Inspection on 24/04/08 for Blue Grove House

This inspection was carried out on 24th April 2008.

CSCI found this care home to be providing an Adequate service.

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 28/07/06

Blue Grove House 13/01/06

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 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Blue Grove House 325 Southwark Park Road London SE16 2JN Lead Inspector Ms Alison Pritchard Key Unannounced Inspection 24th April 2008 10:35 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.V364245.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 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.V364245.R01.S.doc Version 5.2 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 jean.adams@anchor.org.uk www.anchor.org.uk Anchor Trust Patience Oyeniran Care Home 48 Category(ies) of Dementia (48), Old age, not falling within any registration, with number other category (48) of places Blue Grove House DS0000052129.V364245.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP (maximum number of places: 48) 2. Dementia - Code DE (maximum number of places: 48) The maximum number of service users who can be accommodated is: 48 4th March 2008 Date of last inspection Brief Description of the Service: Bluegrove House 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 this home transferred to Bluegrove House 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 comprising 16 bedrooms all with en-suite facilities, a kitchen, a dining area and lounge. There is a secure, rear garden for use by service users. Bluegrove House is situated on bus routes and is close to a local shopping area and a range of leisure facilities. In mid April there were 46 residents in the home. The weekly fees for a placement at the home range between £536 and £599. No additional charges are made. Residents may choose to use the visiting hairdressing service; the prices are detailed in the statement of purpose. Blue Grove House DS0000052129.V364245.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection was unannounced and carried out over three days in late April 2008. The inspection methods included observation of care practice, discussion with residents, relatives and staff, inspection of residents’ files and a range of other records. Care plans were checked and aspects of these residents’ care were examined by case tracking. A short period of time was spent observing residents in two lounges to understand more about life in the home. We also observed a meeting during which information about residents’ progress and needs was handed between staff on different shifts. The views of relatives, staff and involved professionals were sought both through surveys and discussions. The Inspector is grateful for the contributions of everyone who responded to surveys and all of the people who spoke to her during the inspection. The CSCI has access to information gathered through notifications from the home. A document called an ‘Annual Quality Assurance Assessment’ (AQAA) was completed by the previously Registered Manager of the home in advance of the inspection and returned to us. The document provides information about how the home is addressing the National Minimum Standards along with factual information about the operation of the home. All of this information has been taken into account in compiling this report. The Registered Manager and staff from the home facilitated the inspection visits; they were helpful and courteous throughout the process. The last key inspection of the home took place in July 2006; random unannounced inspections took place in August 2007 and March 2008. These were to look at specific issues and they are referred to in the relevant sections of this report. What the service does well: A relative said that ‘the care home provides a caring and reassuring environment for the residents’. Another person commented that ‘overall the home is well run and is a cheerful place to visit. I was very impressed by the time and trouble taken by staff to make the home very cheerful and decorative at Christmas.’ The home is clean and well maintained. The bedrooms and the communal rooms are comfortably furnished with good quality furniture that is suitable for Blue Grove House DS0000052129.V364245.R01.S.doc Version 5.2 Page 6 residents’ needs. There is a range of ways in which the building is designed and equipped to assist residents with disabilities to maintain their independence. This includes the provision of a passenger lift, hand-rails, appropriate seating, hoists and walk in showers. Residents enjoy the range of activities available each weekday in the home and occasional outings to places of interest. The menu includes a range of alternative dishes appropriate for those people who wish to eat Caribbean food. All of the meals include fresh items. What has improved since the last inspection? What they could do better: Although the new format for care plans is an improvement, the plans did not adequately describe the full range of residents’ needs and how they will be met. There must be better information kept about residents’ religious, cultural and linguistic needs. Additional improvements needed include care plan reviews, which should be carried out monthly, or more often if the resident’s needs change. If residents have been found to be absent from the home, risk assessments must be carried out so that they can be protected. Medication practise must be improved. At this inspection, and at a random inspection in early March 2008, there were a number of problems found with medication matters. Although there had been some improvements since early March there remained problems to address. This will be examined at additional random inspections. Some aspects of record keeping need to be improved. Better records of staff recruitment and training must be kept. Health and safety records must also be improved. The home must improve their systems for informing the CSCI about the full range of matters, which they are required to notify us about. Please contact the provider for advice of actions taken in response to this Blue Grove House DS0000052129.V364245.R01.S.doc Version 5.2 Page 7 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. Blue Grove House DS0000052129.V364245.R01.S.doc Version 5.2 Page 8 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.V364245.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Potential residents have enough information to make sure that they can decide about whether the placement is suitable. Potential residents and people important to them can visit the home to assess whether it will be a suitable place for them to live. Assessments are carried out by the home to make sure that they can meet their needs. EVIDENCE: The home has a service user guide and statement of purpose, both of which have been updated to show recent management changes. The documents give essential information to the potential resident. Information about the fees payable at the home are included as are the services residents can expect to receive for the payment. The statement of purpose clearly states that the home does not provide nursing care. Residents and relatives told us that they had visited the home prior to admission, the visit and the information received had helped them to make a decision about whether the home was a suitable placement. The home is given assessments of potential residents’ needs by their social workers and then a Blue Grove House DS0000052129.V364245.R01.S.doc Version 5.2 Page 10 senior member of staff will visit the potential resident to carry out their own assessment. Bluegrove House provides places in a unit on the top floor of the home which it describes as ‘step up/step down’ placement providing short term placements as a step between hospital and home, or if that is not possible, a longer term placement. The unit is not described as providing an intermediate care function and it does not have the full range of facilities, which would be required for such a service. Standard 6 has been judged as not applicable. Blue Grove House DS0000052129.V364245.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care provided must be supported by care plans, which reflect the range of residents’ needs and are reviewed regularly. Risk assessments must be made so that residents are kept safe, Medication practise must be improved to ensure residents’ safety and to promote and protect the residents’ health and well being. EVIDENCE: Anchor Care has introduced a new format for care planning in this and other residential homes. Care plans were looked at on each floor of the home; in total, seven care plans were viewed. Some of the care plans contained inconsistent information; other plans gave incomplete information. Overall the care plans were confusing to read and did not give a satisfactory picture of residents’ needs and how the home was meeting them. The care plan of a resident with diabetes did not include all of the implications of this condition. There was just one reference to the condition, in relation to Blue Grove House DS0000052129.V364245.R01.S.doc Version 5.2 Page 12 the need to see a podiatrist and for staff to check the condition of his feet. There were no details recorded about the implications of diabetes for any other aspects of care. Care plans had not been reviewed monthly, or in response to significant incidents that might indicate changing needs. Despite a resident falling on several occasions the falls risk assessment had not been reviewed since it was first put in place at the end of December 2007. There was a query that this resident may have had a stroke, this also had not led to a review of care. There was information in one file that a resident had been found at a local hospital, and that this had happened on four separate occasions. This should have led to a review and risk assessment, but there was no evidence of any follow up action being prompted as a result of this incident. The CSCI should have been informed of this event, and they have not been informed of some falls and injuries. See requirements 1, 6 and 10. Care plans did not include details about how residents’ cultural and linguistic needs were to be addressed. This was the case for a resident whose first language was not English and whose culture was not shared by any other people resident in the home. There were few details recorded on files seen about how religious needs were met. In most cases seen the person’s religion was noted on the file but, in all but one of the files seen, there were no details about how, or if, the person wished to follow it. See requirement 7. The feedback from residents and the majority of relatives was that they are satisfied with the care provided by the home. A relative said ‘they do care for the residents and make sure that everyone is happy ’, another person said ‘the home is very attentive to my mother’s needs’ and described Bluegrove House as a ‘first rate home’. Residents also said that the help that they receive is good and meets their needs. There have been some problems about accessing adequate assistance from General Practitioners for some residents, particularly people who have shortterm placements. GPs whose catchment area does not include Bluegrove House have been disinclined to continue to provide a service. There has been some reluctance on the part of local GPs to take on responsibility for these residents. The Registered Manager has made considerable efforts to address these issues and has now obtained the agreement of a GP to visit the home each week and provide medical assistance for the residents on Fox Unit. It is anticipated that this will resolve the problems on this floor of the home. The Registered Manager continues to address with the Primary Care Trust issues around the GP assistance provided to the other floors of the home. A random inspection in March 2008 focussed on medication issues, the Lead Inspector and the Specialist Pharmacy Inspector carried out this inspection. Although prescribed medicines for all residents were available at the home, and being given as prescribed on the day of the inspection, there was evidence Blue Grove House DS0000052129.V364245.R01.S.doc Version 5.2 Page 13 that one resident did not receive three prescribed medicines for a period of at least two weeks in January 2008, as the medication administration record was blank. Additionally some medication records for this resident could not be found for two other periods from December to February 2008, therefore there is no evidence that medicines were given during these periods. Medication training for staff who administer medication to residents had been arranged to take place in early May 2008. The action plan put in place by the Registered Manager after the visit in March stated that daily checks of medication were conducted. Nevertheless this had not led to the problem being successfully addressed. At the visits in April there were similar problems relating to the availability of medication for some residents. In addition there was confusion about the medication for one resident who had come to the home from hospital. These matters were discussed with the Registered Manager during the inspection so that she could address them without delay. Since the inspection she has stated that the resident is now being given medication as prescribed on discharge from hospital and being seen regularly by the GP who has recently taken on responsibility for one of the units. Requirements 3, 4, and 5 address medication issues. It is acknowledged that some of these issues relating to the GP service have been difficult to resolve, and have contributed to the medication problems. The Registered Manager agreed that it was unsafe to admit residents to the home without there being clarity about which GP would provide the resident with medical assistance, and that this would be assured in the future. As there are a significant number of problems relating to medication, additional random inspections will be made to check the compliance with requirements. The home’s statement of purpose gives a commitment to showing respect for the residents, and offering care in a manner, which is discreet and sensitive to individual needs. We saw many occasions when staff were warm and respectful towards the residents. Blue Grove House DS0000052129.V364245.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are able to take part in a range of activities in and outside of the home. Some improvements are needed to the way that outings are arranged to make sure that there are sufficient appropriately qualified staff to assist residents. Visitors are able to come to the home at all reasonable times and are made to feel welcome. Residents generally enjoy the meals provided. They include fresh items and take into account the residents’ preferences and needs, although this could be better addressed through improvements in care planning. EVIDENCE: There is an Activities Co-ordinator employed to work at the home. An arranged activity is provided on each weekday. One of these sessions was observed during the inspection. Residents were taking part in a range of activities, including artwork; looking at pictures, some of the Royal family, others of old Bermondsey; listening and singing along to music and chatting with each other, visitors and staff. Residents were engaged in activities and looked content; there was a very relaxed atmosphere during this session. During the inspection Blue Grove House DS0000052129.V364245.R01.S.doc Version 5.2 Page 15 some people chose not to join in and stayed in their lounge where the television was on, some people slept, one read a newspaper. Other activities provided include, entertainment from visiting musicians, games, such as cards and dominoes; painting; films; discussion of current affairs; exercises, bingo, and beauty and nail care. Church services are held in the home and some people are supported to attend Church. The activities have been mentioned as a positive feature of the home by relatives. One person said that the provision of activities has ‘transformed some residents lives - for the better.’ Another person said ‘they go to church on Sunday and I think that is very nice.’ Each of the care plans seen had some information about activities. There is scope for this to be developed further as part of the general improvement of care plans. Visitors are able to come to the home at all reasonable times and during our time at the home we saw visitors being welcomed by staff. A relative also commented on this saying ‘Usually there is a very good atmosphere when entering the home.’ Some residents go out independently. As noted above this should be subject to closer attention by the home, including documented risk assessments. Outings are arranged occasionally, residents are accompanied to go shopping and to other events. The records of a recent outing to a music venue were examined during the inspection. The records showed that five residents went out, accompanied by the Activities Co-ordinator, a member of the housekeeping team and a relative. We consider this level of staffing to be insufficient, as it does not allow for one staff member to return to the home in an emergency and leave a suitably qualified and experienced member of staff with the rest of the group. Outings must be adequately staffed to ensure residents’ safety. See requirement 8. Meals are served in each of the units’ dining rooms. The rooms are light and attractive and tables are well laid with table linen. Choice is provided at each meal and alternatives are available on request. The residents said that they generally like the food, and a relative described the food as ‘first class’. However some feedback received was less positive, indicating that it is an issue to be kept under review. A residents’ meeting was held earlier in the year and focussed on the menu. The chef attended the meeting so was able to answer queries directly. She also visits each of the units to talk to residents about the meals. There is a range of cultures represented by the resident group, the menu is varied and includes Caribbean dishes as alternatives as well as traditional British dishes. Care planning improvements should include consideration of the Blue Grove House DS0000052129.V364245.R01.S.doc Version 5.2 Page 16 food preferences of those people whose culture is not currently catered for. See requirement 7. The chef is given information about residents’ nutritional needs, which arise from their health conditions such as diabetes, and caters for these appropriately. The home receives orders of fresh items, such as fruit and vegetables, meat and bread, regularly throughout the week so there is little need to use frozen items. Blue Grove House DS0000052129.V364245.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints and safeguarding procedures contribute to the protection of residents. EVIDENCE: Anchor Trust has a complaints procedure that is displayed in the home and included in the statement of purpose and service user guide. The contact details of senior managers within Anchor Trust and the CSCI are included in the procedure. Relatives’ feedback was that they are familiar with the complaints procedure and would feel confident to use it if necessary. Residents said that they would discuss any problems with staff and would be happy to do so. A relative said that the response from the home to any concerns has always been in a ‘thoughtful and professional manner’. The Registered Manager described the action that had been taken in relation to a complaint received. The action taken was appropriate and a change in working practices was made to ensure that it would not recur. Anchor has safeguarding vulnerable adults and whistle blowing procedures, copies of which are available in the home. The procedures take account of policy and guidance in this area. They are based on sound principles aimed at the protection of people in their care. Incidents have been referred to the appropriate authorities for further investigation when necessary. The policy allows for the suspension of staff while investigations are carried out and eventual referral to the Protection of Vulnerable Adults (POVA) list when this is necessary. Blue Grove House DS0000052129.V364245.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents live in a clean, well-maintained environment, which is homely and suits their needs. EVIDENCE: The home is purpose built and is well maintained and decorated. Redecoration is planned for later in the year. There are three units, each with sixteen single en-suite bedrooms, a communal lounge and a communal dining area. Each unit has sufficient additional toilets and bathrooms. Each floor of the home is decorated in a different colour to help distinguish the units from each other. All of the communal areas are made homely with items such as ornaments and pictures. The furnishings in the home are good quality and appropriate for the residents’ needs. For example the chairs in all of the lounges are comfortable and appropriate for people who may have trouble standing from a low chair. There are occasional tables in the lounges so that residents can place items close to them. In addition to the units’ communal space there is an additional large Blue Grove House DS0000052129.V364245.R01.S.doc Version 5.2 Page 19 lounge, which is frequently used for activities and larger events. This room has doors leading to the garden. The Registered Manager said that there are plans to develop the garden so that it more closely meets residents’ needs. The garden is secure so that residents can use it safely. Throughout the building are handrails, which assist people, who may have mobility problems and sight impairment, to move safely around the building. A passenger lift allows easy access between the floors. The corridors are wide and brightly lit. Residents said that they are happy with their bedrooms. They may bring personal items to the home and this allows them to personalise their private areas. A resident commented that the member of staff who cleans her bedroom ‘works very hard’. The bedrooms and all areas of the building seen during our inspection were very clean and hygienic. Hand washing facilities are available throughout the building and staff are given information about infection control strategies as part of their induction to the home. There are laundry facilities, for residents to wash items if they wish to do so, and a separate room for laundry to be done on their behalf. The laundry facilities are a suitable distance from food preparation areas. Blue Grove House DS0000052129.V364245.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are enough staff on each shift to provide care for the residents. The recruit and training records must be improved so that we can verify that they are appropriately skilled and that recruitment practise protects residents. EVIDENCE: Records of shift plans showed that generally the staffing for each unit is as follows: • On Salter Unit in the morning there was 1 Team Leader working with 3 care staff; • On Steele Unit in the morning there was 1 Care Co-ordinator working with 3 care staff; • On Fox Unit in the morning there was 1 Team Leader working with 2 care staff. In the afternoon there was 1 shift leader for the whole building and three care staff on each unit. At night time a senior member of staff and three care staff are awake in the building to provide care for the residents. Observation and discussion with staff showed that these staffing levels are generally appropriate. There had previously been extensive use of agency staff. Comments received from relatives were that this had been a difficult time for the home as the temporary staff were unfamiliar with the needs of the residents. The feedback showed that some relatives lost confidence in the home to provide appropriate Blue Grove House DS0000052129.V364245.R01.S.doc Version 5.2 Page 21 care at that time. Now agency staff are not used at the home at all. Vacant posts have been filled, and staff from the Anchor care staff ‘bank’ now fill any gaps on the rota. Some people who are permanent employees at Bluegrove House work additional hours through the staff bank. This has ensured that people who care for residents are familiar with their needs and with the policies and procedures of Anchor Trust. There is a team of people who provide catering and cleaning for the home, an Administrator who assists with office based tasks, and an Activity Co-ordinator. There are 15 members of the care staff team who have achieved, or are working towards NVQ 2 or above. This is approximately 38 of the team, so, although the target figure of 50 of the team has not yet been reached, progress has been made. See requirement 2. At the time of the inspection visits the training records were not available for this to be adequately assessed. However, staff feedback was that, Anchor Trust provides good training opportunities and they felt equipped to carry out their duties. The AQAA also included some details of training that staff have undertaken, including specialist training in working with people with dementia, and in safeguarding issues. This issue will be addressed further at future inspections of the home. See recommendation 1. Six recruitment records were examined to ensure that all of the checks and references required by regulation were in place. The records were not in a good state, - only one of the six files had two written references on file; only two files had evidence of a CRB check on file and only three had a check of the POVA list evidenced. These points were raised with the Registered Manager who was confident that all of the references and checks had been obtained but they were not filed. On the final inspection visit the Registered Manager and a newly appointed Deputy Manager were working together to ensure that the recruitment records were in better order. This issue will be addressed at future random inspections of the home. See requirement 9. Blue Grove House DS0000052129.V364245.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37, 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Manager of the home has been registered under the Care Standards Act and has been assessed by CSCI as being appropriately experienced and is working towards achieving the Registered Manager’s Award. There are gaps in recording of health and safety checks, recruitment and training records and in notifying CSCI about some events in the home. All of these records are important in ensuring the protection of residents and must be improved. EVIDENCE: The Manager was appointed to her post in late December 2007. An application was made to the CSCI for her to be registered under the Care Standards Act 2000. The assessment process was underway at the time of the inspection and she was registered shortly after the inspection, this confirms that she is suitably experienced for the role. She has begun NVQ 4 & Registered Blue Grove House DS0000052129.V364245.R01.S.doc Version 5.2 Page 23 Managers Award training, and is due to complete the course in September 2008. Additionally, she has completed numerous in-house training courses. When the Registered Manager began work at Bluegrove House the post of Deputy Manager was vacant and it was filled during the inspection. It is anticipated that, now the management team is complete, management systems will improve. There are a number of quality assurance systems used to ensure to monitor the quality of the service. Senior managers from Anchor Homes visit the home each month and complete a report of their findings. The visits include discussion with residents and staff as well as an assessment of the premises and examination of records. A quality assurance system called ‘Hospitality Assured’ is used at Anchor homes. It includes a range of quality assessment measures. The reports of the outcome of the system were not examined during the inspection but will be examined at future inspections of the home. Residents who are unable to act for themselves in relation to their finances have their affairs managed by either family members or appointees. Only small amounts of cash are kept on behalf of residents, there are clear records of these and they are subject to audits by Anchor Trust. A small number of items are kept safely in the home on behalf of There is a recording system, which ensures accountability for items and out of the safe. These records were in good order; an additional would be for these records to be subject to management checks, verified by a signature. See recommendation 2. residents. booked in safeguard which are Some of the records were in poor order at the time of the inspection and some could not be adequately examined. These included the training and recruitment records, as noted above. It was also found that the CSCI had not been notified about some issues to which a regulation requiring notification applies. See requirement 10. The fire risk assessment was dated 25th March 2008 and the fire extinguishers were serviced in June 2007. It was difficult to locate some health and safety records. The last recorded fire training session took place in December 2006, and no record could be found of fire drills. After discussion with the Registered Manager she agreed to initiate a programme of fire drills and training in fire issues to ensure that all members of staff. The programme had begun by 2nd May 2008. The most recent test of the fire alarm seen was 3rd April 2008 prior to that they were weekly. The Registered Manager agreed to follow this up with the member of staff responsible for carrying out the tests, as she believed that the tests had been conducted but were not recorded. See requirement 11. Blue Grove House DS0000052129.V364245.R01.S.doc Version 5.2 Page 24 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 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 2 Blue Grove House DS0000052129.V364245.R01.S.doc Version 5.2 Page 25 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. 1. Standard OP7 Regulation 15 (2)(b) Timescale for action The Care Plans must be reviewed 01/07/08 and kept under constant review. This was made at the last key inspection and at a subsequent random inspection the date for compliance was 18/04/08. A new timescale for action is set. 2. OP28 18 (1a) The Registered Manager must take steps to ensure that at least 50 of staff working in the home are suitably qualified. This was made at the last key inspection and at a subsequent random inspection the date for compliance was 18/04/08. Progress has been made towards achieving the target. A new timescale for action is set. 3. OP9 13(2) The Registered Person must ensure that all prescribed medicines are available at the home and given as prescribed. DS0000052129.V364245.R01.S.doc Requirement 01/01/09 02/06/08 Blue Grove House Version 5.2 Page 26 This requirement was made at a random inspection, the date for compliance was 01/04/08, at this visit it was not met, although since then the Registered Manager has stated that it has been met. This will be verified at a random inspection. 4. OP9 13(2) The Registered Person must ensure that staff have had appropriate medication training and have been assessed as competent before they are given the responsibility to administer medicines. This requirement was made at a random inspection, the date for compliance was 18/04/08. Medication training was arranged for early May 2008. Compliance will be checked at a random inspection. 5. OP9 13(2) The Registered Person must ensure that regular medication audits are carried out so that issues with medication handling are picked up and addressed. This requirement was made at a random inspection; the date for compliance was 18/04/08. Although checks had been carried out, issues were not adequately addressed. Compliance will be checked at a random inspection. 6. OP7 13(4)(c) Documented risk assessments 01/09/08 must be conducted so that action can be taken to minimise risk to residents. DS0000052129.V364245.R01.S.doc Version 5.2 Page 27 02/06/08 02/06/08 Blue Grove House 7. OP7 12(4)(b) In order that residents’ cultural, linguistic and religious needs can be addressed, the care plans must include information about these areas of need and how they will be met. In order that residents’ safety is maintained when they are away from the home, each outing must be adequately staffed. So that the recruitment process can be verified as protecting residents, the required checks and references for staff must be on file. Notifications about incidents must be made to CSCI as required by regulation. In order to ensure the safety of residents and staff health and safety checks must be carried out at appropriate intervals and records kept in good order. 01/09/08 8. OP13 18(1)(a) 02/06/08 9. OP29 19(1)(b) 02/06/08 10. OP37 37 02/06/08 11. OP38 17(2) schedule 4 para 14. 23(4) (d)(e) 02/06/08 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 OP30 Good Practice Recommendations A training and development programme should be in place, along with records of staff training needs and achievements. In order to further safeguard residents’ interests, checks of the records of residents’ valuables kept on their behalf, should be verified by a signature. 2. OP35 Blue Grove House DS0000052129.V364245.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Blue Grove House DS0000052129.V364245.R01.S.doc Version 5.2 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!