Inspection on 10/08/05 for Gracelands

This inspection was carried out on 10th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Gracelands 13/08/07

Gracelands 02/08/06

Gracelands 13/12/05

Gracelands 21/02/05

Gracelands 07/10/04

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

CARE HOMES FOR OLDER PEOPLE Gracelands 42-48 Richmond Avenue Bognor Regis West Sussex PO21 2YE Lead Inspector Mrs Kerry Leppard Announced 10 August 2005 @ 09:30, V228906 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 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. Gracelands H60-H11 S59816 Gracelands V228906 130705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Gracelands Address 42-48 Richmond Avenue, Bognor Regis, West Sussex, PO21 2YE Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01243 867707 01243 868331 Macleod Pinsent Care Ltd Ms Paula Byrne CRH(PC) Care home only 31 Category(ies) of DE(E) -Dementia over 65 years of age - 15 registration, with number places of places OP- Old age, not falling within any other category-15 places (MD)- Mental disorder, excluding learing disability or dementia-1 place Gracelands H60-H11 S59816 Gracelands V228906 130705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 15 male and/or female service users in the category of old age, not falling within any other category may be admitted. 2. Up to 15 male and or/female service users in the category of dementia may be admitted. 3. 1 person in the category of mental disorder, excluding learning disability or dementia may be accomodated. 4. Only persons over the age of 65 years may be admitted. 5. Total number of persons to be accommodated may not exceed 31. Date of last inspection 21 February 2005 Brief Description of the Service: Gracelands is a care home registered to accommodate up to a total of thirtyone service users over the age of sixty-five. Within the total number the home is registered to accommodate fifteen service users in the Older People category (OP), fifteen service users with Dementia (DE) (E) and one service user under 65 with a mental disorder. The home is registered to provide personal care only (PC). Gracelands is situated in Bognor Regis within close proximity of local shops and the seafront. The premises are divided into two areas, one accommodating those service users in the category OP and the other accommodating those service users in the category DE (E). The accommodation provided consists of twenty-five single rooms, three double rooms, two lounge/dining rooms, two separate lounges, one separate dining room and a garden at the rear of the property. Macleod Pinsent Care Limited privately owns Gracelands. Mr R Pinsent is the Responsible Individual operating on behalf of the organisation. The Registered Manager responsible for the day-to-day running of the home is Ms Paula Byrne. Gracelands H60-H11 S59816 Gracelands V228906 130705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and was carried out on Wednesday 10th August 2005 between 9.30am and 6.30pm. The registered manager accompanied the inspector on a tour of the building. The inspector spoke with three residents individually and five residents sitting in communal areas. The inspector was unable to gain feedback from all residents due to the level of their disability. Therefore, periods of observation were made. Three staff met and spoke with the inspector on an individual basis and other staff assisted the inspector throughout the day. Following the inspection feedback was sought from five relatives, a district nurse and a community psychiatric nurse by telephone and this has been incorporated into the report. Comment cards have been sent to GP surgeries and feedback from these will be used to inform the next inspection. What the service does well: What has improved since the last inspection? Since the last inspection one bedroom has been redecorated and refurbished to a good standard. A quote has been accepted for the replacement of all windows in the home, which will vastly improve the appearance of the outside of the building. Plans are in place to refurbish two toilet/shower rooms to improve their suitability for residents. Records were available in relation to regular hot water temperature monitoring around home. Gracelands H60-H11 S59816 Gracelands V228906 130705 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Gracelands H60-H11 S59816 Gracelands V228906 130705 Stage 4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection Gracelands H60-H11 S59816 Gracelands V228906 130705 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 Service users needs are assessed. EVIDENCE: A relative told the inspector that the registered manager had visited her relative to assess her needs before she came to stay in the home. The prospective resident and her relatives were also invited to look around the home. Gracelands H60-H11 S59816 Gracelands V228906 130705 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 & 9 Resident’s needs are set out in an individual plan of care. Residents’ health needs are met. Practises in relation to the management of medication have been improved to protect service users. EVIDENCE: Care plans comprehensively set out residents needs and are kept up to date. Care plans will benefit from the reorganisation that is planned to make them easier to follow. A relative told the inspector that she had been able to see her relative’s care plan. Some feedback from relatives indicated that minor improvements could be made to ensure the personal appearance of their relative is of a satisfactory standard. GP, district nurse and community psychiatric nurse support and advice is sought to assist the home to fully meet residents health needs. Some very encouraging and positive feedback was received from relatives and visiting Gracelands H60-H11 S59816 Gracelands V228906 130705 Stage 4.doc Version 1.30 Page 10 professionals about the diligence of the home in relation to residents mental health and well being, including reviewing medication. Medication is stored securely and administered by staff that are trained to do so. Record keeping in relation to administration and disposal is satisfactory. The registered manager acted quickly to rectify an unsafe practise noted during the inspection. Gracelands H60-H11 S59816 Gracelands V228906 130705 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13, 14 & 15 Residents are able to maintain contact with family and friends Residents can exercise choice and control over their lives The menu is balanced and varied. EVIDENCE: The inspector observed that visitors are welcomed into the home and offered refreshment. One resident told the inspector that she had recently had tea with her visitors in the garden. Relatives commented positively on the welcome they receive into the home and one said she has a meal with her relative whilst she is there. One resident told the inspector that she has been offered a telephone but chooses not to have this, instead she corresponds in writing and receives her mail unopened. Three residents who spoke with the inspector talked about their preference to stay in their room, they said that staff respect this choice. One resident’s wish to stay in bed on the day of inspection had also been respected. Residents said that routines are flexible and they can go to bed and get up when they choose. Gracelands H60-H11 S59816 Gracelands V228906 130705 Stage 4.doc Version 1.30 Page 12 Residents told the inspector about their different choices of where they eat their meals. The inspector ate lunch in one of the dining rooms and observed that residents were supported sensitively and were offered and provided with additional helpings of food and drinks. One resident said that she could ask for something different if she does not like the dish being served. It was noted that one residents wish to have something different for supper was respected. Further to the inspector’s observation and feedback received, the registered manager has confirmed that she has explored providing self service drinks in communal areas, serving pureed meals in separate portions, as good practise would dictate and meat alternatives for residents who are vegetarians. Work such as this should continue in consultation with residents and relatives. Gracelands H60-H11 S59816 Gracelands V228906 130705 Stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 Complaints are recorded and acted upon. Residents are protected from abuse. EVIDENCE: The home has recorded two complaints that were passed onto the registered manager and she has acted upon these. The complaints procedure is displayed in the main entrance of the home. Staff who spoke with the inspector had received training to assist them to identify types of abuse and each knew about their responsibility to report suspected abuse Gracelands H60-H11 S59816 Gracelands V228906 130705 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 24, 25 & 26 The environment needs improving to ensure it is safe and pleasant inside and outside. Lavatories and washing facilities could be improved to meet the needs of residents. Residents’ rooms are furnished with their own belongings and well equipped. The home is clean and hygienic. EVIDENCE: The home is in need of redecoration and refurbishment and the registered manager has identified key works to be completed to improve the internal and external environment. Residents who are able to mobilise independently were observed moving freely around the home, using quiet areas to meet visitors and walking in the garden. Gracelands H60-H11 S59816 Gracelands V228906 130705 Stage 4.doc Version 1.30 Page 15 Plans include the refurbishment of two shower rooms that are currently not used to ensure they are better suited to the needs of residents. Feedback also indicated that a review of the equipment provided to ensure it meets the needs of all residents might be beneficial. Those residents’ rooms that were seen were furnished with their own belongings, a lock has been fitted to each door and lockable facilities are provided in some rooms. Those residents who spoke with the inspector in their rooms said they were comfortable and one resident said that she uses the lock fitted to her door at night. The inspector noted that some fire doors were propped open during the inspection. This poses an unsatisfactory fire risk to residents and staff and was rectified during the inspection. Radiator covers have been fitted to protect residents form hot surfaces and water outlets are tested regularly to ensure water temperatures minimise the risk to residents of scalding. The home was clean and there was no specific odour, however feedback indicates that at times this is evident. It was observed and feedback indicated that soap and hand towels are not always available to ensure good hand hygiene. Gracelands H60-H11 S59816 Gracelands V228906 130705 Stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 28 Staffing levels are satisfactory. Staff have achieved National Vocational Qualification to exceed the standard. EVIDENCE: One relative commented positively that staffing levels had been increased and most feedback indicated that generally staffing appears satisfactory to meet residents’ needs. In addition to care staff, domestic and catering staff are employed. A sample week of the rota was looked at and showed that sufficient care hours are being provided in accordance with Department of Health guidance. This guidance relates to care hours only and does not allow for time staff may spend on other non care related tasks such as cooking and this should be considered by the registered persons as care staff do prepare supper. 75 of the care staff at Gracelands have completed an NVQ award at Level 2 or equivalent and staff told the inspector that this training is offered and the necessary support is given to ensure they can be completed. Gracelands H60-H11 S59816 Gracelands V228906 130705 Stage 4.doc Version 1.30 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 35 & 38 The registered manager is fit to be in charge. The home is run in the best interests of the residents. Systems protect residents finances. The health and safety of residents and staff is promoted and protected. EVIDENCE: The registered manager is currently undertaking a National Vocational Qualification at Level 4 and provided a record of other training she has undertaken to update her knowledge and skills. Feedback from one relative indicated that the manager is available and approachable and other comments from residents and their visitors indicated that communication is good and their comments will be listened to and acted upon. Similarly staff said they felt supported and have opportunities to voice their opinion and raise issues. Gracelands H60-H11 S59816 Gracelands V228906 130705 Stage 4.doc Version 1.30 Page 18 A comprehensive system of auditing the home on a monthly basis is being implemented and includes using questionnaires and quizzes to gain residents feedback about the services at the home. The registered manager may wish to further develop this system by including resident and relative meetings and producing a development plan for the home based on the feedback received. Accurate records are maintained of any money belonging to residents stored for safe keeping by the home. Accidents are recorded, audited and linked to risk assessments for the protection of service users and staff. Facilities and equipment are serviced regularly and the inspector was able to observe the staff team responding calmly and efficiently to the fire alarm during the inspection. Gracelands H60-H11 S59816 Gracelands V228906 130705 Stage 4.doc Version 1.30 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 1 3 3 3 x 3 3 3 STAFFING Standard No Score 27 3 28 4 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x 3 x x 3 Gracelands H60-H11 S59816 Gracelands V228906 130705 Stage 4.doc Version 1.30 Page 20 Yes 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 19 Regulation 23 (2) (d) Requirement The registered person shall ensure that all parts of the home are reasonably decorated. Timescale for action December 2005 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. 2. Refer to Standard 7 33 Good Practice Recommendations It is recommended that the provision of personal care be improved to ensure residents personal appearance is satisfactory. It is recommended that the homes quality assurance system be developed to include resident and relative meetings and a development plan for the home. Gracelands H60-H11 S59816 Gracelands V228906 130705 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 2nd Floor, Ridgeworth House Liverpool Gardens Worthing, West Sussex BN11 1RY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Gracelands H60-H11 S59816 Gracelands V228906 130705 Stage 4.doc Version 1.30 Page 22 - 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. 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