Inspection on 13/01/06 for Blue Grove House

This inspection was carried out on 13th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Blue Grove House 25/03/09

Blue Grove House 24/04/08

Blue Grove House 28/07/06

Blue Grove House 30/08/05

Blue Grove House 04/12/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Blue Grove House 325 Southwark Park Road London SE16 2JN Lead Inspector Caroline Wilson Unannounced Inspection 13th January 2006 10:00 X10015.doc Version 1.40 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 Blue Grove House DS0000052129.V276545.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 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. Blue Grove House DS0000052129.V276545.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Blue Grove House Address 325 Southwark Park Road London SE16 2JN Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 7394 2300 020 7231 4284 jeanadams@anchor.co.uk Anchor Trust Ms Jean Adams Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Blue Grove House DS0000052129.V276545.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30 August 2005 Brief Description of the Service: Blue Grove is a purpose built residential care home registered for 48 older people. It is owned and run by Anchor Trust. The home was opened in October 2003 to replace an ex-local authority home. Many of the service users from the home transferred to Blue Grove when it opened. Many of the staff who worked at this home and are familiar to the service users also moved to work here. The accommodation is on three floors, each with a group living unit comprising16 bedrooms all with en-suite facilities, a kitchen, a dining area and lounge. There is a secure rear garden for use by service users. Blue Grove is situated on bus routes and is close to a local shopping area and leisure facilities. Blue Grove House DS0000052129.V276545.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced. Two inspectors spent the day at the home. The manager, deputy and majority of staff on duty were spoken with. Ten service users were spoken with in the communal areas and in their own bedrooms. Care plans were examined, recruitment, medication and other records were inspected as were policies and procedures. What the service does well: What has improved since the last inspection? 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. Blue Grove House DS0000052129.V276545.R01.S.doc Version 5.1 Page 6 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 Outcomes Statutory Requirements Identified During the Inspection Blue Grove House DS0000052129.V276545.R01.S.doc Version 5.1 Page 7 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 the following standard(s): 3, 4 & 6 The home uses information from placing authorities in individual care plans. The home needs to carefully consider the needs of their intermediate care service users whose needs differ from those needing longer term care. EVIDENCE: A sample of seven service user’s individual records were inspected. Detailed assessment information from the placing local authority is held on service user files. This information is used to draw up individual care plans for service users. Many of the service users have mental health needs and a new intermediate service is being developed. The manager told the inspectors that currently seven out of a maximum 16 beds were occupied by intermediate care service users. Anchor have plans to develop the service provided to care for people with dementia and for intermediate care. This includes additional staff training and specific staffing levels including an activities worker. These plans, when activated, will increase the ability of the service to meet service user’s needs. Blue Grove House DS0000052129.V276545.R01.S.doc Version 5.1 Page 8 The inspectors spoke with 2 service users who are receiving intermediate care. There are plans for the top floor of the home to be designated for people requiring intermediate care. One of the service users currently receiving intermediate care said that the care that they receive was “Okay.” The good things about the home was that the home was secure, the food was alright but that they did not always get what they asked for. For example, they received muffins instead of waffles. They would also like to be offered more spicy food such as curries and stir-fries. One intermediate care service user said that the home is geared mostly to care for service users physical needs but that they would appreciate it if they received more one-to-one time with staff to cater for their emotional needs. Blue Grove House DS0000052129.V276545.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 9, 10 & 11 Information held in care plans is clear and concise. The storage of care plans needs careful consideration. The medication system requires further attention. EVIDENCE: A sample of seven care plans from each of the three units were inspected in order to assess the care planning arrangements. The care planning information is kept in different parts of the home. For example, archive and assessment information in the main office, care plans in a box file in each unit’s medication room, care plan objectives elsewhere and manual handling risk assessments fixed to the rear of service user’s bedroom doors. When all this information had been assembled, with the assistance of staff, the information was clear, workable and had been reviewed regularly. However, one staff member to whom the inspector spoke was not completely familiar with the assessed needs of service users to whom she provided a keyworking service. The practice of retaining the care planning information in different parts of the home could be confusing to staff. A recommendation is given for the storage of care planning documents to be reviewed. Blue Grove House DS0000052129.V276545.R01.S.doc Version 5.1 Page 10 The inspectors noted that the care planning documents in use were dated as being introduced in 2001. The manager advised that they were soon to be reviewed by Anchor with the aim of introducing new style care planning documents. The inspectors examined medication records and storage arrangements on two of the three units. The inspectors were told that only the manager, the deputy and three senior staff administer medication. A senior worker confirmed that she had received training from Boots. Adequate arrangements are made in relation to storage. A large photograph of each service user is visible on their charts. On one occasion when a service user was not given medication the reason was not written on the chart. One service user’s medication chart did not tally with the medication remaining in their box. This occurred on more than one occasion. A requirement is given about this. There had been a recent incident concerning medication reported to CSCI. This involved a service user who self-administers her own medication. The inspectors identified that the self-medication risk assessment in use was not sufficiently detailed and did not assess all possible risks. A requirement to draw up a new risk assessment, which has been agreed by the service user and/or social worker and relative, is given. The inspectors noted that agreements covering service user’s wishes concerning death and terminal illness were on the care plans seen. A payphone is situated in a private area, however, it had been out of use for some time. Blue Grove House DS0000052129.V276545.R01.S.doc Version 5.1 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 the following standard(s): 12,13, 15, Service users need to be consulted on their preferred choice of activities and this can co-incide with the employment of the home’s activities co-ordinator. The food is generally good. However, a survey of meals has yet to be undertaken. EVIDENCE: An activities organiser comes to the home once a week. There is a programme, which states that the service users undertake activities twice a day. Service users were engaged in a sing-a-long on the morning of the inspection. Funding for an Activities Co-ordinator will be released in April 2006. The manager said that the survey on activities, as required at the last inspection visit, had not yet been carried out. The requirement to do this is restated in this report. The manager said that they struggle to get service users involved in activities. One service user who is provided with intermediate care undertakes activities outside of the home. Another said that they would like to get involved but the only activity that they have involves playing cards. They added that they would prefer health and beauty sessions or playing bingo. Blue Grove House DS0000052129.V276545.R01.S.doc Version 5.1 Page 12 Service users maintain contact with their families regularly. One visitor was spoken to and said that they found the home to be, “ a very nice place.” The food was described as being, “lovely.” Service users were generally happy with the food provided, though one said that “the food is ok. There is a lot of bread and pastry. There is not much of a choice.” Some found that the food was not ‘spicy’ enough and that they would welcome dishes such as curries and Chinese food on the menu. No survey regarding the menus have been undertaken at present. Blue Grove House DS0000052129.V276545.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 16 & 18 A programme of training, including adult protection, is to be implemented in the forthcoming year. All complaints records need to be available. EVIDENCE: The manager and deputy have recently attended Adult Protection Training. They are waiting for Southwark Council to provide this course for the other staff members. In the interim, the manager will share what she has learnt with her staff. They are presently aware of what constitutes abuse. The requirement to provide such training was given at the last inspection and is restated in this report. The inspectors were shown the new complaints record book. The old complaints book could not be found. Only one complaint, dated 21 September 2005, had been recorded. A requirement is given to ensure that all complaints records are available for inspection. Blue Grove House DS0000052129.V276545.R01.S.doc Version 5.1 Page 14 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 the following standard(s): 19,21, 23,25, 26 The home is clean and well maintained. EVIDENCE: The home is clean and hygienic. Furniture and decoration in the home was in place to make the home comfortable and homely. Each service users bedroom was large enough and individualised to their personal tastes. The toilets and bathrooms were suitable for their purpose. Blue Grove House DS0000052129.V276545.R01.S.doc Version 5.1 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Efforts have been made to improve the staffing situation for the benefit of service users. The training programme for staff was difficult to understand. EVIDENCE: Staffing has been difficult over the past few months, with high levels of sickness and annual leave which has meant that known agency staff have had to be recruited to ensure adequate staff cover. Six more staff have recently been employed and are in the process of awaiting Criminal Records Bureau/ Protection of Vulnerable Adults (CRB/POVA) checks. Training has been limited since the last inspection. This will be rectified as a new training officer has since been employed. Seven members of staff are listed as currently undertaking NVQ training. The inspectors were shown a timetable of training. However, it was difficult to ascertain whether the training had already taken place or whether it was to be undertaken in the forthcoming year. A requirement is made about this. Some staff were previously employed by London Borough of Southwark. Of these one had no CRB check, however, they had been employed by the Borough continuously for approximately 20-years. Another member of staff did not have any details of past employment on their application form. There Blue Grove House DS0000052129.V276545.R01.S.doc Version 5.1 Page 16 were no photographs of staff on files, though the manager provided evidence that she is in the process of completing this task. Blue Grove House DS0000052129.V276545.R01.S.doc Version 5.1 Page 17 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35, 36 A quality assurance system has been implemented. Arrangements to safeguard service user’s money is in place. However, arrangements for contacting appointees where interest has been accrued has not been followed. Staff are said to be supervised regularly, however, no records were available to conform this. EVIDENCE: The manager showed the inspectors the quality assurance system in use. A self-assessment manual is used whereby each of the National Minimum Standards are assessed. The aim is for Anchor to complete one of these each month. A completed self-assessment for medication was shown to the inspectors. Blue Grove House DS0000052129.V276545.R01.S.doc Version 5.1 Page 18 The manager demonstrated the arrangements made to safeguard service user’s money. The inspectors were told that a new system had been introduced in December 2005. However, the policy and procedure covering the arrangements to look after service user’s money was not available and it was difficult to tell what system or process had been adopted. A sample of records relating to service users were seen. Service user’s money is held in a pooled account. Two service users had over £1000 in the pooled account and seven service users had in excess of £380 in the account. The manager said that when service users had over £150 social services or relatives were contacted to arrange for interest bearing accounts. This was not happening for the above service users and a recommendation is given for this work to be carried out. A requirement is given for the service to have in place a suitable policy and procedure covering the arrangements for safeguarding service user’s money. A sample of the home’s accident records were inspected. These were detailed and provided relevant information about accidents. The manager told the inspectors that supervision is provided to staff but that it is not recorded yet. One staff member spoken with confirmed that she had supervision every six weeks. The manager said that she was to document the staff supervision in the near future. The requirement about this given in the last inspection is re-stated. Blue Grove House DS0000052129.V276545.R01.S.doc Version 5.1 Page 19 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X 2 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X 3 X 3 X 3 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 2 2 X X Blue Grove House DS0000052129.V276545.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 1 OP9 Regulation 13 (2) Requirement The registered person must ensure that accurate records of medication administered to service users are maintained and that stock checking systems are in operation and effective. The registered person must ensure that medication selfadministration risk assessments in use are more detailed and are signed by service users, relatives and/or social workers. The registered person must ensure that consultation takes place with service users about preferences for activities inside and outside the home. Previous timescale of 31/10/05 not met. The registered person must ensure that all complaints records are available for inspection. The registered person must ensure that all staff have received adult protection training. Previous timescale of 31/03/06 not met. DS0000052129.V276545.R01.S.doc Timescale for action 01/04/06 2 OP9 13 (2) 01/04/06 3 OP12 16 (2) (m) 01/05/06 4 OP16 22 (5) 01/04/06 5 OP18 18 (1) (c) (i) (ii) 01/05/06 Blue Grove House Version 5.1 Page 21 6 OP30 18 (1) (c) 7 OP35 17 (1) (a) 8 OP36 18 (2) 9 OP12 12 (3) 10 OP16 16(2) (i) The registered person must ensure that a training and development programme is drawn up for all staff which identifies the training staff require. Previous timescale of 31/10/05 not met. The registered person must ensure that there is a policy and procedure in place covering the arrangements for safeguarding service user’s money. The registered person must ensure that staff receive regular supervision and that records of supervision are kept. Previous timescale of 31/12/05 not met. The registered provider must ensure that intermediate care service users’ needs are fully met as far as practicable ascertain and take into account their wishes and feelings. The registered person must ensure that a survey is undertaken to ascertain service user’s food preferences. 01/04/06 01/06/06 01/05/06 01/04/06 01/06/06 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 OP35 Good Practice Recommendations The registered person should ensure that interest bearing accounts are provided for those service users who have large amounts of money looked after in a pooled account at the home The registered person should ensure that the payphone is fully operational at all times. The registered person should review the storage DS0000052129.V276545.R01.S.doc Version 5.1 Page 22 2 3 OP16 OP7 Blue Grove House arrangements currently in use for care planning information. Blue Grove House DS0000052129.V276545.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Blue Grove House DS0000052129.V276545.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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