support plans are reviewed frequently. Grove Cottage DS0000070243.V356122.R01.S.doc Version 5.2 Page 13 The inspector learnt that a service user had had a fall getting out of the bath, a couple of days previously, and that as a result of this his personal care routine would be changed, also changes would be needed to his support plan. The deputy manager said that she had intended to amend the plan and create a risk assessment on the day of the inspection. The inspector noted a file of generic risk assessments is also kept covering topics like, entering a bedroom and extension leads. The inspector was quite satisfied with the support plans, risk assessments and evidence of reviewing. The inspector viewed the record of residents meetings, the minutes of which are signed by the service users. The meetings had been held regularly at least once a month. The minutes demonstrated decision making by the service users. In addition the varied programmes of the service users testified to their preferences being followed. At the placement review the service user expressed his views clearly and they were respected. The inspector viewed good risk assessments. They rated the levels of risks and detailed the actions taken to reduce them. They covered a range of topics for service users, including self-medication and over the counter medicines, keyholding, visits home, and a risk assessment on a holiday. Grove Cottage DS0000070243.V356122.R01.S.doc Version 5.2 Page 14 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 and 16. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users enjoy a variety of community activities. Relationships are supported and rights respected. A healthy diet is offered and meals are taken in a pleasant room. EVIDENCE: The inspector viewed the timetables which are kept for each service users programme of activities. Service users take part in a wide variety of activities outside of the home. One, who is an independent traveller on public transport attends Map-Squad, another attends Wm Brinson Day centre, another Coburn Centre. Service users also attend a Mens group, Mencap activities including Gateway club, Bubble club and Albany Theatre activities as well as parties and social events they get invited to. Grove Cottage DS0000070243.V356122.R01.S.doc Version 5.2 Page 15 Some service users also visit their families. On the day of his review one service user had been to his brothers house locally. One service user has visits at the home from a friend. The inspector was pleased to note that the organisation has a policy on sexuality and relationships. In this policy there was an emphasis on the rights of service users, and the value of respect. The inspector felt that the policy reflects the values of equality and diversity. The inspector noted that service users have signed consent to sharing information forms. She felt this indicated that the right of service users to confidentiality is respected. The service users have varying levels of independence in cooking and domestic tasks. The inspector sensed there is also a reluctance in some to undertake shopping and cooking tasks. The deputy manager said cooking of meals is the one area where most prefer staff to take a lead. The dining room adjoins the kitchen and is a pleasant space with a large round table and chairs. When the inspector arrived people were having sausage sandwiches for breakfast. The inspector noticed bowls of fresh fruit available. There were pictures of food on the refrigerator and a big shopping list on the wall, also a record of meals eaten. The deputy manager said that service users are pro-active is suggesting meals they would like to eat. During the course of the inspection the deputy manager asked a service user if he had had lunch (as it was around 3.30p.m.). He said clearly that he had not, but did not want any and was going to have a cup of tea. The deputy manager reminded him that there were snacks in the kitchen if he wanted something. Grove Cottage DS0000070243.V356122.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The support offered by the home is individualised and effective. The home provides emotional as well as physical support. Self-medication is supported. Two recommendations have been made too improve practice. EVIDENCE: The manager stated that none of the service users need much support with personal care beyond occasional prompting. During the course of the inspection one service user had had a bath quite independently. As mentioned above the personal care needs of one service user are being examined in the light of a recent fall. The home is aware of manual handling issues and the deputy manager was clear that staff are not trained to undertake manual handling. Grove Cottage DS0000070243.V356122.R01.S.doc Version 5.2 Page 17 The care that the home provides is in the nature of a safe and secure base of support, guidance and assistance for dealing with everyday issues and encouragement to attend medical appointments etc. One service user has challenging behaviour particularly outside of the home and he has two to one support in the community. The service user files evidenced a conscientious approach to health matters. There was well recorded evidence of attendance at dentists, opticians, foot clinic, general practitioner (G.P.) appointments etc. Notes had been made with the results of appointments. During the course of the inspection a service user was accompanied to see his G.P. by a carer. One service user had a health action plan but the other two did not. The inspector recommends that these are prepared for all service users (see recommendations). The inspector viewed the medication policy which states that only those staff trained, may administer medication and that training should be ongoing and updated yearly. The arrangements for the administration of medication were viewed. As previously mentioned only one service user takes prescribed medication. He self-medicates and the medication and Medication Administration Record (MAR) sheet are kept in a locked box in his room. The inspector recommends that all old labels and paperwork in the box and folder are disposed of to reduce the margin for error (see requirements). Grove Cottage DS0000070243.V356122.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users views are fully considered and they are protected from abuse, neglect and self-harm. EVIDENCE: The inspector viewed the Moans and Groans folder. This would appear to be a listening book. It is a place to note minor concerns raised by service users. An example would be a light bulb needing replacement. Appropriate resolutions had been recorded next the moans and groans, and it was noted that they were not frequent or repetitive. In addition the inspector noted a complaints booklet written by the organisation for service users. The inspector viewed the adult protection policy which was comprehensive and detailed. She noted that it clearly stated the role of the home is to keep people safe. The role of the local authority is to investigate. This is correct and the organisation is commended for stating it clearly in its policy. The inspector noted a copy of the local authority protection policy in the office. Grove Cottage DS0000070243.V356122.R01.S.doc Version 5.2 Page 19 The visitors book appeared to be appropriately kept up, with all visitors to the home signing in. The inspector noted that staff sign in to the communication book when they come on shift. A primary focus of the home is to protect service users from self-neglect. Staff encourage service users to attend to their own personal care, and to ensure that their clothes and rooms are clean. The staff strive to promote autonomy but also ensure good care. In this they are generally successful. The inspector was satisfied that the home demonstrates a commitment to listening to service users and to protecting them. Grove Cottage DS0000070243.V356122.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment is comfortable and homely, clean and safe. EVIDENCE: Number 44 Grove road is a very old house. The inspector acknowledges that it is not easy to keep a house of this age looking fresh, particularly the paintwork on doors, skirting boards etc. However the decorative state of the house is not bad and is good in places. The top floor bathroom is newly refurbished and in very good order. The basement bathroom and the ground floor cloakroom are satisfactory. Halls stairs and landings are freshly painted and quite acceptable. The kitchen, dining room are also in reasonable condition. The sitting room Grove Cottage DS0000070243.V356122.R01.S.doc Version 5.2 Page 21 has a large discoloured area above the radiator. The wall or the whole room should be repainted (see recommendations). The inspector viewed two bedrooms. She was shown his bedroom by a service user. It was personalised and the service users told her he likes his room and sleeps well there. The other bedroom seen is in a very poor state due to the treatment of the service user. The deputy manager stated that it is to be completely refurbished with replacement bed, sofa, curtains, flooring etc. The home was generally clean and hygienic. There was an unpleasant odour in the bedroom mentioned above. The deputy manager explained to the inspector what is planned in the refurbishment to prevent the future occurrence of this, a plastic covered mattress, washable flooring etc. As mentioned previously the home has a good sized garden which was tidy and obviously a lovely space in the summer months. The inspector was generally satisfied with the environment of the home Grove Cottage DS0000070243.V356122.R01.S.doc Version 5.2 Page 22 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 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staffing situation is strong but needs to be more stable. A recommendation has been made regarding training. EVIDENCE: The manager of the home is currently seconded to another home some distance away. In his absence the deputy is managing the service. The usual staffing is two on every day shift, and one sleeping overnight staff. The sleep in quarters are quite adequate, conveniently located off the office and with a proper bed and plenty of space. Currently the home is using bank and temporary staff. This is not ideal but the inspector felt that the staff are competent. The manager is registered to manage the service and is apparently undertaking the registered managers award. The deputy has NVQ 3 in care. She stated that 50 of the carers have NVQ 2 or above and that this is now a recruitment criteria. The inspector Grove Cottage DS0000070243.V356122.R01.S.doc Version 5.2 Page 23 noted that one carer had Learning Disability Award Framework (LDAF) at level 2. The inspector viewed the recruitment policy which indicated a robust approach to safety, requiring proper vetting and the verification of references. The inspector viewed the staff files for the keyworkers of the three service users, whose files she had viewed. All had two references and clear Criminal Records Bureau disclosures and all had completed application forms and been formally interviewed. The recruitment process offered equal opportunities and was nondiscriminatory. The staff group is culturally diverse as is the service users group. The staff files contained clear lists of training undertaken by staff. The inspector noted that the manager had last undertaken adult protection training and first aid training in 2005. He had undertaken mental capacity training this year, which is good. The deputy manager had undertaken six training courses since she started with the organisation early this year. However the inspector noted that she this did not include medication training. The third file evidenced that the worker had undertaken seven training courses this year. In all cases certificates for training were present on files. The inspector formed the view that the organisation has an active approach to training. However the manager needs to ensure that all staff have training in core basics, and that these are kept up to date. The inspector sees core basics as: First Aid Food and Hygiene Fire Adult Protection Health and Safety and Medication training for any staff who administer medication. The inspector strongly recommends that the manager plan for all staff working at the home to achieve the above (see recommendations). Grove Cottage DS0000070243.V356122.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run, service users views are taken into account and their wellbeing is promoted. EVIDENCE: The inspector felt that the home is well run. On the day of the inspection the deputy manager was occupied with service users needs and reviews. However she was able to instantly locate all the information and evidence the inspector needed, in terms of files, policies and records. She was also able to expand on and explain issues which the inspector raised. Grove Cottage DS0000070243.V356122.R01.S.doc Version 5.2 Page 25 The inspector noted that as well as Residents Meetings, staff attend Residents Focus meetings and Staff Meetings, and that a service user attends the staff meetings. She felt that this strong communication and sharing system contributed to the success of the home. The documentation written by the organisation and also by the home is succinct and clear. The recording is of a good standard. The inspector feels that the deputy manager has been quite stretched in being left in charge of a home she has worked in for less than a year, and trusts that this will not go on beyond January 2008, when the manager is scheduled to return to the home. The home has a kind of day book, which guides staff about what must be done on a shift, staff initial when they have carried out the tasks. The inspector noted in the files of service userss, completed quality assurance questionnaires. She was not able to find much other evidence of quality assurance activity but the home does have a business plan for 2007-2008. This is a relevant and useful plan for the home. The inspector viewed some of the safe working systems of the house. The home has a health and safety policy. This states that Control of Substances Hazardous to Health (COSHH) substances must be stored securely and that safety data sheets must be retained for them. The inspector viewed records for water temperatures, for refrigerator and freezer temperatures and also for checking the contents of the refrigerator for out of date or opened but unlabelled foods. All these records were kept regularly and were satisfactory. There is a record kept for the checking of the First Aid boxes and this is done regularly. The home keeps a number of records regarding fire protection. The Kidde book records regular fire drills, three so far in 2007. One of the service users has impaired mobility. The inspector was pleased to see that he has a fire exit on his floor and no stairs involved in his evacuation. The book also evidences monthly checks of the emergency lighting and weekly fire alarm tests. The outside contractor has serviced the fire alarm system and emergency lighting twice in 2007. The extinguishers and fire blanket were checked in June 2007. Grove Cottage DS0000070243.V356122.R01.S.doc Version 5.2 Page 26 There are service users who are hard of hearing and the Royal National Institute for the Deaf (RNID) alarms, installed for their benefit are tested monthly. The home has completed a fire risk assessment which looked satisfactory to the inspector. The London Fire and Emergency Planning Authority (LFEPA) wrote to the service in February 2007 and required them to meet certain conditions. The inspector was satisfied that the conditions had been addressed, apart from one. This condition was regarding the means of escape from the top floor bedrooms which is down a flight of stairs. The escape could be compromised by a fire in the cupboard located up there which houses the immersion tanks and their electrics. LFEPA advise this can be achieved by providing fire resisting cupboarding and doors ensuring the cupboard is suitably sealed. The inspector checked one door of the cupboard which appeared to be clad in a fire resisting material. The inspector was told by the deputy manager that both the boiler and the immersion tank are to be renewed soon. The inspector felt reasonably confident that the manager has addressed the conditions and fire safety in the home is of a good standard. Grove Cottage DS0000070243.V356122.R01.S.doc Version 5.2 Page 27 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 x 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 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 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Grove Cottage DS0000070243.V356122.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No 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. 1. 2. 3. 4. Refer to Standard YA18 YA20 YA24 YA35 Good Practice Recommendations The inspector recommends that Health Action Plans are prepared for all service users The inspector recommends that all old labels and paperwork are cleared from the service users medication box and folder to reduce the margin for error. The wall in the sitting room where the radiator hangs, or the whole room should be repainted. The manager should ensure all staff have undertaken training in the core basics as follow: First Aid Food and Hygiene Fire Adult Protection Health and Safety and Medication training for any staff who administer medication. Also that such training is kept updated preferably annually. Grove Cottage DS0000070243.V356122.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Grove Cottage DS0000070243.V356122.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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