Inspection on 13/12/05 for Gracelands

This inspection was carried out on 13th December 2005.

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 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 10/08/05

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 K Leppard Unannounced Inspection 13th December 2005 10:45 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 Gracelands DS0000059816.V266505.R01.S.doc Version 5.0 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. Gracelands DS0000059816.V266505.R01.S.doc Version 5.0 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 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) 01243 867707 01243 868331 Macleod Pinsent Care Limited Ms Paula Byrne Care Home 31 Category(ies) of Dementia - over 65 years of age (15), Mental registration, with number disorder, excluding learning disability or of places dementia (1), Old age, not falling within any other category (15) Gracelands DS0000059816.V266505.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Up to 15 male and/or female service users in the category of old age, not falling within any other category may be admitted Up to 15 male and/or female service users in the category of dementia may be admitted. 1 person in the category of mental disorder, excluding learning disability or dementia may be accommodated Only persons over the age of 65 years of age may be admitted. Total number of persons to be accommodated may not excede a total of 31 10th August 2005 Date of last inspection 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, one separate lounge and a garden at the rear of the property. Macleod Pinsent Care Limited privately owns Gracelands. Mr Russell Pinsent is the Responsible Individual on behalf of the organisation. The Registered Manager responsible for the day-to-day running of the home is Ms Paula Byrne. Gracelands DS0000059816.V266505.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was conducted on Tuesday 13th December 2005 between 10.45am and 3.45pm. At the time of the inspection twenty four residents were living at Gracelands. The inspector toured the premises and spoke with four visitors and four residents. 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. The registered provider has submitted an application to change the registration of Gracelands to thirty residents in the category DE(E), Dementia, over 65 years. What the service does well: What has improved since the last inspection? What they could do better: The Requirements for action following this inspection are: Risk assessments must be completed where a risk to a resident’s health, safety or welfare has been identified. Gracelands DS0000059816.V266505.R01.S.doc Version 5.0 Page 6 The home remains in need of ongoing redecoration and refurbishment to ensure the environment is of a satisfactory standard. Fire doors must not be ‘propped’ open. Staffing levels must be reviewed using the Department of Health guidance to ensure resident’s needs are met at all times. The home’s recruitment procedure must be robust for the protection residents. Training, including induction and fire, must be provided to staff to ensure they are safe to do the job they are employed to do and that resident’s health, safety and welfare is promoted and protected. It is recommended that Care records be reviewed and updated monthly. A programme of meaningful activity is established based on resident’s hobbies, interests and recreational needs. The homes quality assurance system is developed to include resident and relative meetings and a development plan for the home. 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 DS0000059816.V266505.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Gracelands DS0000059816.V266505.R01.S.doc Version 5.0 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 the following standard(s): 3&6 Resident’s needs are assessed prior to their admission to the home. Intermediate care services are not provided at the home. EVIDENCE: Records relating to two recently admitted residents demonstrated that an assessment of need was completed by a representative from the home prior to the resident’s admission, one of which was in addition to a social services assessment of need. Currently, the home is registered to accommodate 15 residents in the category of DE(E), Dementia, over 65 years of age. Records available and Regulation 26 reports from earlier in the year indicate that more than 15 residents have dementia. The registered person must continue work to carry out the necessary assessments of these residents to ensure their needs are met by the home. Gracelands DS0000059816.V266505.R01.S.doc Version 5.0 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 the following standard(s): 7 & 10 Resident’s needs are set out in a plan of care. Resident’s privacy and dignity is maintained. EVIDENCE: Three care records were sampled, two of which related to residents who had come to live in the home over one month ago. The care plans set out residents needs in relation to their personal care, however those relating to recent admissions did not include risk assessments, even where daily records indicate that a resident is at particular risk from falling. Risks to resident’s health, safety and welfare must be assessed with evidence of the actions being taken to minimise the risks. Care records must also be kept up to date through monthly reviews. Residents and visitors feedback indicates that privacy in the home is respected. One resident commented ‘my privacy is respected completely’ another explained that although staff do not always knock on doors, this does Gracelands DS0000059816.V266505.R01.S.doc Version 5.0 Page 10 not cause her concern. Staff demonstrated a satisfactory understanding of privacy, dignity and choice issues for residents. Gracelands DS0000059816.V266505.R01.S.doc Version 5.0 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 the following standard(s): 12 Care records do not support the home to match the lifestyle in the home to resident’s preferences and expectations. EVIDENCE: On the morning of the inspection musical entertainment was provided and this is a weekly occurrence. Resident’s feedback about the entertainment varied, most enjoyed it and others said they prefer to spend time alone in their room, which is respected by staff. Feedback indicates that a visiting church representative brings communion to the home and that staff do support residents to go out of the home on occasion. Care records maintained by the home do not include sufficient information, if any, about resident’s hobbies, interests and their social needs. It is recommended that in order to fulfil these needs through a programme of meaningful activity some information should be sought from residents and/or their representatives. Gracelands DS0000059816.V266505.R01.S.doc Version 5.0 Page 12 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 the following standard(s): Outcomes for these standards were not assessed. EVIDENCE: Gracelands DS0000059816.V266505.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 19, 20, 21 & 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. The standard of cleanliness and hygiene could be improved. EVIDENCE: One lounge/dining area has been redecorated since the last inspection and the result is a light and airy room, which some residents and visitors commented positively on. However, the home remains in need of a substantial amount of redecoration and refurbishment to ensure a satisfactory standard of accommodation is offered. Priorities include replacing windows, carpets and flooring, bathroom facilities and equipment. Gracelands DS0000059816.V266505.R01.S.doc Version 5.0 Page 14 Work has begun on one of two shower rooms that have been identified for refurbishment. This work cannot be completed until the window has been replaced and the current status of the room is untidy and unwelcoming and includes the use of a garden chair instead of the appropriate equipment for assisted showering. The inspector noted that a fire door was ‘propped’ open, this particular issue was brought to the registered persons attention during the last inspection and it has now been agreed that this will be resolved within one week after the inspection. The registered person has confirmed that the posting of necessary signage is the work outstanding from the fire officer’s last report. Confirmation must be provided to the Commission for Social Care Inspection when full compliance has been achieved. On the day of inspection domestic staff were not being deployed for domestic duties and the result was a lack of cleanliness, tidiness and vigilance in relation to the appearance of the home. (linked to staffing levels at Standard 27) The inspector also noted that hand washing facilities such as soap and hand towels are still not being provided in all resident’s rooms and toilets throughout the home. It is a requirement that the issues relating to the premises be addressed. Gracelands DS0000059816.V266505.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 & 30 Staffing levels should be reviewed in line with Department of Health guidance to ensure all residents’ needs are being met. Recruitment procedures are not sufficiently robust. Training is provided to staff, however induction training must be improved. EVIDENCE: On the day of inspection staff identified on the rota for domestic duties were providing personal care support to residents and not all staff that the rota indicated were on duty were present in the home. The registered person is required to review staffing levels at the home using the Department of Health guidance based on the dependency of residents accommodated in the home and demonstrate that staffing is sufficient at all times to meet the needs of residents and manage unplanned absences. It was agreed that this requirement would be addressed within one week of the inspection. Recruitment records were sampled in relation to the two most recently employed members of staff. The records did not demonstrate that a robust recruitment procedure is in place at the home, including obtaining Criminal Records Bureau (CRB) disclosures and Protection of Vulnerable Adults (PoVA) checks on staff before they commence employment. This does not protect residents from harm or abuse and must be addressed. Gracelands DS0000059816.V266505.R01.S.doc Version 5.0 Page 16 Discussions with staff and records of training indicate that a variety of training, including National Vocational Qualifications (NVQ’s) is provided to staff at the home. When an employee’s previous training is accepted the registered persons should record this. Records relating to induction were not in place for one member of staff and the other had not completed the six week programme. The registered persons must ensure that staff are trained for the job they are employed to do, to protect residents from harm and abuse and maintain their health and safety. (see standard 38 also) Gracelands DS0000059816.V266505.R01.S.doc Version 5.0 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 & 38 The home’s quality assurance system would benefit from resident and relative meetings. Training provision and record keeping does not promote the health, safety and welfare of residents and staff. EVIDENCE: The recommendation from the last inspection that the home’s quality assurance system be supplemented with resident and relative meetings has not been acted upon to date. Future inspections will monitor residents and relative’s involvement in the development of Gracelands in order that it is run in the best interests of the residents. The registered person must also ensure that monthly Regulation 26 reports are conducted to monitor the service. Gracelands DS0000059816.V266505.R01.S.doc Version 5.0 Page 18 Records of accidents noted in daily records could not be located for inspection and accident records in general were not in good order. As noted at Standard 7, risk assessments must reflect that action has been taken to prevent and minimise the risk of accidents and incidents. An immediate requirement was issued during the inspection in relation to fire training. Records and discussions with staff indicate that not all staff are aware of the procedure to follow should the fire alarm sound and training updates have not been provided at intervals suitable to the work staff do at the home. This does not promote and protect the health and safety of residents and staff at the home. Gracelands DS0000059816.V266505.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 1 1 1 X X X X 1 STAFFING Standard No Score 27 1 28 X 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X X X 1 Gracelands DS0000059816.V266505.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 13 (4) c Requirement The registered person shall ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. The registered person shall after consultation with the fire authority make adequate arrangements for detecting, containing and extinguishing fires. The registered person shall ensure that all parts of the home are kept clean and reasonably decorated. The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users ensure that at all times suitbaly qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. Staff records must include the DS0000059816.V266505.R01.S.doc Timescale for action 07/02/05 2. OP19 23 (4) c i 20/12/05 3. OP26OP21 OP20OP19 OP27 23 (2) d 13/01/05 4. 18 (1) a 20/12/05 5. OP29 19 (1) 07/02/05 Page 21 Gracelands Version 5.0 6. OP30 18 (1) c i 7. OP38 23 (4) information and documents specified within Schedule 2. The registered person shall, 07/02/05 having regard to the size of the care home, the statement of purpose and the number and needs of the service users ensure that the persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform. The registered person shall after 13/12/05 consultation with the fire authority make arrangements for persons working in the care home to receive suitable training in fire prevention and to ensure by means of fire drills and practises at suitable intervas that the person working in the care home and, so far as practicable, the service users, are aware of the procedure for saving life. 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. 3. Refer to Standard OP7 OP12 OP33 Good Practice Recommendations It is recommended that care records be reviewed and updated monthly. It is recommended that a programme of meaningful activity be established based on residents hobbies, interests and recreational needs. 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 DS0000059816.V266505.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Worthing LO 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 DS0000059816.V266505.R01.S.doc Version 5.0 Page 23 - 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!