Inspection on 03/06/05 for Birchdale

This inspection was carried out on 3rd June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Birchdale 10/11/08

Birchdale 22/05/08

Birchdale 28/11/07

Birchdale 04/07/07

Birchdale 21/07/06

Birchdale 18/10/05

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Granville Court 6 Tennyson Avenue Bridlington East Yorkshire YO15 2ES Lead Inspector Karen Ritson Unannounced 3 June 2005 10:45 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 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 Older People. 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. Granville Court J53 JO4 S62588 Granville Court V228266 030605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Granville Court Address 6 Tennyson Avenue Bridlington East Yorkshire YO15 2ES 01274 498050 01274 497352 N/A Pennine Care Services Ltd. Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Deputy Manager: Rebecca Willis Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Dementia - over 65 years of age (25) Granville Court J53 JO4 S62588 Granville Court V228266 030605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of service users in categories OP and DE(E) who may be admitted for respite care is limited to a maximum of four (4) at any one time. Date of last inspection N/A Brief Description of the Service: Granville court is situated in Bridlington town centre. It is a period house, in keeping with thoses around it. The home is in close proximity to local amenities including transport, shops, health care and leisure facilities. It is registered to provide care for a maximum of 25 older people, some of whom have dementia. The accomodation has twenty single bedrooms and three floors with access by a passenger lift to the upper floors. The service users have the choice of two lounges. A small courtyard style garden is located at the rear of the property, which has been made accessible to service users. Wheelchair access to the home is facilitiated via a permanent ramp to the main entrance. Granville Court J53 JO4 S62588 Granville Court V228266 030605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on Friday June 3rd 2005. It took thirteen hours to complete, which includes preparation and report writing time. The acting manager was not available having recently left employment with the home. The manager from Revelstoke care home, (also owned by Pennine Care Ltd) and the supervisor on duty were available throughout the inspection. The timing of the inspection was such that staff had experienced little time to adjust to the lack of management. There had been disquiet amongst staff and the owner of the home had met with them to discuss management issues the week of the inspection. The acting manager decided to leave her employment before this meeting took place. As a result staff were just beginning to get to grips with the paperwork and make sense of the systems left by the previous acting manager. The supervisor and the manager of Revelstoke were helpful throughout the inspection. Despite the difficulty of the circumstances there was a cheerful and relaxed atmosphere throughout the day The home has provided a satisfactory action plan to address the requirements detailed at the close of this report in relation to staffing, management plans and health and safety. What the service does well: What has improved since the last inspection? What they could do better: Staffing problems have caused difficulties. The latest acting managers’ sudden departure has put pressure upon remaining staff and staffing levels have not been adequate recently. Urgent consideration is needed regarding future Granville Court J53 JO4 S62588 Granville Court V228266 030605 Stage 4.doc Version 1.30 Page 6 management of the home. This is now being addressed. Evidence of health and safety documentation was not to hand and this has led to requirements and low scores for those standards affected. 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. Granville Court J53 JO4 S62588 Granville Court V228266 030605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Granville Court J53 JO4 S62588 Granville Court V228266 030605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 Service users are informed about the way in which the home assesses needs, which enables a choice to be made regarding admission to the home. EVIDENCE: Assessment documentation was in place, with risk assessments, particularly regarding falls. The assessments are detailed and thorough. Service users said that their care needs were well understood and met. Granville Court J53 JO4 S62588 Granville Court V228266 030605 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 , 8 and 9 Service users health care needs were met with regard to care planning and involvement of specialist health care professionals, however, service users were at risk regarding the homes procedure on handling packet medication. EVIDENCE: Care planning documentation was detailed and thorough. Although informal reviews are carried out regularly, these are not recorded on a monthly basis. Paperwork is in place for the recording of monthly reviews and the supervisor in charge on the day of inspection said she would implement this. Those service users who are able to sign agreement with their care plan have done so. Evidence was seen in daily notes that health care professionals and other specialists had been consulted in drawing up the care plan and in meeting ongoing care needs. For example those service users who required the services of a community psychiatric nurse, or who needed speech therapy were given access to them.Service users said that staff understood their care needs well, however there had been a period of time when there had not been sufficient staff on duty to carry out care duties without rushing. This issue is covered under the staffing section of the report. Medication is suitably stored in a locked trolley, which is padlocked to the wall in the office. Controlled medication is stored in a separate metal container within this. The home has Granville Court J53 JO4 S62588 Granville Court V228266 030605 Stage 4.doc Version 1.30 Page 10 medication delivered monthly from the Heaton pharmacy, Bradford, in Nomad packs. Medication is also prescribed in packets where the nomad packs are not appropriate. It was difficult to reconcile the number of tablets remaining in these packets with the number of tablets signed in. This was because there had not been a clear system of returns at the end of each prescription period. The number of tablets held in packets must tally with the number recorded on the sheet. An immediate requirement notice was left regarding this and the supervisor verbally agreed a plan of action to rectify the situation. A written action plan confirming this is required. All staff have received training in the safe handling of medication. Only senior carers are authorised to administer medication. Granville Court J53 JO4 S62588 Granville Court V228266 030605 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of the above standards were looked at this inspection. EVIDENCE: Granville Court J53 JO4 S62588 Granville Court V228266 030605 Stage 4.doc Version 1.30 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Service users are complaints are dealt with and they are protected from abuse. EVIDENCE: The home operates a complaints policy and procedure. Complaints and outcomes were logged. The complaints policy was held in different places and was in various formats, one of which did not include the contact details of the nearest CSCI office, one of which did not specify a timescale for response to a complaint. All versions of the complaints policy and procedure should be resolved into one, containing all required information. Service users said any concerns they had were listened to and the home had a positive attitude towards encouraging them to speak up if there was a problem. They said they were listened to and any concerns were acted upon. All staff have received abuse training through induction and foundation training programmes. The home also has a policy and procedure on abuse and whistle blowing. Staff said they felt confident about what constituted abuse and would know who to speak to if they felt an abusive situation was occurring. Granville Court J53 JO4 S62588 Granville Court V228266 030605 Stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 Service users live in an environment which has been made safe and is undergoing an extensive refurbishment. EVIDENCE: Since Pennine care have taken over ownership of the home, there have been many improvements to the environment. New carpets have been fitted to most communal areas and some of the service users rooms have been redecorated. The maintenance worker was spoken to. All radiator covers have been fitted, new furniture for communal rooms has been ordered, double operable locks for service users rooms are ordered and will be fitted soon. Water regulators are to be fitted. The maintenance worker is undergoing a PAT testing course so that he may carry out all the testing across the homes owned by Pennine care. A new thermostat has been fitted to the tank to keep stored water at the correct temperature to avoid the risk of Legionnaires disease. The grounds were tidy and safe. The home complies with the local fire service and Granville Court J53 JO4 S62588 Granville Court V228266 030605 Stage 4.doc Version 1.30 Page 14 environmental health department. Service users said they were very happy with the changes to the environment so far. They said that Mr Bassan and the staff kept them informed about plans for the home and asked their opinion about what changes they would like to see to the way the home was presented. Granville Court J53 JO4 S62588 Granville Court V228266 030605 Stage 4.doc Version 1.30 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 30 EVIDENCE: The staff rotas were examined for the weeks of and following the inspection. Both the supervisor and the manager from Revelstoke said that staffing was at a minimum for the week of 30th May onwards. However, the shortage had been addressed through a recent recruitment drive and new staff were on duty that week, shadowing senior staff and more were due to commence the following week. The supervisor acknowledged that it would take some time for the home to be fully staffed with experienced workers. The manager had left her post with little notice earlier in the week, which had caused a further staffing shortage. For the week commencing 6th June staffing was adequate for the number of service users in the home. This would allow for staff to engage in activities with service users, for example, to go out to shops or sit and chat. Over 50 of staff have NVQ 2 or higher and all are employed following a thorough recruitment procedure which includes gaining two reference for each candidate, POVA checks before commencement of service and supervision until CRB checks come through. All staff have received TOPSS induction and foundation except those who were very newly appointed who had dates for when this would commence. Service users said that they had been aware af the shortage in staff but were reassured when Mr Bassan had spoken with them about new recruitment. They said they felt confident that the staffing situation would be rectifies because as one service users said. “He always does what he says he will do” Granville Court J53 JO4 S62588 Granville Court V228266 030605 Stage 4.doc Version 1.30 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32 and 38 Service users do not benefit from a clear management of the home. The health, safety and welfare of service users are not fully protected. EVIDENCE: The home lacks a manager. At present there is no acting manager. The manager from Revelstoke assisted with the inspection with the supervisor on duty. Service users said it was unsettling that the last manager had left so suddenly. Much work has been carried out to make the environment safe, which includes a fire risk assessment, environmental health compliance and thorough staff training in almost all areas of health and safety. Updated infection control training is planned for the near future. However, perhaps due to the fact that the manager has recently left employment and had her own methods for storing information, the other members of staff could not locate the maintenance certificates for electrical systems, equipment or gas safety. An immediate requirement notice was left regarding this and the supervisor said she thought that that maintenance certificates were all up to date, but she Granville Court J53 JO4 S62588 Granville Court V228266 030605 Stage 4.doc Version 1.30 Page 17 could not locate the evidence. COSHH and environmental risk assessments had not been completed. Service users said that they felt safe and were pleased with the progress being made with the environmental improvements which included enhancing its safety. Granville Court J53 JO4 S62588 Granville Court V228266 030605 Stage 4.doc Version 1.30 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x x x x STAFFING Standard No Score 27 1 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 1 x x x x x 1 Granville Court J53 JO4 S62588 Granville Court V228266 030605 Stage 4.doc Version 1.30 Page 19 NA Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard 9 27 38 Regulation 13 18 12,13 Requirement The number of tablets not in nomad contaners must be reconciled with the recording. Staffing numbers must be adequate. risk assessment are required for COSHH and environment. Certificates are required for maintaining electrical systems, equipment and gas safety Consideration must be given to management arrangements in the absence of a registered manager for the home. Timescale for action Immediate requirment left. 10/06/05 Immediate requiremen t notice left. Immediate requiremen t notice left. Action plan by 17/06/05 4. 38 12,13 5. 32 8 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Granville Court J53 JO4 S62588 Granville Court V228266 030605 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection York Area Office Unit 4, Triune Court Monks Cross York, YO32 9GZ 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. Extracts may not be used or reproduced without the express permission of CSCI Granville Court J53 JO4 S62588 Granville Court V228266 030605 Stage 4.doc Version 1.30 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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