Care Home: John Grooms Court

What the care home does well What has improved since the last inspection? What the care home could do better: CARE HOME ADULTS 18-65 John Grooms Court 215 Sprowston Road Norwich Norfolk NR3 4HZ Lead Inspector Mr Jerry Crehan Unannounced Inspection 10th December 2007 09:20 John Grooms Court DS0000070231.V356386.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 John Grooms Court DS0000070231.V356386.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. John Grooms Court DS0000070231.V356386.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service John Grooms Court Address 215 Sprowston Road Norwich Norfolk NR3 4HZ 01603 429400 01603 484121 mannorwich@grooms-shaftesbury.org.uk www.grooms-shaftesbury.org.uk Grooms-Shaftesbury 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) Mr Michael Flavell Care Home 22 Category(ies) of Physical disability (22) registration, with number of places John Grooms Court DS0000070231.V356386.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 6th June 2006 (Under new ownership since 29th June 2007) Brief Description of the Service: John Grooms Court is a purpose built home and can accommodate up to 22 adults who have a physical disability. Situated on the outskirts of Norwich city centre the home is close to local amenities and shops. The accommodation is on the ground and first floors, and comprises of 18 single and two double bed sit style self-contained flats. Each flat has a kitchen and en-suite bathroom with sitting room and sleeping area. The second floor accommodation is not registered for service users, but is currently used by the management as offices, training area and other administration purposes. In addition to the self contained accommodation there is a communal dining room and sitting room. There is a small external area at the rear/side of the premises where there is a raised garden and patio. Off street parking on site is limited and the car parking area and rear of the premises is gated for safety and security reasons. The home’s fees are set at £753 per week. John Grooms Court DS0000070231.V356386.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. This report gives a brief overview of the service and current judgements for each outcome group. Three comment cards were received from relatives of people who use the service. These reflected good views about the home and the service it provides to people who live there. Fifteen comment cards were received from people who live at the service, again reflecting positively about the service. This view was also reflected by positive comments made by people spoken with at the time of the inspection visit. Records held by the Commission and previous inspection reports were checked. This key inspection comprised an unannounced visit to the home that took place over 8 hours on 10th December 2007. The inspector was accompanied for part of the inspection visit by an ‘expert by experience’. An expert by experience is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. Feedback from the expert is included within the report. The role of the expert within this inspection visit was to observe daily life at the home and how people who use the service are supported, consider the suitability of the building for people with physical disabilities, and to talk to people who use the service about their care, support and chosen lifestyles. Opportunity was taken to tour the premises, look at care records and policies, observe care delivery to people who use the service, communicate with people who use the service, speak with staff and the Manager. The inspection report reflects regulatory activity since the last inspection and evidence from inspection of Key Standards. The fee’s for the home are £753 per week. John Grooms Court DS0000070231.V356386.R01.S.doc Version 5.2 Page 6 What the service does well: • The service undertakes good assessments of the aspirations and needs of prospective service users, and service users are involved in this process. Staff are good at writing about the care that people need in ‘care plans’. Service users are involved in developing and reviewing their own care plans, and say that staff know what care and support they need. The lifestyle choices for service users are excellent. People who use the service make choices about their preferred lifestyle, and are well supported to develop and maintain their life skills. The health and personal care that people receive is good and based on their individual needs. The way that staff manages and administers medication is good. Staff are knowledgeable and enthusiastic about their roles. They show care and respect for service users. Staff are supported through the availability of good induction and ongoing training with input from people who use the service. • • • • What has improved since the last inspection? • • • The service ensures that all recording relating to service users, such as incident reports, is held on their individual files. Service users receiving respite services also have individual care plans. Service users are protected by very good staff recruitment and induction training practices. John Grooms Court DS0000070231.V356386.R01.S.doc Version 5.2 Page 7 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. John Grooms Court DS0000070231.V356386.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 John Grooms Court DS0000070231.V356386.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): Standards 1 & 2 People who use 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. Prospective people to use the service have their needs thoroughly assessed, and access to all of the information they need about the service they may choose. EVIDENCE: The manager confirmed that the home is registered for 22 people. However two bedrooms are shared though not used as such – they are used for single occupancy only. The manager explained that this situation is unlikely to change, as they do not wish to offer shared accommodation. Consequently the home offers care to a maximum of 20 people. A sample of files was looked at provided evidence of comprehensive individual needs assessment for prospective service users. Assessments seen addressed healthcare, social care and psychological needs that formed the basis of individual care planning and risk assessment. There was evidence of good practice in the level of attention paid to the personal and social life requirements of prospective service users, such as relationships, social interaction and leisure interests. The manager stated that members of the management team at the home carry out assessments. John Grooms Court DS0000070231.V356386.R01.S.doc Version 5.2 Page 10 The admission procedure is supported by the home providing suitable information to prospective service users in formats appropriate to the needs of the individual. John Grooms Court DS0000070231.V356386.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): Standards 6, 7 & 9 People who use 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. Individual needs, aspirations and choices are promoted through clear care planning and assessment of risk. People who use the service are supported to make decisions about their lives within their capacities. EVIDENCE: Several care files were looked at during the site visit. Care files contained a ‘personal profile’ of the service user including a photograph and professional and family contact information. Each file contained detailed care plans that were signed by service users (covering areas including communication, personal care, social life, nutrition and mobility). A care plan to address a service user’s eating/drinking and swallowing needs had been developed with the support of a community health professional (a speech and language therapist). The plan was clear and detailed for staff to follow, and included a risk assessment and strategy in the event of difficulties. John Grooms Court DS0000070231.V356386.R01.S.doc Version 5.2 Page 12 Risk assessments that describe the support requirements of the individual were available in care files. Risk assessments covered areas such as out of date food being kept, money security and self-medication. Those reviewed set out to achieve a balance between providing support to service users and enabling them to take risks as part of an independent lifestyle. A comprehensive medication self administration risk assessment for a service user provided good evidence of this and providing staff with a checklist to consider. A service user who is at risk from falls should be supported by a falls risk assessment that seeks to identify particular risks and to mitigate against them where possible (See Requirement 1). Service users care plans are reviewed on a regular basis with their involvement and input. This was evident from care files and from discussion with service users during the visit. The expert noted that: ‘On observing interaction between staff and service users who were present at the time of the inspection visit, there seemed to be a good rapport and the relationships between service user and staff member appeared to be quite equal and mutually respecting. The atmosphere in general was calm happy and relaxed’. In comment cards received by the Commission prior to the inspection visit all of the 15 service users who responded indicated that they can do what they want to do during the day, in the evening and at the weekend. A service user receiving a period of respite care spoken with during the visit said that the care staff are very good, they know what his needs are and they know how they should meet them. John Grooms Court DS0000070231.V356386.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): Standards 12, 13, 15, 16 & 17 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service make choices about their preferred lifestyle, and are well supported to develop and maintain their life skills. Social, recreational and educational activities meet individual’s various expectations. EVIDENCE: Service users engage in activities at the home and outside of the home with the support of care staff. At the time of the inspection visit there a number of service users were pursuing activities outside of the home in a variety of community settings. A number of service users were participating in art and craft activities on offer at the home, some people were using specialist or adapted equipment suited to their needs. Activities take part in a large dining/activities room lead by a dedicated activities coordinator who has undertaken specialist NVQ training. There was a very good rapport between service users and staff and a relaxed and calm atmosphere for people to pursue their chosen activities in with plenty of support. John Grooms Court DS0000070231.V356386.R01.S.doc Version 5.2 Page 14 Most service users were engaged in making preparations for Christmas such as drawing and painting seasonal pictures or making a ‘winter wonderland’ feature. The expert commented that: ‘Quite recently a drama production pertaining to the works of John Grooms was staged in Ipswich, five of the service users accompanied by some staff members attended this event driven by one of staff drivers and I gather this was greatly enjoyed by all. Prior to the event it was planned that the attendees would present handmade roses, as the drama presentation surrounded the story of the Whitechapel flower girls, these were received by the cast members with great pleasure’. From records seen and discussion with staff and service users there are activities on offer every day, with options such as ten-pin bowling, going to the cinema or the zoo. There is a karaoke at the home once a fortnight and there was a Christmas Eve trip to Cambridge to see a pantomime planned. Two service users are currently participating in adult education courses in numeracy and literacy at college. The home has access to its own transport including two adapted mini buses. Public transport is used by service users including bus services and the train. Some service users spoke about their arrangements for maintaining contact with their relatives. These arrangements vary for individuals. Some contact takes place at the home, or from the home. Other service users are supported by the home in contact at their relatives home. The expert found that: ‘Service users were also able to invite friends and family to visit and those who needed to stay overnight were able to make use of the visitors flat on the top floor’. The daily routine within the home promotes individual choice, as observed during the inspection visit, and service users are able to spend their time as they choose. There are sufficient care staff and other dedicated staff to enable service users to pursue their chosen activities in and outside of the home. All the service users that were spoken to commented favourably on the quality of the meals. Meals seen at the time of the visit looked good, and there are two hot meals on offer each day to ensure that every service user gets a hot cooked meal whatever their choice of activity during the day. The expert also commented that: ‘Service users also had the choice of eating in the dining room or cooking a simple meal on a Baby Belling in their own apartment, it appeared that most elected to eat in the dining room. Most of the comments I received suggested that the food was very good and that they had an input into menu planning’. John Grooms Court DS0000070231.V356386.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): Standards 18, 19 & 20 People who use 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 health and personal care that people receive is based on their individual needs. Well-trained staff provide good healthcare support to people who use the service. EVIDENCE: Individual care plans evidence the high levels of support that are provided to service users to meet their specific personal and health needs. Service users indicated that staff are available to meet personal needs and they are not kept waiting for undue lengths of time if they require assistance. Fourteen of the fifteen comment cards received from service users indicated that carers always or usually listen and act on what they say. One service user indicated that ‘sometimes they are busy, but will usually find time to talk’. There is evidence of good practice to support the healthcare of service users, involving consultation with and advice from a range of community health care professionals. Care staff have access to training in health care matters including first aid and medication. John Grooms Court DS0000070231.V356386.R01.S.doc Version 5.2 Page 16 The home uses a monitored dosage system for medication. Only members of the home’s management team and senior staff are responsible for medication handling and administration. Medication seen is stored securely and appropriate records are kept for the receipt of medication into the home, its administration and any medication returned to the pharmacy. There are several service users accommodated at the home who have responsibility for their own medication. These arrangements are supported by comprehensive risk assessment guidelines. Sample audits of medication were undertaken for both medication trolleys and records tally with medication held. There are clear guidelines for care staff in the event of administration of ‘PRN’ (when required) medicines. Staff record the reason for the administration of any PRN medicine on the MAR (medication administration record) chart. All senior staff with responsibility for the administration of medicines, including PRN medicines have received relevant training. John Grooms Court DS0000070231.V356386.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): Standards 22 & 23 People who use 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. Arrangements for responding to the concerns and complaints of service users and staff are good. People who use the service are protected from abuse. EVIDENCE: The home has a detailed complaint procedure that service users are evidently aware of. Each of the service users spoken to at the visit and those who returned comment cards indicated that they know how to make a complaint. Many service users commented that they would speak with their key worker or with a manager. Records of complaints and comments within the home provided evidence that the manager has appropriately recorded and investigated four complaints in the last twelve months, including their outcomes. A procedure for responding to allegations of abuse (‘Whistle blowing’) is in place that staff are aware of. Care staff have received relevant and up to date training in adult protection. Evidence of this training was seen in records reviewed. In some instances it was difficult to find evidence of the testing of learning, or validation, in training materials and questionnaires (See Recommendation 1). The home has experience of making appropriate adult protection referrals and seeking advice through the joint Norfolk ‘Safeguarding’ Protocol. John Grooms Court DS0000070231.V356386.R01.S.doc Version 5.2 Page 18 The home provides all service users with individual safe storage facilities for monies or valuables. The procedure and practice for handling service users personal allowance monies or valuables was reviewed and was satisfactory. It is recommended that a second staff member witness and sign for any financial transaction for service users monies held by the home (See Recommendation 2). Service users who require financial support/advocacy are referred to an independent advocacy service if they wish. John Grooms Court DS0000070231.V356386.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): Standards 24 & 30 People who use 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 environment at the home is safe, suitably maintained and designed to support the needs of people who use the service and their carers. EVIDENCE: The premises are suitable for the homes stated purpose and in keeping with the local community. The interior accommodation is in a good state of repair, with good quality furnishings and fittings. A communal lounge area has recently been improved with the refurbishing of an adjoining conservatory. There is a small patio/garden area that is well kept and accessible for service users. John Grooms Court DS0000070231.V356386.R01.S.doc Version 5.2 Page 20 Service users accommodation is individual flats each with their own doorbell and letterbox. Flats seen were personalised to reflect people’s own tastes and preferences. The expert noted that: ‘The service users appeared to enjoy the freedom of their own accommodation, furnished with their personal furniture and in some instances decorated by themselves or friends. One flat in particular was very vibrant in bright colours with personal touches in the form of posters and pictures’. The expert also noted that: ‘On both floors of the residence, facilities for bathing with assistance (in the form of large ‘Parker’ baths) are available to wheelchair users or other service users requiring help. There are also refurbished large shower rooms’. The manager stated that there are plans being considered to develop further accommodation on the top floor of the home, and that he would advise the Commission of any proposals. The manager advised that service users accommodation is fully cleaned once a week and that bathrooms are cleaned daily. Cleaning was in progress during the inspection visit and the home was clean and hygienic. Care staff have had infection control training and guidance. John Grooms Court DS0000070231.V356386.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): Standards 32, 34 & 35 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff at the home are well trained, skilled and deployed in good numbers to support the specialist needs of people who use the service. EVIDENCE: There were eighteen service users accommodated at the home at the time of the inspection visit. Usually four or sometimes five care staff are working throughout the day. Each shift is lead by a senior carer. There are two waking night staff members on duty each night. The expert commented that: ‘The manager and staff whom I had the opportunity to speak with were extremely passionate, enthusiastic and involved in the running of the home’. Staff observed and spoken with have a good understanding of their role and respect the service users they support. From observation it is also evident that service users have confidence in their care staff, who they generally describe as ‘very good’. Comments from relatives of service users also reflect positively on the care provided such as ‘I am so grateful that my daughter is being looked after so well’. John Grooms Court DS0000070231.V356386.R01.S.doc Version 5.2 Page 22 The home has a comprehensive training programme in place as evidenced by training records on file and discussions with staff. From information provided by the manager there are 85 of care staff with a qualification of NVQ 2 or above. Three further care staff are currently undertaking this training which would see over 90 achieved. The manager is commended for this considerable effort. All comment cards received from staff indicate that their induction and foundation training is relevant, helps them to understand and meet service user need and keeps them up to date with new ways of working. There is evidence from records that they have access to a range of mandatory training courses as part of their induction training package. Other specialist training provided to staff include, medication, disability equality, sexuality, diabetes awareness and communication. From discussion with care staff and a review of staff files, it was evident that service users are protected by good recruitment practices. Evidence of obtaining enhanced CRB checks, two references, and proof of identity prior to appointment were seen. The manager explained that there is service user participation in staff interview panels, and that service users are also involved in induction training for newly appointed staff. The expert found evidence that one former service user provided input in disability equality training for staff. These are examples of very good practice. John Grooms Court DS0000070231.V356386.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): Standards 37, 39, 41 & 42 People who use 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 management and administration of the home promotes the health and care of people who use the service, and has developed very effective quality assurance systems. EVIDENCE: The ownership of the home changed in 2007. The operational activities of the former Proprietor (the Shaftesbury Society and John Grooms) have been undertaken by Grooms Shaftesbury from 29th June 2007. This has resulted in changes of some policies and procedures within the service, however, there has been continuity of management and continuity within the staff group. John Grooms Court DS0000070231.V356386.R01.S.doc Version 5.2 Page 24 The manager of the home holds City and Guilds 325/3 – Advanced Management in Care and has substantial relevant experience in this area of social care, including managing John Grooms Court for the past four and a half years. He indicated that he has completed approximately 80 of the Registered Managers Award training programme and hopes to complete the course to qualify in early 2008. The manager is described by staff as fair, approachable and someone who will take action when required. The manager has been delegated wider management responsibilities by the new Proprietor. He is aware that this has caused some anxiety at the home as to his future there, though he states that he is able to maintain the responsibilities at the home in addition to others he has outside the home. The expert made the observation that: ‘The fact that the unit manager has a dual role could work well provided that he is afforded the ability to spend appropriate time within the home’. There is an experienced management team for the home who have the confidence of the staff team and of service users. The expert was informed by staff and service users that: ‘regular service user meetings are held where users’ opinions and ideas are discussed, these meetings are planned on a monthly basis. A system of questionnaires and surveys is also in operation’. The home has in place an Annual Development Plan that incorporates the views of service users; service user surveys are undertaken annually as evidenced by records on display within the home. The manager provides copies of these to the Commission along with other monitoring information required by regulation. It is recommended that the recording of confidential information in the home’s communication book cease, in order to better protect service users privacy (See Recommendation 3). The home demonstrates good practices ensuring service users health, safety and welfare. Relevant health and safety training for staff, including moving and handling, first aid, food hygiene training, fire training and good records support practices. John Grooms Court DS0000070231.V356386.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 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 4 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X 3 3 X John Grooms Court DS0000070231.V356386.R01.S.doc Version 5.2 Page 26 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. 1 Standard YA9 Regulation 14(2)(a) Requirement The manager must ensure that appropriate analysis and intervention for service users identified at risk from falls is recorded in individual care plans. This is to assist in ensuring the health and welfare of service users. Timescale for action 10/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA23 YA23 YA41 Good Practice Recommendations It is recommended that evidence of learning and validation be kept in individual staff training files. It is recommended that a second staff member witness and sign for any financial transaction for service users monies held by the home. It is recommended that the recording of confidential information in the home’s communication book cease, in order to better protect service users privacy. John Grooms Court DS0000070231.V356386.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 John Grooms Court DS0000070231.V356386.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. 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