Inspection on 19/12/06 for Ghyll Grove Residential and Nursing Home

This inspection was carried out on 19th December 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ghyll Grove Residential and... 05/02/08

Ghyll Grove Residential and... 07/03/06

Ghyll Grove Residential and... 07/03/06

Ghyll Grove Residential and... 07/03/06

Ghyll Grove Residential and... 07/02/06

Ghyll Grove Residential and... 08/06/05

Ghyll Grove Residential and... 07/06/05

Ghyll Grove Residential and... 07/06/05

Ghyll Grove Residential and... 14/09/04

Ghyll Grove Residential and... 27/05/04

Ghyll Grove Residential and... 14/01/04

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

CARE HOMES FOR OLDER PEOPLE Ghyll Grove Residential and Nursing Home Ghyllgrove Basildon Essex SS14 2LA Lead Inspector Carolyn Delaney Unannounced Inspection 08:00 19 December 2006 & 12 January 2007 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 Ghyll Grove Residential and Nursing Home DS0000015535.V316788.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. Ghyll Grove Residential and Nursing Home DS0000015535.V316788.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ghyll Grove Residential and Nursing Home Address Ghyllgrove Basildon Essex SS14 2LA 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) 01268 273173 01268 288289 www.bupa.com BUPA Care Homes (CFHCare) Limited Manager post vacant Care Home 150 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (150), of places Terminally ill (4) Ghyll Grove Residential and Nursing Home DS0000015535.V316788.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 4. Nursing and Personal Care to be provided for up to a maximum of one hundred and fifty (150) Older People. Nursing and Personal Care to be provided for up to a maximum of thirty (30) Older People who have a diagnosis of Dementia and who require nursing care Accommodation and Personal Care to be provided for up to a maximum of thirty (30) Older People who do not require nursing care and have a diagnosis of Dementia. Nursing Care for people who have a diagnosis of Dementia to be provided on Kennett House only. Accommodation and Personal Care for people who do not require nursing care and who have a diagnosis of Dementia to be provided on Thames House only. Nursing and personal care to be provided for up to a maximum of one person who is over the age of sixty years and under the age of sixty five years who has a diagnosis of Dementia. This person to be accommodated on Kennett House 7th March 2006 5. 6. 7. Date of last inspection Brief Description of the Service: Ghyllgrove provides accommodation and nursing care for up to a maximum of one hundred and fifty people who have a variety of nursing and care needs including up to a maximum of sixty people who have dementia. Accommodation is provided in five purpose built single storey houses each with a small garden/ patio area, which residents can access. All residents are accommodated in single bedrooms. The home is situated close to Basildon town centre in a mainly residential area. Ghyll Grove Residential and Nursing Home DS0000015535.V316788.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced Key Inspection carried out between 08.00 and 18.30 on 19th December 2006 and 12th January 2007. Records including assessments, care plans, daily care notes and risk assessment documents in respect of three people living at the home were examined. The relatives of thirty-four residents at the home were contacted by post so as to offer them the opportunity to make comments about the services provided by the home. Twenty responded. In addition the general practitioners who have patients living at the home were contacted. None responded. A number of residents and relatives who were visiting the home on both days of the inspection were spoken with. Seven members of staff including the homes manager were spoken with and a number of records including duty rota’s and staff recruitment files were examined. A tour of the premises was carried out and the serving of breakfast, lunch and supper were observed. Each of the Key Standards as identified in the intended outcomes sections of this report have been inspected during this Key Inspection. Other standards, which have not been assessed at this time, may be assessed at the next inspection visit. Where other standards have not been inspected on this occasion they will have been inspected at the previous inspections. Reports in respect of previous inspections may be accessed via the Commissions website www.csci.org.uk Below is a brief overview of the findings of the inspection, which are covered more fully throughout the main body of the report. What the service does well: Each of the twenty residents relatives who completed surveys said that they were happy with the overall care provided by the home. The majority of comments made by people about the home were very positive. One resident’s relative said that the care provided was ‘excellent.’ Another relative said that staff working at the home were very good and that they were ‘very satisfied with the care provided by the home.’ Ghyll Grove Residential and Nursing Home DS0000015535.V316788.R01.S.doc Version 5.2 Page 6 Staff at the home ensure that people are only offered a place at the home once a detailed assessment of their nursing and care needs has been carried out. While comments about the meals provided by the home were mixed the majority of comments were positive and there were some very complimentary comments made. The atmosphere and staff interaction observed on both Thames and Chelmer house was noted to be very positive. On both these houses staff interacted well and spent time engaging in conversation and participating in activities with residents and the atmosphere was relaxed and residents appeared happy. Staff are recruited robustly, trained and supervised so that protect the welfare of people living at the home. The acting manager has continued to make improvements in the way in which the home is managed. What has improved since the last inspection? What they could do better: More must be done so as to ensure that residents receive the medical treatment, which they require particularly when residents are at risk of or have developed pressure sores. More could be done so as to take into account the feelings and wishes of the people living at the home so that the care and routines of the home can be tailored to better meet their needs and expectations. The provision of recreation and occupational activities for people living at the home could be improved. Some residents and their relatives commented that more activities could be provided and that staff could spend more time with residents. Ghyll Grove Residential and Nursing Home DS0000015535.V316788.R01.S.doc Version 5.2 Page 7 The people who live at the home should be consulted about the type of activities they would like to participate in and the programme of activities should reflect the wishes and capabilities of residents. Some areas of the home are in need of redecoration and improvement so as to provide a more domestic and homely environment for the people who live there. In particular Kennett house lacks a homely feel and is somewhat ‘institutional’ in its layout and decoration. The numbers and skill mix of staff should be reviewed regularly in accordance with the needs and dependency levels of the people living at the home so as to ensure that so far as possible there are sufficient numbers of suitably skilled and qualified staff working at the home for the needs of residents. 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. Ghyll Grove Residential and Nursing Home DS0000015535.V316788.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 Ghyll Grove Residential and Nursing Home DS0000015535.V316788.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 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Ghyllgrove provides detailed information about the services provided by the home and there is a robust and consistent procedure for assessing peoples nursing and care needs so as to ensure that the placement will suit each individual. EVIDENCE: Each of the six residents / their relatives who completed ‘Have Your Say About…’ said that they had received enough information about the home before making a decision to move in. The decision to move into the home was made by relatives for three of the six residents. One of the resident’s relatives did that they had been offered the opportunity to visit and view the home at any time of their choosing. One relative commented that while they were provided with information about the home that reality of living there is ‘a different matter’ indicating that the actual experience of living at the home is not as good as the information would Ghyll Grove Residential and Nursing Home DS0000015535.V316788.R01.S.doc Version 5.2 Page 10 lead one to believe. However a number of people who were spoken with during the course of the two days of inspection indicated that they were happy living at the home. Five of the six people said that they had received a contract when they moved into the home. The other person did not answer this question. Staff at the home carry out an assessment of a persons nursing and care needs before a place at the home is offered. The assessments for four people living at the home were assessed. Each of the four assessments were well written and included detailed and specific information about the person they referred to. Ghyllgrove does not provide intermediate or rehabilitative care. Ghyll Grove Residential and Nursing Home DS0000015535.V316788.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. Resident’s personal and health needs are identified and staff plan care to meet these needs. However some staff do not ensure that risks to a persons health and welfare are managed properly or that residents receive the care and treatment, which is appropriate for their condition. EVIDENCE: Of the six residents who completed ‘Have Your Say About …’ surveys one said that they always receive the care and support they need, four said that they usually did and one said that they sometimes did. Care plans were sampled for people living on each of the five houses. In general care plans were well written in respect of a persons nursing and medical needs however there was little in the way of information recorded about peoples wishes for how they would like to spend their time, receive care and treatment and any particular preferences or dislikes. Ghyll Grove Residential and Nursing Home DS0000015535.V316788.R01.S.doc Version 5.2 Page 12 Of the twenty residents relatives who completed surveys seventeen said that they were kept informed of important matters about residents. Eighteen said that they were consulted if their relative was unable to make decisions about their care. One relative indicated that they felt there was a good partnership between the family and the home. Of the six residents who completed ‘Have Your Say About …’ surveys one said that they always receive the medical support that they need, two said they usually did and three said they sometimes did. One relative commented that they were ‘unsure whether a G.P or district nurse has seen Mum since she arrived at the home.’ Another relative commented that on two occasions when they spoke with staff about their mother’s deteriorating condition that staff failed to take action saying that ‘she was no different’. However the resident had suffered a stroke and was later admitted to hospital. The home has a system for assessing risks to a person’s health and welfare including assessing the risks to a person of developing pressure sores/ ulcers. However where people have been identified as being at particular risks there was little evidence in some instances to show that staff had taken the appropriate action such as monitoring the individuals condition and seeking specialist advice and treatment where the current treatment was ineffective. As a result a number of people at the home did not receive prompt and appropriate treatment for their pressure sores. The procedures for the receipt, storage, administration and disposal of medicines were assessed on Medway, Thames, Roding and Kennett houses. A sample of Medication Administration Records (MAR) were examined and staff were observed administering medicines to a number of residents. MAR, which were examined, were well maintained and there was evidence that staff administer medicines according to how they have been prescribed by the persons general practitioner. During both days of the inspection most people living at the home looked well cared for and staff were observed to carry out care in a manner, which respected the persons privacy and promoted dignity. However some people were noted to have dirty fingernails and stained clothing and being unable to attend to these needs independently were dependent on staff intervention, which was not always provided. Ghyll Grove Residential and Nursing Home DS0000015535.V316788.R01.S.doc Version 5.2 Page 13 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 adequate. This judgement has been made using available evidence including a visit to this service. More could be done so as to ensure that the people living at the home are supported in making decisions and participating in occupations and activities, which meet their needs. EVIDENCE: Of the six residents who completed ‘Have Your Say About …’ surveys one said that there were always activities arranged by the home, which they could participate, however that they were not the activities which they would choose to do. Of the remaining five two said that there usually were, one said that there sometimes were and one said that there were never activities, which they could participate in. During the two days of the inspection it was noted that the more capable and able people living at the home enjoyed a better range of activities and could make choices about how they spent their time. However those who were less able due to physical or mental deterioration were offered little in the way of occupation or means of stimulation. Some staff were seen to interact and Ghyll Grove Residential and Nursing Home DS0000015535.V316788.R01.S.doc Version 5.2 Page 14 spend time engaging in conversation and activities with residents. This was particularly good on Thames House and Chelmer House. However some staff on the other houses appeared disinterested and spent time chatting amongst themselves even at times when they were offering care and support to residents. A small number of residents were seen to be able to exercise control over their lives and to spend their days, as they would wish. For others staff made decisions for residents without consulting them even it was possible to do so. During both days of the inspection there were some planned activities on at least one of the five houses. However staff did not appear to be aware of what was available and where there were no planned activities staff appeared to be too busy to provide any opportunities for socialising and occupation for residents. Each of the twenty residents relatives who completed surveys said that they were welcomed into the home at any time and that they could visit their relative / friend in private. In addition to the above, one inspector completed an observation within Kennet House using a methodology called SOFI. This stands for Short Observation Framework for Inspection and is designed to record an observation during the inspection of care homes where people have dementia. The observation is designed to provide a first hand experience of sitting alongside people for 1-2 hours during a regular part of the day in a communal space within the care home. The observation aims to record individual residents state of mood, an insight into who and how they interact and an insight into staff interaction with residents during this time. These observations can be used alongside other information collected during an inspection to help inspectors assess the quality of care provided. During the 2 hour observation from 10.05 a.m. to 12.05 p.m. three residents were observed over 24 five minute time frames i.e. 10.05 a.m./10.10 a.m./10.15 a.m. etc. The outcome of the observation was that out of a possible 24 occasions all three residents were noted to have at least one positive mood state i.e. expressed signs of happiness/enjoyment and/or well being. In the same timeframe there were 28 occasions when all three residents were deemed passive i.e. no observable signs of positive or negative mood. There was only 1 occasion, when a resident appeared withdrawn i.e. awake but appeared to be in their own inner world. Two residents were observed to sleep for short periods of time during the observation. Out of 41 individual engagement/interactions by care staff with residents, only 4 were seen to be positive i.e. gave the resident eye contact, interacted appropriately with the resident, waited for a response from the resident etc. In the main staff interactions were observed to be task orientated i.e. taking someone to the toilet/giving someone a drink. Interactions by staff were in Ghyll Grove Residential and Nursing Home DS0000015535.V316788.R01.S.doc Version 5.2 Page 15 general observed to be neutral with few good interactions and some poor interactions. The observation of the inspector was that care staff are very busy with tasks and are unable to spend quality time with individual residents. Residents were observed to be ignored and there were few verbal interactions/non verbal interactions i.e. words of comfort/a smile/a touch of the hand etc. At the time of the observation the activities co-ordinator was providing activities/stimulation for residents. The observations noted were that some activities provided are inappropriate for some residents because of their poor cognitive ability and mental capacity. Where a resident was unable to respond verbally or act quickly, a response or action was not waited for and pursued by the activities co-ordinator. Of the six residents who completed ‘Have Your Say About …’ surveys two said that they always liked the meals at the home. One person commented that the ‘range of food was excellent, the portions were a good size and healthy.’ Of the remaining four one said that they usually like the meals, one said that they sometimes did and two said that they never did. One relative commented that the menu mainly consisted of minced beef, chicken nuggets and burgers and that there was little variety in the salads offered. During both days of the inspection there was a choice of meals offered for both lunch and evening meals. Residents were offered hot and cold drinks and snacks in between meals. Most of the residents who were spoken with during the inspection visit said that the food was good. Residents were offered a three-course lunch and supper and staff assisted and supported residents according to their needs. However on Roding house staff were noted to offer little encouragement or support to one resident who was unable to feed themselves. Ghyll Grove Residential and Nursing Home DS0000015535.V316788.R01.S.doc Version 5.2 Page 16 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 adequate. This judgement has been made using available evidence including a visit to this service. Ghyllgrove has policies, procedures and systems in place for dealing with complaints and protecting the people who live there from harm, abuse and neglect. Generally these systems work well but occasionally staff fail to act in accordance with them, which results in poor practices, and poor care provision to residents. EVIDENCE: Ghyllgrove has a policy and procedure for dealing with complaints. Six of the twenty residents relatives who completed surveys said that they were not aware of the homes complaints procedure. Each of these said that they had not had cause to make complaint. Each of the six people who completed ‘Have Your Say About…’ surveys said that they always knew who to speak with if they were unhappy, and how to make a complaint. Of the five one person said that they had complained about items of clothing being ‘ruined’ in the laundry and other items going missing. However the resident received no response from the staff or the homes manager in respect of the complaint made. Fourteen of the twenty residents relatives who completed surveys said that they were aware of the homes complaints procedure, seven said that they had Ghyll Grove Residential and Nursing Home DS0000015535.V316788.R01.S.doc Version 5.2 Page 17 made complaints. The majority of these people did not include specific information regarding the complaints made. Three people said that their complaints had been in respect of laundry and clothing going missing. One person had complained about the quality of the food and one person complained that ‘things have gone missing from their room’. One of the thirteen said that the issues had been dealt with well. There has been a marked reduction in the number and seriousness of complaints made about the care that people living at the home receive since the current acting manager has been employed at the home. Ghyllgrove has a policy and procedure for dealing with the protection of people living at the home from being subjected to abuse, harm or neglect. Since the last key inspection there have been two PoVA alerts raised in respect of the home. Both of these are regarding staff’s failure to manage and treat resident’s pressure sores in an appropriate and effective manner. This is of concern as there has been a similar incident at the home, which was investigated under PoVA within the last two years. However proper and prompt action was taken once these issues were raised and the homes acting manager and the BUPA’s operations manager for the home have taken action and introduced measures including a more open and effective working relationship with the local tissue viability specialist nurses so as to ensure that nursing staff working at the home refer people for specialist advice and treatment promptly as required. Ghyll Grove Residential and Nursing Home DS0000015535.V316788.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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Ghyllgrove is well maintained and some areas are homely and nicely decorated. However there were odours in some areas and some communal areas are not homely in nature EVIDENCE: Each of the five houses are purpose build single storey units, which can accommodate up to thirty people. All residents have their own bedroom. The home employs maintenance staff to ensure that all areas are kept in a good order and that repair and replacements of furniture, fixtures and equipment is carried out promptly so as to minimise the risks to people living at the home. Ghyll Grove Residential and Nursing Home DS0000015535.V316788.R01.S.doc Version 5.2 Page 19 Some of the communal areas have been recently refurbished and are very homely. In particular Thames house has comfortable sitting and dining areas and the house is nicely decorated. The other houses vary and in particular Kennett House is very stark and bare with very little in the way of decoration. Of the six residents who completed ‘Have Your Say About …’ surveys five said that the home is always fresh and clean. The other person said that it sometimes is. Some people commented that the toilets could be cleaned and checked more regularly. One person said that their room is not always cleaned properly. One person said that the replacement of carpets in the corridor had helped to reduce the smell in the home. During the two days of the inspection, isolated odours were detected in some areas of Roding house, which were persistent throughout the day. Ghyll Grove Residential and Nursing Home DS0000015535.V316788.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, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels are not always reviewed in accordance with the changing needs of the people who live at the home so as to ensure their needs can be met. Staff are recruited in a consistent and robust manner. Staff are provided with training for the roles they are to perform and the needs of the people who live at the home EVIDENCE: Each of the six residents who completed ‘Have Your Say About …’ surveys said that staff were usually available when needed. One person commented that ‘staff frequently gave the impression that they were short staffed which is why certain things were not done.’ Thirteen of the twenty residents relatives who completed surveys said that in their opinion there were always sufficient numbers of staff on duty. During the inspection visits the staff duty rotas were examined on ach of the five houses. There was not always evidence that where staff were absent due to sickness etc that replacement cover had been provided and a number of Ghyll Grove Residential and Nursing Home DS0000015535.V316788.R01.S.doc Version 5.2 Page 21 staff said they were often ‘short staffed.’ Some of the staff duty rotas did not include the full name of staff working at the home. The recruitment files for two members of staff who had been recruited to work at the home since the last key inspection were assessed. There was evidence that all of the checks in respect of identity, skills and experience and suitability to work with older people had been carried out prior to these people commencing work at the home. There was also evidence that upon commencing work at the home that staff complete a detailed induction period. There was evidence that all staff working at the home undertake periodic training updates for safe moving and handling, fire safety and Protection of vulnerable adults. There is also a programme for other more specialised training including care planning, pressure area management and training in respect of a number of illness and conditions associated with the ageing process. Ghyll Grove Residential and Nursing Home DS0000015535.V316788.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, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Ghyllgrove is a well managed home. However some work needs to be done so as to ensure that staff work in accordance EVIDENCE: The homes acting manager has been employed at the home for approximately eighteen months and has been instrumental in implementing a number of improvements at the home, notably a reduction in the number and seriousness of complaints made in respect of the care and services provided. Ghyll Grove Residential and Nursing Home DS0000015535.V316788.R01.S.doc Version 5.2 Page 23 The home is generally well managed however there are a number of areas (as described throughout this report) where it is not evident that the home is managed in the best interests of the people who live there. People who live at Ghyllgrove have the option of retaining their monies and valuables however they may if they choose to hand over monies and valuables for safekeeping. Where monies are held on behalf of residents there are detailed records maintained which are regularly audited so as to minimise the risk of mishandling. Staff working at the home are supervised so as to monitor care practices and to ensure that staff are aware of work in accordance with the homes policies and procedures. There are detailed records available in respect of the repair, maintenance and replacement of the electrical, gas, fire and mechanical systems and equipment in the home so as to protect the residents, those who work in and visit the home. Ghyll Grove Residential and Nursing Home DS0000015535.V316788.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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 3 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Ghyll Grove Residential and Nursing Home DS0000015535.V316788.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(2) Requirement Care plans in respect of the care and treatment, which people living at the home are to receive, must be reviewed and revised as necessary and in accordance with any changes to the care and treatment to be provided. People living at the home must have access to treatment and care in accordance to their particular healthcare needs. Residents must be wherever it is practicable, consulted about the programme of activities and opportunities for socialising, recreation and occupation and their wishes should be reflected in the range of activities provided by the home. Staff must carry out their duties in accordance with the homes policies, procedures and any other systems in place so as to minimise the risk to residents of harm, abuse and neglect Staffing levels must be reviewed so as to ensure that staff are employed in sufficient numbers to meet the needs of the people DS0000015535.V316788.R01.S.doc Timescale for action 30/04/07 2 OP8 13(1) (a) (b) 16(2) (n) 30/04/07 3 OP12 31/05/07 4 OP18 13(6) 30/04/07 5 OP27 18(1) (a) 30/04/07 Ghyll Grove Residential and Nursing Home Version 5.2 Page 26 living at the home 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 OP7 Good Practice Recommendations Care plans should include details of each individuals preferences for how they spend their time and any preferences or dislikes they may have in relation to daily activities of living. More should be done so as to ensure that all people living at the home receive a satisfactory standard of care in relation to their personal hygiene needs. Care plans and other information recorded for people who are nearing the end of their lives should be more individualised to reflect the person’s particular wishes. More should be done so as to ensure that people living at the home are supported in making choices about their lives, how they spend their time and how they receive care and treatment. The communal areas could be made more domestic and homely. 2. 3 4 OP10 OP11 OP14 5 OP19 Ghyll Grove Residential and Nursing Home DS0000015535.V316788.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Ghyll Grove Residential and Nursing Home DS0000015535.V316788.R01.S.doc Version 5.2 Page 28 - 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!