Inspection on 05/02/08 for Ghyll Grove Residential and Nursing Home

This inspection was carried out on 5th February 2008.

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

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... 19/12/06

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 Pauline Marshall 5 &6 th th Unannounced Inspection February 2008 08:45 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.V359392.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.V359392.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) Ltd Adrienne Gean Welton 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.V359392.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. 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 four (4) people who are over the age of fifty-five years and who have a diagnosed Terminal Illness. 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 Nursing care for people who have a diagnosed Terminal Illness to be provided on Roding House only. 19th December 2006 8. Date of last inspection Brief Description of the Service: Ghyll Grove 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. All prospective residents are provided with a Statement of Purpose and Service User Guide that supplies them with up to date information on the home. Fees range from £436.00 to £680.00 and there are additional charges for Ghyll Grove Residential and Nursing Home DS0000015535.V359392.R01.S.doc Version 5.2 Page 5 hairdressing, chiropodist and newspapers. Ghyll Grove Residential and Nursing Home DS0000015535.V359392.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This was an unannounced key inspection that took place over a two-day period and was carried out by two inspectors. The process included discussions with the manager, staff and people who live at the home. A random sample of policies, procedures, safety records, staff and residents’ files were examined and a tour of the premises took place. The manager completed and returned the an annual quality assurance assessment (AQAA) and this has been used throughout the report. Surveys were sent to people living in the home, their relatives, health and social care professionals associated with the home and staff that work there,e to obtain their views on the service the home provides. The response was very positive and comments from these surveys have been used throughout the report. All of the key standards were inspected. What the service does well: The manager deals effectively with people’s complaints and there is plenty of information displayed around the houses that explains the complaints process. The home provides good quality accommodation and the furniture and fittings are in a good state of repair. The rolling programme for refurbishment is clear and the decoration and maintenance of all five houses is good. Staff is well trained and are given the opportunity to gain a recognised NVQ qualification. The manager provides each individual house with a good level of staff that has the correct skills to meet the needs of the people that live there. People who live in the home said, “ the home is wonderful, I can’t praise staff enough, I feel safe here and it’s a nice happy atmosphere”. The relatives of people living in the home said, “ I’m very impressed with the home, the care is very good and I feel very welcome” and “ I couldn’t fault it here, the home is always very clean and the laundry service is very good”. Ghyll Grove Residential and Nursing Home DS0000015535.V359392.R01.S.doc Version 5.2 Page 7 Ghyll Grove has a very experienced manager who constantly updates her knowledge and skills and provides the staff team with clear leadership and direction. What has improved since the last inspection? What they could do better: Staff must take action when they discover the temperatures are not right for storing medication. Staff must make sure that when different doses of painkillers are given it is accurately recorded on the administration records. When employing new staff the application forms must be checked more thoroughly for any gaps in the applicants’ employment record and if any are identified the manager must explore the reasons why. The application form asks applicants their reasons for leaving their previous employment and some of the applicants did not state their reasons; the manager must make sure that all application forms are fully completed and that any gaps are looked into. Evidence of staff fitness should be held for all staff working at the home. All staff should receive regular formal supervision from their line manager to provide them with a good support system. All staff should have regular fire drill practice to ensure that they are competent to act appropriately if a fire occurred in the building they are working in. Ghyll Grove Residential and Nursing Home DS0000015535.V359392.R01.S.doc Version 5.2 Page 8 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.V359392.R01.S.doc Version 5.2 Page 9 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.V359392.R01.S.doc Version 5.2 Page 10 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. People can expect to receive up to date accurate information about the home and they will be provided with a thorough assessment of their needs prior to moving in. EVIDENCE: The manager reviewed the homes Statement of Purpose and Service User Guide in December 2007 and has made further amendments since then to ensure that they are fully up to date; both documents are now dated and provide good details of the service that the home provides. Relatives of people living in the home said in their surveys that they had received good information about the home prior to their family member moving in. Ghyll Grove Residential and Nursing Home DS0000015535.V359392.R01.S.doc Version 5.2 Page 11 Prospective residents received a detailed assessment of their nursing and care needs before a decision was made about admission to the home. This ensured that there was a discussion about their expectations and concerns. The manager or a senior member of staff carried out the assessments. QUEST individual assessment documentation had been introduced since the last inspection. We sampled the pre-admission assessments on all five houses; they were detailed and generally of a very good standard. A number of relatives told us that staff made a particular effort to help new residents settle in and adjust to the changes of being in a care home. Ghyll Grove does not provide intermediate care. Ghyll Grove Residential and Nursing Home DS0000015535.V359392.R01.S.doc Version 5.2 Page 12 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 good. This judgement has been made using available evidence including a visit to this service. People can be confident that care plans contain the relevant information for staff to meet their assessed needs. People can be confident that they will be treated with dignity and respect. Whilst medication is generally well managed, some areas of practice do not fully protect people. EVIDENCE: All residents and relatives we spoke with expressed satisfaction with the standards of care in the home. One resident said “I feel confident that I’m getting the care I need. The staff know what they’re doing”. Another said “You get marvellous treatment here”. We sampled the care documentation on all of the five houses. Staff on the houses had access to the pre-admission assessment and carried out a further assessment on admission. The resident was reassessed further in six to twelve months or sooner if their condition changed. The standard of care plans was Ghyll Grove Residential and Nursing Home DS0000015535.V359392.R01.S.doc Version 5.2 Page 13 variable. Some were of a very good standard and reflected the needs, interests, preferences and preferred routines of residents. Others needed to be more person centred. On occasions the assessments and care plans had not been updated and did not reflect the residents’ current condition and care needs. The home had a range of methods to assess risks to residents’ health and welfare. This included nutritional, moving and handling risks and the risk of developing pressure sores. The prevention and treatment of pressure sores had improved considerably since the last inspection. Staff received good support and advice on the treatment of wounds or sores from the BUPA and Primary Care Trust Tissue Viability Nurses. Link nurses in the home attended a monthly forum to review wound care in the home. Residents told us that they saw the GP promptly when they had a health concern. There were systems in place to ensure that residents had access to optical and dental checkups and hearing tests when necessary. Staff on the residential units said that they received good support from the community nurses. Relatives told us that communication with them was very good and that staff kept them up to date with any health concerns. We observed staff using a range of communication methods with residents, particularly for those with dementia; this is to be commended. We carried out an assessment of the systems for managing and administering medicines on all five houses. We looked at a sample of medication administration records (MAR). The MAR were generally well completed. However, the systems for recording the administration of painkillers, where a variable dose was prescribed, needed to be improved as it was not always possible to establish exactly how many doses residents’ had received. We checked the Controlled Drugs (CDs); they were appropriately stored and recorded and balances were correct. The administration of homely remedies was generally well recorded but the balances were not always correct and a few medicines were past their expiry date. Staff were monitoring the temperature of the clinical rooms and the drugs fridges but were not taking action when temperatures were outside the limits for the safe storage of medicines. Staff were on occasions taking verbal orders for a newly prescribed medicine. Staff should not take verbal orders to initiate new treatments for prescription only medicines. Staff administering medicines had received training and an assessment of competence. Ghyll Grove Residential and Nursing Home DS0000015535.V359392.R01.S.doc Version 5.2 Page 14 Residents told us that staff respected their privacy and treated them in a respectful manner. We observed staff interacting in a caring manner that respected residents’ dignity. Residents who needed assistance with their personal care looked well groomed and appropriately dressed. Ghyll Grove Residential and Nursing Home DS0000015535.V359392.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): 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. People can expect to be offered a range of activities both in the home and out in the local community. People can expect to receive a good wholesome diet. EVIDENCE: Each of the five houses had an activity co-ordinator. Residents said that they sometimes joined in activities on other houses, which made the day more interesting and gave them the opportunity to access a greater variety of activities. At the time of inspection some residents were making lanterns for Chinese New Year. The activities on offer included 1:1 time chatting to residents, walks in the grounds, seated exercise classes, bingo, art and crafts and various games. Residents said that they enjoyed the cooking sessions with the chef. A resident who had had to leave their pets on admission said that they particularly enjoyed the cats in the home. A relative said “staff are excellent and there’s good entertainment”. Ghyll Grove Residential and Nursing Home DS0000015535.V359392.R01.S.doc Version 5.2 Page 16 Staff told us that they tried to arrange more entertainments in the winter and more outings in summer. A trip to watch fireworks had been arranged in the autumn and residents had fish and chips while out. One of the activity coordinators told us how they used sensory objects for interaction and stimulation of residents with more advanced dementia; this is to be commended. We saw some good person centred activity records. Senior staff were aware that some care staff needed to be encouraged to participate more in activities and 1:1 sessions with residents. Relatives said that they were made to feel very welcome in the home and could make themselves and the resident a cup of tea whenever they wanted. Residents confirmed that they could get up and go to bed at a time that suited them. Some residents were up early and some were observed still in bed midmorning. Staff told us ways in which they offered residents choices and encouraged them to retain their independence. Resident and relatives generally considered that the standard of meals was good. The majority of residents described them as “good” and “very nice”. Although one resident said “The food is good but it’s not as hot as it could be sometimes”. The menu provided choices at all mealtimes and a range of alternatives for residents who did not like what was on the menu. Staff confirmed that special diets were catered for. The meals we saw looked nutritious and well presented. Staff said that residents with short-term memory loss and dementia were shown different meals at the time, to enable them to have a more genuine choice. Relatives told us they were pleased that residents who needed assistance to eat were given the help they needed and that staff monitored their weight on a regular basis. Protected mealtimes had been introduced on one of the dementia units and staff said that the mealtimes were calmer and residents ate more when there were fewer distractions. A relative said that the resident they visited was “fussy about their food but thinks it’s lovely”. Residents told us that they enjoyed a drink of wine, sherry or beer with their Sunday lunch. Ghyll Grove Residential and Nursing Home DS0000015535.V359392.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. People can be confident that their complaints will be dealt with effectively and that they will be protected from abuse. EVIDENCE: The home has a comprehensive complaints procedure that is used throughout the BUPA organisation. The manager of Ghyll Grove keeps a copy of the procedure together with her complaints log and makes monthly returns of all complaints and compliments to the head office of BUPA. Each complaint examined was dealt with according to the homes policy, they were recorded on the complaints record forms and included a completed managers investigation form and action plan. The manager states in her annual quality assurance assessment (AQAA) that complaints literature is displayed prominently in the home and people spoken with and surveyed confirmed that they were aware of the complaints procedure; there were also complaints leaflets available in each of the houses both in the welcome pack and in the foyer. One relatives survey stated, “I can go and see matron if I want to complain or am not happy”. There has been two protection of vulnerable adults (POVA) issues at Ghyll Grove since the last inspection; one has been closed under the POVA procedure and the issues of care practice that were identified as a result of the Ghyll Grove Residential and Nursing Home DS0000015535.V359392.R01.S.doc Version 5.2 Page 18 POVA were appropriately dealt with by the manager. There is a BUPA policy and procedure that works within the Local Authority safeguarding procedures and staff surveyed and spoken with were fully aware of both procedures and the instructions for their use. Ghyll Grove Residential and Nursing Home DS0000015535.V359392.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, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can expect to live in a safe, homely, clean and comfortable environment. EVIDENCE: Ghyll Grove consists of five separate houses; Medway, Kennett, Thames, Roding and Chelmer and each house provides accommodation for up to 30 people. Medway, Kennett and Roding can provide nursing care and Roding is able to provide nursing care for up to four terminally ill people. Thames provides care for people with dementia and Chelmer provides care for people with residential care needs only. The manager accompanied me on a tour of three of the houses and all were well kept and well decorated; there were some areas requiring attention such Ghyll Grove Residential and Nursing Home DS0000015535.V359392.R01.S.doc Version 5.2 Page 20 as scuffed bathroom doors and paintwork. The manager said that these would be rectified as part of the 2008 refurbishment plan. The manager employs a maintenance man, a handy man and a gardener and the maintenance man is responsible for carrying out regular weekly, monthly, three monthly, six monthly, annual and five yearly checks around all of the buildings. There is a clear written schedule of the tasks to be carried out and the maintenance man records the date of completion. Routine repairs are recorded in each individual house’s maintenance book and are reported to the handyman by the senior person on shift at the time they are identified. The manager confirmed in her annual quality assurance assessment (AQAA) that there is a rolling decoration programme in place and the home is due for refurbishment this year. The maintenance books were inspected on each of the five houses and routine repairs were carried out in a timely manner. There were minor issues identified in the scheduled maintenance records around the recording of weekly tests on a monthly basis; these were discussed with the manager and the maintenance man and it was agreed that the recording sheet would be amended accordingly. Each of the five houses has a housekeeper who is responsible for ensuring the cleanliness of the environment. Each of the five house inspected were clean, tidy and odour free. Staff spoken with said how effective the domestic staff were and people living at the houses commented on how “nice and clean” their room always is. Comments were made on the cleanliness of the home in many of the surveys that have been returned to the CSCI from relatives and advocates. Relatives’ surveys included comments that “the home provides safe and comfortable accommodation that is always clean and fresh” and “ the home has a big TV set which is better for people with poor sight and the fish tank helps to calm my relative”. Ghyll Grove Residential and Nursing Home DS0000015535.V359392.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 adequate. This judgement has been made using available evidence including a visit to this service. Whilst staff are well trained and supplied in sufficient quantities to meet the needs of the people living at the home, shortfalls in the recruitment process could potentially put people at risk. EVIDENCE: Four weeks rotas were examined for each of the five separate houses; Medway rota showed that there were mainly six staff in the morning, six staff in the afternoon and three staff awake during the night. On four occasions over the four-week period there were five staff working in the afternoon and on one occasion there were five staff working in the morning. On eight occasions there were seven staff working in the morning and on two occasions there were eight staff working in the morning. The rota showed that there was an additional member of staff working on one of the waking night shifts. It was clear from the other rotas examined that the manager always ensures that there are appropriate numbers of skilled and experienced staff on duty in each of the five houses. The manager said that it has been necessary in the past to ask staff to work between houses where there is a shortfall on one house and a surplus of staff on another. Staff spoken with and surveyed said Ghyll Grove Residential and Nursing Home DS0000015535.V359392.R01.S.doc Version 5.2 Page 22 that they did not mind working in other houses from time to time and that this was not a regular occurrence. The manager employs qualified nurses to work in the houses that provide nursing care and there is a qualified nurse on duty in these houses twenty-four hours each day. The manager said that the home is working towards training care staff to a minimum of NVQ level 2 and senior care staff to NVQ level 3. There are currently twenty staff that have completed their NVQ 2 or above and another seven working towards it. Staff surveyed and spoken with said they were pleased to be offered the opportunity to gain a recognised qualification and that they felt supported by the home to attain it. People who live at the home and their relatives said in their surveys “staff are usually available when you need them and are always pleasant, cheerful and approachable and there are always adequate competent staff on duty” and “most staff have a caring attitude to residents”. Twelve staff files were examined and some shortfalls were identified, which included four staff application forms showing gaps in their previous employment that had not been investigated. The application form asked applicants to state their reasons for leaving their previous employment; some of the application forms examined did not contain any reasons for leaving previous employment. There was no evidence of fitness on any of the staff files examined. The manager said that the application form has been improved recently and has provision for recording a declaration of workers fitness. One of the staff files contained only one reference and there was a copy of a letter sent to the employee requesting that they seek another reference and it appeared that this had not been followed up. The manager said that some criminal records bureau (CRB) checks had previously been destroyed under CRB guidance and that all of the newer ones are now kept until they have been inspected. Staff spoken with and surveyed confirmed that a criminal records bureau (CRB) check and references are obtained before they are allowed to start work at the home. There was evidence of staff training on all of the staff files examined, some contained much more than others. A training matrix has been devised to assist in compiling training programmes that meet the needs of the current residents. The manager organises regular monthly training in nutrition, Quest resident of the day, death, dying and bereavement, Mental Capacity Act, bed rail training, basic food hygiene, fire, COSHH, adult safeguarding, moving and handling, challenging behaviour and infection control. Staff is paid to attend Ghyll Grove Residential and Nursing Home DS0000015535.V359392.R01.S.doc Version 5.2 Page 23 all training, which is mostly provided in the homes training room by the homes trainer. External trainers provide some of the more specialised training. Staff spoken with and surveyed commented on how good the training was at Ghyll Grove and said “the home does well in keeping us up to date with training and knowledge” and “the service makes sure we go for the relevant training that will help us with our job”. Ghyll Grove Residential and Nursing Home DS0000015535.V359392.R01.S.doc Version 5.2 Page 24 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, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can expect to live in a safe well managed home that is run in their best interests. EVIDENCE: The registered manager is a first level nurse who has thirty years experience in caring for frail elderly people and she has completed her Registered Managers Award. The manager regularly updates her knowledge and skills and is a moving and handling trainer. Staff spoken with and surveyed said that the manager is approachable and they feel confident of any issues being dealt with effectively. People living in the home appeared very pleased to see Ghyll Grove Residential and Nursing Home DS0000015535.V359392.R01.S.doc Version 5.2 Page 25 the manager when she accompanied me around three of the houses and they were relaxed and happy when talking with her. The manager carries out regular surveys to ensure the quality of the service that is provided at Ghyll Grove. In addition to the regular surveys there are regular audits carried out throughout the home and BUPA has appointed a Quality and Compliance team that will work from the area office. The manager has to provide the quality and compliance team with an improvement log that has to be completed on the day of the CSCI inspection and faxinated to the team within twenty-four hours of the inspection. The log includes details of the feedback given by the CSCI at the time of the inspection and identifies the key areas in need of improvement to enable the home to implement any changes as soon as possible. One relatives survey stated “the home does just about everything well and there is really no need for improvement”. Another relatives survey states “ I think the care home definitely does very well and I am more than satisfied”. There was evidence of the provider making regular monthly visits under regulation 26 and a new reporting form has been developed which was discussed because the form did not make provision for identifying the individual house where there were any issues. The manager said that this would be discussed at the next providers visit. The manager completed her annual quality assurance assessment (AQAA) in good time and gave a very detailed assessment of how well the home is doing and provided good information on her plans for any improvements. Staff spoken with and surveyed was aware of the homes quality assurance policies. The home does not hold residents finances, however there are small amounts of cash held by Chelmer where relatives of residents provide spending money. Six residents cash transaction and cash records were inspected at random and they were all found to be correct. People living at the home were spoken with and they said that they were happy about the way their “spending money” was looked after by the staff and that they liked having a small amount of cash for hairdressing and papers. Of the twelve staff files examined there were shortfalls in the recording of supervision notes; one staff member had started work at the home in July 2007 and had one supervision recorded since then. The manager said that plans were in place for more regular staff supervision to take place and a schedule has been drawn up to ensure that it happens. Senior staff spoken with said they were now aware of their responsibilities to supervise their staff. Ghyll Grove Residential and Nursing Home DS0000015535.V359392.R01.S.doc Version 5.2 Page 26 Fire safety training is offered to staff twice monthly; fire equipment and the fire alarms have been recently checked and the last fire inspection took place on 8/6/07 and it identified five issues that needed to be addressed. Four of the issues raised by the fire inspector have been dealt with appropriately; the fifth was a requirement to carry out a fire risk assessment that is to be reviewed at regular intervals. The manager said that the health and safety officer at BUPA’s head office is carrying out a genetic fire risk assessment. Fire drills have not taken place often enough for all staff and residents to be familiar with the procedure. The manager said that the home would need to carry out two fire drills each month to ensure that all staff and residents have the opportunity to take part in a drill twice a year. This was discussed and the importance of staff being competent in carrying out an evacuation of the building should a fire occur was agreed. All other safety certificates were in place and up to date. Ghyll Grove Residential and Nursing Home DS0000015535.V359392.R01.S.doc Version 5.2 Page 27 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 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 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.V359392.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No 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 OP9 Regulation 13 (2) Requirement Staff must take action when the storage temperature of medicines is outside the recommended ranges, to prevent residents being given medicines that may have degraded. Staff must ensure that records clearly identify the dosage and frequency of medicines administered to residents. Timescale for action 31/03/08 2. OP29 19 Schedule 2 3. OP38 23 (4) (C) (iii) To protect people living in the 31/03/08 home a robust recruitment process must take place and it has to include checks on applicants’ employment history, their fitness and the reasons for them leaving their previous employment. Regular fire drills must be carried 31/03/08 out to ensure that staff is competent to evacuate themselves and people living in the home in the event of a fire. Ghyll Grove Residential and Nursing Home DS0000015535.V359392.R01.S.doc Version 5.2 Page 29 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 OP36 Good Practice Recommendations All staff should receive formal supervision at least six times each year. Ghyll Grove Residential and Nursing Home DS0000015535.V359392.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Colchester Fairfax House Causton Road Colchester Essex CO1 1RJ 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.V359392.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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