Inspection on 09/05/06 for 2 The Grove

This inspection was carried out on 9th May 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

2 The Grove 09/01/06

2 The Grove 24/05/05

2 The Grove 04/11/04

2 The Grove 25/05/04

2 The Grove 01/12/03

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 2 The Grove Westoning Bedfordshire MK45 5JW Lead Inspector Unannounced Inspection 9th May 2006 13:40 2 The Grove DS0000014906.V289281.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 2 The Grove DS0000014906.V289281.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 2 The Grove DS0000014906.V289281.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 2 The Grove Address Westoning Bedfordshire MK45 5JW Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01525 717098 www.macintyrecharity.org MacIntyre Care Mrs Carolyn Dunbar Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 2 The Grove DS0000014906.V289281.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th January 2006 Brief Description of the Service: 2 The Grove provides a home for up to six service users with learning disabilities. It is a purpose-built house on a small, enclosed estate of three registered homes, all belonging to Macintyre. The home is situated in the village of Westoning and is walking distance of local shops, a church, and public houses. The house is divided into two sections accommodating two and four service users. Each section has a separate kitchen and lounge as well as a utility room. The larger section has two bathing facilities with toilets and also a separate toilet. The smaller unit is able to provide accommodation for two people with physical disabilities. One of the bedrooms downstairs was turned into an office and this provided more space for staff. The office room upstairs was turned into an activity/quiet room for service users and has an en-suite shower and toilet. There is a large rear garden with three swings, a slide, football net, a hammock, and a patio area, and a garden shed. The garden was well used by service users, and meet their needs. 2 The Grove DS0000014906.V289281.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over three hours. The registered manager was not at the home but the manager overseeing the home in the absence of the manager was available for the inspection process. The inspection comprised of talking to staff and service users, and case tracking two young peoples files randomly. The home has recently gone through a very sad time due to the death of a staff member and the loss of a service user who died of natural causes. The manager, staff and advocacy alliance have supported the service users during this time. What the service does well: What has improved since the last inspection? The home had two lounges, and two kitchens with a small dining area on the ground floor and on the first floor. Since the last inspection, one of the bedrooms down stairs was turned into a pleasantly decorated dinning room. The service users were very happy with this change. This meant all the staff and service users could sit in the same room. The upstairs lounge was not used and was turned into a bedroom. 2 The Grove DS0000014906.V289281.R01.S.doc Version 5.1 Page 6 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. 2 The Grove DS0000014906.V289281.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 2 The Grove DS0000014906.V289281.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5, “Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service.” Prospective service users are given the opportunity to spend time in the home. This enables them to meet the service users, staff and to ask any questions about life in the home. EVIDENCE: No new service users had been admitted to the home since the last inspection. However a vacancy had recently occurred at the home for a service user. The inspector was informed that a needs assessment would be carried out before the person moved into the home. The home had policies and procedures on the assessment process. Each service user had a written contract. The service users in the home had visited the home prior to their admission. The home had a statement of purpose but the information needed expanding in some areas. The service users guide was very colourful and user friendly. 2 The Grove DS0000014906.V289281.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 “Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service Service user’s assessed needs and personal goals are reflected in their individual plan. EVIDENCE: Two service users’ care plan files were looked at in detail. The plans contained detailed information about the service users intimate guidelines, personal hygiene, daily routine, staying healthy, likes and dislikes, finances, cultural/religious needs and managing health care needs. Yearly reviews and reviews with the day care centre were seen in the file. The information in the care plan needs to be in the right order. Service users had (PCP) person centred planning meetings to discuss their hopes, dreams and aspirations with a circle of people that are involved with their care. Information on how the service users communicated with staff was also recorded. The staff spoken to stated that they used different methods to talk with service users and this included using pictures, makaton sign language, verbal communication and body language. Information on risk assessments was kept in different files and those seen were monitored by staff and management. 2 The Grove DS0000014906.V289281.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16, 17. “Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service Service users are able to enjoy a full and stimulating life style with a variety of options to choose from. EVIDENCE: All the service users attended the organisation’s day care service and enjoyed this. The care plans had information on the activities that the service users enjoyed doing and how they were helped by staff to achieve this. One service user spoken to stated that he liked living at the home and found the staff very helpful. It was also stated that it was his birthday the next day, and staff had helped him to choose his birthday present. The service user also liked trains and the staff took him out for a day on the trains. One of the service users had a day back at the home to work on his independent living skills on a one to one with staff. It was stated that all service users had this personal development training day once a week at the home. Records were kept of all personal training days for each person. Those seen showed that the staff encouraged service users to make decisions about they wanted to do. Records showed that service users had one to one with staff to talk about things such 2 The Grove DS0000014906.V289281.R01.S.doc Version 5.1 Page 11 as what they would like on the menu, and what activities they want to undertake. Another service user spoken to stated that they liked the staff, the food, their room and enjoyed living at the home. Service users who needed an advocate were provided with this service. One service user was receiving this support. All the service users were seen to be very relaxed and at home. The care plan had details about friends and families with dates of visits and pictures of people involved in their lives. Two service users in the home attended church service on Sundays. 2 The Grove DS0000014906.V289281.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20, 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service Service users have individual health care plans that gives a full overview of their general health to ensure that their needs are met. EVIDENCE: The care plans contained detailed information on how service users received personal support. Information on morning and evening routines and on intimate care guidelines was recorded. Female staff gave personal care to female service users. The male staff supported the male service users when ever possible. Detailed information was recorded on how service users health care needs were being met for two service users care plans seen. For example there was information on how to stay healthy, goals to improve my health, managing seizures, and challenging behaviour, aggression, and infection control. The doctors, opticians, occupational therapist, dietician, and dentist appointments, were well recorded. On the day of the inspection a speech therapist had visited one of the service users and it was stated that this went well. 2 The Grove DS0000014906.V289281.R01.S.doc Version 5.1 Page 13 All staff who had received the medication training, gave out medication to service users. Information on what medication the service users took was recorded in their care plan. The medication cabinet was well maintained and the records were recorded well. The files inspected had information on service users’ final wishes. The staff spoken to were able to give detailed information on service users needs for those that were case tracked. 2 The Grove DS0000014906.V289281.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 “Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service The staff have good knowledge and understanding of adult protection issues, which protect service users from abuse EVIDENCE: The home had a simple and easy to understand complaints procedure and this was available in the statement of purpose and displayed in the home. The service users files inspected had information on what made them vulnerable to any kind of abuse. And how the home tried to minimise this from happening. The home had devised a system whereby anything that the service did not like or seen to be unhappy was recorded by staff. The staff then discussed this in their meeting and with the service to ensure that this incident did not happen again. This was monitored by management. One service user who was able to communicate verbally informed the inspector that if he felt sad or unhappy, he would tell his mother or a member of staff. The staff spoken to had training on protecting service users from any kind of abuse. They also gave examples of knowing when service users were not happy by understanding their behaviour. 2 The Grove DS0000014906.V289281.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service Service users live in a safe and comfortable environment that meets the needs and life style of the people who live in the home. EVIDENCE: The home was clean, spacious and very homely. The service users were able to access all parts of the home. The home had two lounges, and two kitchens with a small dining area on the ground floor and on the first floor. Since the last inspection, one of the bedrooms down stairs was turned into a pleasantly decorated dinning room. The service users were very happy with this change. The inspector was informed that one service liked to sit in the dinning and enjoyed looking at the lovely view of the garden. The upstairs lounge, which was not used very often by service users, was turned into a bedroom. All service users had individualised bedrooms, which were personalised to meet their needs. The ornaments, pictures, sensory items seen in the rooms showed that the service users were supported to maintain their hobbies. The floor in one of the service users room had a tile that had come out. This was however reported to the manager and someone was coming out to repair this. 2 The Grove DS0000014906.V289281.R01.S.doc Version 5.1 Page 16 The garden was very well equipped with activities that the service users enjoyed. However the garden needed attention as the grass had over grown. There was old furniture in the garden that needed removing. The courtyard garden at the side entrance was very pleasant. 2 The Grove DS0000014906.V289281.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35, 36 “Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service Training and induction provided by the organisation was very good indicating that service users needs are met by competent and suitable staff. EVIDENCE: The senior support worker had been off work for some time. The home had a vacancy for a night staff for 4 nights. At present these hours were being worked by a part time day staff. One member of staff was on maternity leave. An acting senior support worker from another home was helping out in the home. This member of staff was on an induction at the time of the inspection. The home had three relief staff who regularly worked at the home. They and the permanent staff and agency staff covered the vacancy hours. It was stated that the home tried to have three staff on per shift where possible. However sometime there were two on duty due to staff shortage. The inspector was informed that the needs of service users were changing and it was stated that they needed more support and more one to one with staff. Some service users needed two staff to one service user when out in the community. The staff spoken to were able to give a detail picture of how they met the needs of the service users that were case tracked. One staff said “I love working here” and the team is great. All staff found the manager very 2 The Grove DS0000014906.V289281.R01.S.doc Version 5.1 Page 18 supportive and excellent. However some staff expressed concerns regarding with another member of staff. The inspector was informed by the manager that was overseeing the home that they would discuss this with her line manager to resolve this concern. All staff confirmed that they had received a good induction and they all enjoyed working with the service users. It was said that the service users accepted staff “as family” and service users missed them when they came to work. It was said that the home was very good in meeting the needs of the service users. They undertook the certificate in working with people with learning disabilities course. The staff discussed the training courses that they had been on and this included all the mandatory training. It was stated by staff that the home had gone through very sad time. This was due to one staff member who had died and the unexpected death of a service user who died of natural causes. Every one in the home was going through the bereavement process. It was stated that the manager and her manager had been very supportive to the staff and service users. The service users were also provided with support from advocacy alliance. Some staff felt that the senior level of management within the organisation had not been very supportive to the home. Supervision with staff had lapsed due to the sad events that had happened in the home and the manager being off sick. The staff files inspected were satisfactory and contained relevant information to ensure service users were protected by the home’s recruitment procedures. Information kept on agency staff used at the home was well recorded. 2 The Grove DS0000014906.V289281.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home was being run efficiently in the best interest of service users. EVIDENCE: The homes manager had been off sick for two weeks. A manager from another home was over seeing the home and usually spent a few hours at the home sorting management issues. The staff were aware of who to contact for any advice required. The manager over seeing the home was present at the inspection and it was stated that every thing was fine. Observation showed that the interaction between staff and service users was very positive and the home was running efficiently. Quality assurance had not been done for this year. It was stated that a new system was being introduced. The manager had undertaken questionnaire and those received were very positive. Regulation 26 visits were still being sent to the CSCI. Health and safety and care planning was being monitored. 2 The Grove DS0000014906.V289281.R01.S.doc Version 5.1 Page 20 Fire alarm, emergency lightening, and fire drills were carried out regularly. The home also undertook health and safety audits on a regular basis. Service users were involved in the training of fire drills. 2 The Grove DS0000014906.V289281.R01.S.doc Version 5.1 Page 21 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 3 4 3 5 3 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 x 3 x x x 3 2 The Grove DS0000014906.V289281.R01.S.doc Version 5.1 Page 22 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 2 The Grove DS0000014906.V289281.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: 0845 015 0120 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. 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