Inspection on 25/03/09 for Blue Grove House

This inspection was carried out on 25th March 2009.

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 24/04/08

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 09/07/2009.

CARE HOMES FOR OLDER PEOPLE Blue Grove House 325 Southwark Park Road London SE16 2JN Lead Inspector Ms Alison Pritchard Key Unannounced Inspection 10:50a 25 & 26 March & 22nd April 2009 th th 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.V374586.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.V374586.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 connie.oppong@anchor.org.uk www.anchor.org.uk Anchor Trust Post vacant 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.V374586.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 24th April 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 early May 2009 there were 43 residents in the home. The weekly fees for a placement at the home range between £531 and £624. 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.V374586.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 one star. This means the people who use this service experience adequate quality outcomes. This inspection was unannounced and carried out over three days in March and April 2009. The inspection methods included observation of care practice, discussion with the people who live in the home and with staff and inspection of a range of records. Care plans were checked and aspects of care were examined by case tracking. The views of service users, relatives, staff and involved professionals were sought and taken into account in compiling this report. We are grateful for the contributions of everyone who responded to surveys and all of the people who spoke to us during the inspection visits. The CQC has access to information gathered through notifications from the home. A document called an ‘Annual Quality Assurance Assessment’ (AQAA) was completed by the 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. Shortly before this inspection the previously Registered Manager of the home left her post so was unavailable to assist with this inspection. The Deputy Manager, a Registered Manager from another Anchor home and staff from the Bluegrove House facilitated the inspection visit; they were helpful and courteous throughout the process. What the service does well: We were told by people on all floors of the home that the staff are helpful and respond quickly when they use the call bell to ask for assistance. Several people said that they are pleased that the home is kept very clean. One person said ‘it’s a wonder the carpet doesn’t wear out it is cleaned so often’. Another person said ‘It is really fine, I like my room, really clean.’ Many of the people we spoke to said that they are pleased that they have en-suite facilities. Relatives of people who live at the home told us that they are pleased with the care their relative receives. They said that they can visit freely and are kept informed about important matters. Blue Grove House DS0000052129.V374586.R01.S.doc Version 5.2 Page 6 Many of the people who we talked to said that the meals are very good. One person described them as ‘the best.’ Several people praised the staff, one person said ‘everybody is so kind to me’. The people who live at Bluegrove benefit from a garden which is easily accessed from the ground floor. A gardener / handyperson has recently been employed and will be maintaining the garden in a safe and attractive condition. Visitors from a local Church hold Church services in the home. One person said that she is pleased she is able to take Communion on these visits. What has improved since the last inspection? What they could do better: There were three issues which raised at the last inspection, and not met on this visit. • At the time of the inspection the home had not informed the CSCI (now CQC) of a range of matters which they are required by regulation to do. We made a requirement on the day of our first visit about this. More notifications have been made since then. • Care plans need to contain more detail of the cultural, religious and linguistic needs of the people who live at the home, along with details of how the home intends to meet them. • Care plans need to be reviewed at a minimum of monthly intervals, although some had been done, not all met this standard. Blue Grove House DS0000052129.V374586.R01.S.doc Version 5.2 Page 7 Other matters which we found needed improvement are: • On admission to the home a person’s risk of developing pressure sores needs to be assessed to make sure that the appropriate action is taken to minimise the risk. • Senior staff should monitor the residents’ weight monitoring charts to make sure they are correct and necessary action is taken in response to changes. • Medical assistance must be sought promptly when a resident complains of pain and there are signs that they are injured. • Entries on care notes must be made in a professional and respectful manner. • Staff should receive management guidance on how care notes must be used to monitor residents’ health and well being. • Written information must be available for staff on the circumstances in which medication given on an ‘as needed’ basis is required. • Records of complaints must be full and detailed. • Lists of residents’ property must be complete and updated regularly. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Blue Grove House DS0000052129.V374586.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.V374586.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. Standard 6 is not applicable. Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. People thinking of coming to live at Bluegrove House are able to gather enough information to decide whether it will be a good move. The staff at the home also take care to gather the right information to assess whether they can meets the person’s needs. this means that it is more likely that the placement will go well. EVIDENCE: People who are considering moving to Bluegrove House and their family have the opportunity to visit the home before they move in, as do other people who are acting on their behalf. We were told that, as well as having the chance to talk about the home, written information is given to them when they visit. This allows them to make an informed choice about whether it will be a suitable placement for the person to move to. The admission process includes obtaining a full assessment from the person’s social worker. Senior staff from the home also carry out an assessment to make sure that they feel that the home can meet the person’s needs. Blue Grove House DS0000052129.V374586.R01.S.doc Version 5.2 Page 10 The service user guide has information about the admission procedure. It states that six weeks after a person has moved to the home a planning meeting will be held with the person, their family and anyone else involved with their care to make sure that they are satisfied with the way they are looking after them. Bluegrove House provides places in a unit on the top floor of the home which it describes as a ‘step up / step down’ placement. It provides short term care as a step between hospital and home, or if that is not possible a longer term placement may be arranged. The unit is not described as an intermediate care placement, and it does not have the full range of facilities available to provide this specialist care. Standard 6 is not applicable. Blue Grove House DS0000052129.V374586.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 people who live at the home will benefit from improvement to care planning and health care arrangements. Although care plans contain a good range of the person’s needs, and are signed by them, or a relative, they must be reviewed at least once a month. They must also include details of the person’s social, religious and linguistic needs. Some improvements are needed to the way that care notes are made. Assessments of the risks of the people who live at the home developing pressure sores will ensure that they are provided with equipment which may prevent this. People who live at the home are usually able to see health care professionals when they need to; but there was one instance when the advice of medical professionals had not been sought when it was required. Although there have been improvements to the management of medication, written guidance is needed about when to give medication given on an ‘as needed’ basis. Blue Grove House DS0000052129.V374586.R01.S.doc Version 5.2 Page 12 EVIDENCE: We looked at a range of care plans on all three floors of the home, eight in total. There were care plans for a range of relevant issues for each service user. Care plans included reference to physical, medical and social issues and we noted that, in many cases, the plans had been signed by the person concerned, or by a relative, indicating their agreement. In some cases we found that the appropriate assessments had not been completed resulting in a gap in the care planning. One example was a person whose risk of developing pressure sores had not been assessed at the time of their admission to the home. The person was found to have developed a pressure sore approximately five weeks after their admission to the home. The assistance of community nursing services was sought appropriately and the necessary equipment supplied. Pre-emptive action triggered by a risk assessment may have been important in preventing this problem. See requirement. Although in some cases the care plans were reviewed monthly as required, others were not. An example of this was a person whose care plan about her diet had not been reviewed since October 2008, and her dietary assessment was undated. The same person’s risk in relation to pressure care had no record of review since 2007. See requirement. We found that a weight-monitoring chart showed that a person had lost a significant amount of weight in a short period. There was no care plan to address this, nor any reference to action, which had been taken as a result. The Deputy Manager was told about this concern on the day of the inspection visit so that the matter could be investigated. He has since informed us that investigations proved that there was a recording error and the person was not at risk. On the first day of inspection staff were receiving training in nutritional needs and weight monitoring. This should assist in ensuring that staff are aware of the action to take if it appears that someone has lost weight without apparent reason. Monitoring by senior staff of these issues is recommended to ensure that the welfare of the people who live at Bluegrove is promoted. See recommendation During the inspection we heard of a person who had bruising and was complaining of pain. We were concerned to find that, although this had been noticed during the morning of one of our visits, by 2pm medical attention had not been sought. The injury was judged to be related to a fall some days earlier. We passed this concern to the Deputy Manager who contacted the GP and further investigations, including an x-ray, were arranged. It is required that a more proactive approach is taken to such injuries to ensure that Blue Grove House DS0000052129.V374586.R01.S.doc Version 5.2 Page 13 concerns are followed up comprehensively to protect the people living at the home. See requirement. We looked at the care plan of a person who has high care needs. We found good records of contact with health care professionals and indications that a good range of professionals are involved, including community nursing services, psychiatric professionals and speech and language therapists. We found that improvements are needed to the recording of important information about the welfare and progress of people who live at the home. On one file we found that a service user had been described as ‘very weak’. This entry was made ten days before the date of our visit, no further entries had been made on the record regarding the person’s health and well being. In the same record an entry on 23rd March stated that the person needed close observation, there were no detailed notes after this, one entry stated ‘personal care given’ with no further details. This showed little understanding of the purpose and value of recording systems. In another case we found that a service user had been described as ‘obstinate’ and a comment was made that ‘she refused to yield’. This entry demonstrated a lack of respect for the service user. See requirement. We checked medication arrangements on all three floors of the home. There was a significant improvement since our last visit in April 2008. People who wish and are able to look after their own medication are supported to do so. The majority of the records had a photograph for identification purposes, some of the ones that did not were people who had been recently admitted. Information about allergies was recorded in most cases but there were some gaps in this area on each floor of the home. We noted that a senior staff member had clarified dosage details with a GP when the instructions for a medication were insufficiently clear. The member of staff we spoke to about this was able to explain the reason for the medicine being given. In one case the information about when to give a medication prescribed on an ‘as needed’ basis was not adequately recorded: there was no information in the medication file or in the person’s care plan. In some cases there was a list of the resident’s currently prescribed medication and the reason for it being prescribed (a medication profile); this would be useful in each case for staff reference. See requirement. People who live at the home said that they are able to have privacy, for example by choosing to spend time in their rooms when they wish. All of the people we saw in the home were well dressed and their appearance enhanced their dignity. A hairdresser visits the home regularly and an appropriately Blue Grove House DS0000052129.V374586.R01.S.doc Version 5.2 Page 14 equipped room is available for her use. The service user guide gives a commitment to respecting each person’s individuality. Blue Grove House DS0000052129.V374586.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A newly appointed activity co-ordinator is developing an activity programme for the home. There are a number of activities which people who live at Bluegrove House enjoy, including musical entertainment, church services, games and art activities. People who live at the home said that they enjoy the meals and can have choice, including meals which reflect their cultures. EVIDENCE: An activity co-ordinator has recently been appointed after a long time without anyone in this position. The post holder was previously a member of the care staff team, so is familiar to and with people who live at the home. The files of the people who live at the home varied in the degree of detail they contained about their interests and social needs. Some included information about their interests and social history and details of how these needs would be addressed by Bluegrove House. Other files did not include details of their interests, if they wished to follow specific activities. Some files included information about how the person wished to express their religion and cultural activities, others had less detail recorded. Representatives Blue Grove House DS0000052129.V374586.R01.S.doc Version 5.2 Page 16 of a local church make weekly visits to the home. One person told us that she particularly appreciated the opportunity to take Communion when the visits are made. Musical entertainers visit the home occasionally and provide musical sessions in the activity room on the ground floor. Other activities include games, art sessions and discussion groups. There is a garden to the rear of the home. It is anticipated that it will be used for activities in the warmer weather. A fish pond provides a focal point. We were told that school children made visits to the home at Christmas. The information we received before the inspection stated that an action plan will be developed to encourage more community involvement for the people who live at the home. This is welcomed as some people commented that they would like to go out more often. Some people are able to go out independently and no unnecessary restriction is made to their activities. The lack of risk assessments relating to people who wished to go out but were unable to do so safely was a concern at the last inspection. The AQAA stated that the area of risk assessment is to be improved to ensure that people’s chosen lifestyles are not made unnecessarily. Friends and family are able to visit freely and we met several people who came to visit the home. They said that they are welcomed and felt comfortable coming to visit. We were also told that family members are kept informed about important issues to do with their relative. Each of the three units has a dining room with tables for groups of four people. The rooms are light and airy and tables are dressed with linen. There is a kitchen area next to each dining room where drinks can be made, breakfasts and snacks prepared. The main meals are prepared in the kitchen on the ground floor and brought to the units in a hot trolley. People who live at the home said that they enjoy the meals, can make choices and generally there is an option available that they like. The menu includes meals which meet the cultural needs of the people who live at the home, and dietary needs are accounted for. There are Caribbean dishes available as alternatives as well as traditional British dishes. The meals include fresh dishes. The cook at the home is familiar with the tastes of the people who live there, for instance they are able to identify which resident groups prefer fruit rather than cake and will provide meals to reflect their wishes. Blue Grove House DS0000052129.V374586.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people who live at the home know how to complain and are confident it will be dealt with properly. Records need to be kept in better order so that there is evidence of the action taken to investigate and, if appropriate, to make improvements. Notifications required to be made to the CSCI (now CQC) had not been made with consistency, despite this being required at our last inspection. Property lists need to be complete up to date and kept to protect the interests of the people who live in the home. EVIDENCE: Anchor Trust has a complaints procedure, which is displayed in the home and included in the statement of purpose and the service user guide. The contact details of senior managers in Anchor Trust are included in the procedure. People who live at the home said that they would feel confident to raise concerns with staff. The information we were given on the AQAA received prior to the inspection was that there were seven upheld complaints in the year before the form was completed. We looked at the records of complaints held in the home and found that they were not maintained well. Examples of the issues we identified were that there was no information recorded about how complaints were Blue Grove House DS0000052129.V374586.R01.S.doc Version 5.2 Page 18 investigated; some, but not all, complaints did not include acknowledgement of the complaints; some complaints were undated and one did not include information about whether they were found to be upheld or not. It is required that records of complaints and the action taken in response is kept in better order and available for inspection. See requirement. Anchor Trust has a safeguarding and a whistle-blowing procedure and works in co-operation with Southwark Health and Social Services in cases which raise concerns about service users’ safety. The policies allow for the suspension of staff to allow for investigation and referral to the Protection of Vulnerable Adults list (POVA) when necessary. Staff may raise concerns with Anchor Trust through an ‘alert line’ and they are informed of this through publicity in the home. A care specialist has been appointed within Anchor Trust to take a lead on safeguarding issues, monitor complaints and other quality assurance indicators. At the time of the inspection the home had not informed the CSCI (now CQC) of a range of matters which they are required by regulation to do. We made a requirement on the day of our first visit about this. More notifications have been made since then. The majority of staff have received training in safeguarding issues. Staff were clear about the action to take in the event that they observe inappropriate care being provided. We looked at the property lists on the files of people who live at the home. In some cases the lists of property were incomplete, some listed only residents’ clothes, not their other possessions. In order to protect residents’ interests these lists need to be complete, updated regularly and be seen as part of the home’s safeguarding strategy. See requirement. Blue Grove House DS0000052129.V374586.R01.S.doc Version 5.2 Page 19 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, 23, 24, 25, 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is safe, homely, clean and appropriate for the needs of the people who live there. EVIDENCE: The home is purpose built and is well maintained and decorated. 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 Blue Grove House DS0000052129.V374586.R01.S.doc Version 5.2 Page 20 them. In addition to the units’ communal space there is an additional large lounge, which is frequently used for activities and larger events. This room has doors leading to the garden. The garden is secure so that residents can use it safely. Since we last visited a gardener has been employed and discussion with her showed that she understands the needs of residents to have a safe and attractive space outside. 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. People who live at the home who we spoke to said that they are happy with their bedrooms. They may bring personal items to the home and this allows them to personalise their bedrooms. Several people said that they particularly like having en-suite facilities. 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.V374586.R01.S.doc Version 5.2 Page 21 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 good. This judgement has been made using available evidence including a visit to this service. There are enough staff to provide good quality care for the people who live at the home. They are well trained. Care needs to be taken to ensure that vacancies on the domestic staff team do not affect other members of staff so that they cannot carry out their own work. Staff recruitment is safe and thorough. EVIDENCE: On each unit there are three members of staff working throughout the day. During the week, in office hours, there is at least one member of the management team (Deputy or Interim Manager) in charge. In the evenings and at weekends there is also a shift leader in charge of the building and to whom other staff may go for advice. At night time there is a senior member of staff and three care staff awake in the building. There are additional staff to cover catering duties, administrative work, cleaning and maintenance. We were concerned to find that there is currently only one cleaner employed at the home, rather than, as previously, three, one for each floor of the home. Cleaning is done by care staff on the floors where there are vacancies, as is the laundry, sometimes the maintenance worker covers the cleaning duties. We were told that, sometimes, additional care staff are on duty to cover cleaning duties. The managers of the home must monitor this. The purpose of monitoring is to ensure that the additional duties do not have an impact on the quality of care or on essential maintenance duties. Blue Grove House DS0000052129.V374586.R01.S.doc Version 5.2 Page 22 It is anticipated that these cleaning posts will be filled shortly as recruitment was underway at the time of the inspection visits. There are no vacancies on the care staff team. At the time the AQAA was completed there were 36 permanent care staff, and 12 bank care staff. Of these 35 staff hold, or are working towards NVQ level 2 or above. This represents 73 of the total care staff team. This is an improvement on numbers qualified at the time of the last inspection. The additional training undertaken by staff includes care planning; dementia care; diabetes; pressure care; nutritional screening; safeguarding; food hygiene and medication. This is a good range of relevant training topics and will benefit the people who live at the home. We checked five recruitment records when we visited the home and were provided with information shortly after our visit. This confirmed that the recruitment practice is thorough, includes the correct range of checks and references and contributes to maintaining the safety of the people who live in the home. This is an improvement on our findings when we last visited the home. Blue Grove House DS0000052129.V374586.R01.S.doc Version 5.2 Page 23 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, 36, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements pending the appointment of a permanent manager of the home are suitable and staff expressed confidence in them. There are quality assurance systems designed to assess the quality of the service. Health and safety matters are well managed. More staff being trained in infection control measures would be beneficial for the people who live at Bluegrove House. EVIDENCE: At the time of the inspection the previously Registered Manager had recently left her post at the home. Interim management arrangements were made, with the Registered Manager of another Anchor Home providing management Blue Grove House DS0000052129.V374586.R01.S.doc Version 5.2 Page 24 support and working alongside the Deputy Manager. Recruitment to the vacant post was underway at the time of our final visit of the inspection. We were pleased that this had been addressed quickly so that the home benefits from permanent management and leadership. There are a number of quality assurance systems used to monitor the quality of the service. Senior managers from Anchor Trust visit the home each month and complete a report of their visit. Anchor Trust has a procedure to ensure that, in cases where they are responsible for the financial affairs of people who live in the home, safeguards are in place and their interests are protected. An area for improvement is the frequency with which staff are supervised. This had been identified by the interim Manager of the home and she has drawn up a supervision schedule. Team building days have been held over the last year to ensure that the staff team are working well together. We heard that recent staff meetings have been important in establishing communication among the team. We looked at a selection of health and safety records, particularly the fire safety records. We found that a date is scheduled for the review of the fire risk assessment (7th April 2009); that weekly checks of the fire alarm systems and emergency lights are made and that the fire extinguishers have been serviced within the last year. A fire drill took place on the day before our first visit, they are conducted at regular intervals. We were provided with satisfactory information about other health and safety checks carried out in the home. Staff have undertaken a range of training courses which are relevant to maintaining safety in the home. These include back care; food hygiene and infection control. We noted that only four staff have received infection control training and recommend that this be extended to more members of the staff team. Blue Grove House DS0000052129.V374586.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 3 3 X 4 4 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 2 3 Blue Grove House DS0000052129.V374586.R01.S.doc Version 5.2 Page 26 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) Requirement The care plans must be reviewed and kept under constant review. Some progress has been achieved in this are. A new timescale for action is set to allow it to be achieved for all care plans. 2. 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. Some progress has been achieved in this are. A new timescale for action is set to allow it to be achieved for all care plans. 3. OP37 OP18 37 Notifications about incidents must be made to CSCI as required by regulation. An immediate requirement was made about this matter on the first day of our visit to the home. Blue Grove House DS0000052129.V374586.R01.S.doc Version 5.2 Page 27 Timescale for action 01/07/09 01/07/09 26/03/09 4. OP8 13(4)(c) An assessment of the risk of a person developing pressure sores must be conducted on a person’s admission to the home. This will ensure that appropriate action is taken to minimise the risk. 01/07/09 5. OP8 13(1)(b) Medical advice must be sought when a resident complains of pain and has signs of an injury. This will ensure the health and well being of all of the people living in the home. 01/06/09 6. OP7 18(c)(i) Staff must receive management guidance and training about the purpose and value of recording and how to make notes in a respectful and professional manner. This will ensure that recording systems contribute to the provision of good quality care. 01/07/09 7. OP9 13(2) There must be written guidance available for staff about the circumstances in which medication given on an ‘as needed’ basis is required. This will ensure that prescriber’s instructions are followed consistently and ensure residents’ health care needs are met. 01/06/09 8. OP16 22, 17(2) schedule 4, para 11 The records of complaints must include the date they were made; acknowledgement of the complaint to the complainant; information about whether they were found to be upheld and the action taken in response. 01/06/09 Blue Grove House DS0000052129.V374586.R01.S.doc Version 5.2 Page 28 This will ensure that the complaints are dealt with thoroughly and according to the regulatory requirements. 9. OP18 13(6) Lists of property belonging to people who live in the home must be complete and updated regularly. This will protect the interests of the people who live in the home. 01/07/09 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 OP8 Good Practice Recommendations Senior staff should ensure that weight monitoring charts are correctly completed and that variations in weight are responded to appropriately. This will help to ensure the health and well being of the people who live in the home. 2. OP38 Training in infection control should be offered to more members of the care staff team. This will ensure that they are fully aware of the range of measures needed to maintain safe conditions in the home. Blue Grove House DS0000052129.V374586.R01.S.doc Version 5.2 Page 29 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.V374586.R01.S.doc Version 5.2 Page 30 - 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!