Inspection on 16/02/07 for Granville House

This inspection was carried out on 16th February 2007.

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

Granville House 17/09/09

Granville House 11/08/09

Granville House 18/10/07

Granville House 21/11/05

Granville House 26/04/05

Granville House 19/01/05

Granville House 01/06/04

Granville House 02/03/04

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

CARE HOMES FOR OLDER PEOPLE Granville House 40 Woodgreen Road Wednesbury West Midlands WS10 9QS Lead Inspector Mr Jon Potts Unannounced Inspection 16th February 2007 10:35 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 Granville House DS0000004857.V340234.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. Granville House DS0000004857.V340234.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Granville House Address 40 Woodgreen Road Wednesbury West Midlands WS10 9QS 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) 0121 502 2654 F/P0121 502 2654 Mr Avtar Singh Sandhu Mrs Amarjit Kaur Sandhu Wendy Francis Care Home 21 Category(ies) of Dementia - over 65 years of age (16), Old age, registration, with number not falling within any other category (21) of places Granville House DS0000004857.V340234.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Care staffing levels are to be maintained at the following minimum levels for: An occupancy level of between 16 to 21 service users, there must be a minimum of five staff during peak periods (peak periods being 8am 1pm and 4.30pm - 8/9pm) with four at all other times during the residents waking day. An occupancy level of between 10 to 15 services users, there must be a minimum of four staff during peak periods (peak periods being 8am - 1pm and 4.30pm - 8/9pm) with three at all other times during the residents waking day. Night staffing must consist of a minimum of two waking nights staff with additional night staff provided where service users need dictate. There must be appropriate and continued dementia care training for staff in accordance with the assessed needs of the resident group. This training must also be provided in accordance with the homes statement of purpose and service user guide. The provider must forward documented evidence of the conservatory having appropriate building regulation approval to the CSCI, prior to its use by any of the residents. 20/2/06 2. 3. Date of last inspection Brief Description of the Service: The home is an adapted and extended traditional detached property that is sited within a short distance of Wednesbury Town centre with access to good transport links and the M6 motorway. Accommodation in the home includes three lounges, a conservatory, dining area with toilets and bathrooms on every floor. Communal areas are divided into separate units with a number of key padded doors around the home to assist with security and the safety of residents. There are 14 single and 3 shared rooms, these on three floors, with only the first floor accessible via shaft lift. There is parking to the front and rear of the home and a patio and small garden area to the side and rear. There are a number of aids available including adapted baths, raised toilet seats and call system. The home is run by a manager who oversees staff including seniors and carers. There are also some ancillary staff in place including cook, domestic and handyman. The home provides a service to older people with dementia (this a change to the service since the time of the last inspection). Whilst nursing may be provided by primary health care staff on occasions (such as district nurses) the home does not itself offer any nursing care. Granville House DS0000004857.V340234.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over two days and involved what was primarily an assessment of the homes performance against key national minimum standards. Evidence was drawn from a number of sources but including the tracking of resident’s care, which involved looking at care records, talking to residents about these and life in the home, as well as considering the views/knowledge of staff. Other evidence was drawn from reading other documentation including that related to health and safety and staffing. There was also information supplied pre inspection by the homes manager and from residents and relatives (the latter through CSCI questionnaires). The residents, staff and management are to be thanked with their ready assistance with the inspection process. What the service does well: What has improved since the last inspection? The home has addressed all but one of the requirements from the previous inspection with this done through better evidencing of residents/their representatives involvement in care planning, and some improvements in care documentation in respect of risk assessment. There was also evidence that the home has recently addressed concerns regarding meal provision that were apparent from some comments received pre inspection, and staffing levels have increased (the latter due in part to CSCI expectations when the home varied its registration to dementia care). The training of staff in numerous areas has continued and this is reflected in the knowledge of good practice expressed by those staff spoken to by the inspector. Granville House DS0000004857.V340234.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Granville House DS0000004857.V340234.R01.S.doc Version 5.2 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 Granville House DS0000004857.V340234.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives have the information needed to choose a home that will meet their needs. They have their needs assessed and a contract which tells them about the service they will receive. EVIDENCE: Admissions are not made to the home until a full needs assessment has been undertaken, this by the provider or manager with possible involvement of other staff, with assessments obtained from the funding authority when this is applicable. The home then confirms that it can meet the needs of the individual through the service they deliver as detailed in the statement of purpose. Evidence confirms that the assessment is conducted professionally and sensitively and has involved the family or representative of the resident where this is possible. Granville House DS0000004857.V340234.R01.S.doc Version 5.2 Page 9 Prospective residents are offered the opportunity to spend time in the home, and if not able to due to circumstances a permanent placement at the home is not agreed until the resident has spent at least a month at the home, usually longer. Where service users are unable to visit the relatives are welcomed to have a look around the home and are offered information on the service in verbal and written format. The manager is usually involved in going to see the prospective resident prior to admission to give them information, and enable them to ask any questions about life in the home, in addition to carrying out an initial assessment. Admissions to the home only usually take place if the service is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident. There has been one admission since the last inspection that was problematic due to assessment information not matching the needs of the resident post admission. This did result in a complaint, which was investigated by the provider. Learning from this incident has informed the homes consideration of later potential admissions. Admissions would be considered within the management team, although the manager would have an expected degree of influence over any admissions. Each resident is provided with a statement of terms and conditions at the point they move to the home. This sets out in detail what is included in the fee, the role and responsibility of the provider, and the rights and obligations of the resident. This is clear, jargon free, easy to understand and gives the resident a fair understanding of what they can expect. The manager actively promotes opportunity for discussion and clarification. Granville House DS0000004857.V340234.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The health and personal care, which a resident receives, is provided and generally based on individual needs, although there is some occasions where there is weaknesses in care planning. Medication is generally well managed with some exceptions where improvement is required. The staff have a good awareness of the principles of respect, dignity and privacy and these are put into practice. EVIDENCE: Each resident has a care plan with some evidence of the residents or relative’s involvement evidenced by their signature where they wished to have this involvement. The plan in most cases includes the basic information necessary to plan the individual’s care and includes varied risk assessment elements. Granville House DS0000004857.V340234.R01.S.doc Version 5.2 Page 11 The standard of the plans was variable with some better than others, this in part due to the key workers taking responsibility for maintaining plans in conjunction with residents. Overall health and personal care needs were well detailed although there were some areas where information could have been better; for example one resident was seen to have lost weight since October last year, with no detail of the action the home was taking detailed in the plan. There was indication that this weight loss did seem to relate to a period of ill health this documented in other records. The information seen in the plans was on the whole, based on discussion with residents and staff, accurate. Recording in some of the plans in respect of the individuals residents preferences in respect of their social and emotional care could be better despite formats in the case files that would assist staff to collate information towards this, some of these forms not or only partly completed. There was evidence of information in the plans been subject to regular review and some changes made as a result of these. Practice is supported by policies, procedures and practice guidance. Residents have access to health care services that meet their assessed needs both within the home and in the local community. Some residents were able to retain their own GP (dependent of catchment areas) and all have access to dentists, opticians and other community services (according to individual choice) with the exception of one resident where there was no involvement with the community psychiatric nurse despite indication that this maybe beneficial. Overall resident’s health is monitored and appropriate action taken with the home seeking professional advice on health care issues in most cases, which are then actioned, with records kept supporting the action the home was taken, this including fluid records and turn charts. There is evidence in care plans that in some cases health care treatment and intervention is closely monitored, with records of general health care information including weight monitoring, nutritional and tissue viability assessment. The home has a medication policy which is accessible to staff, medication records are generally up to date for each resident and medicines received, administered and disposed of are recorded. There were some issues where improvement could be made this including the following: - The triggers for the administration of as needed medication (i.e. haloperidol) need to be clearly detailed in care plans. - Prescribed creams were seen to be kept in residents bedrooms but were not locked up as should be the case. - There was no list of staff names against their initials in the front of the medication folder. Granville House DS0000004857.V340234.R01.S.doc Version 5.2 Page 12 Staff spoken to well are aware of the need to treat residents with respect and to consider dignity when delivering personal care, citing numerous examples of good practice in relation to this area of practice. Residents further confirmed these practices as accurate, as did some of the records, a number of which explored resident’s views in respect of such as the gender of carers. The home arranges for residents to enjoy the privacy of their own rooms and provides screens in shared rooms. Residents are happy with the way that most staff deliver their care and respect their dignity with the homes policies and procedures upholding good practice in this area. Granville House DS0000004857.V340234.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 good This judgement has been made using available evidence including a visit to this service. Residents are able to choose their life style, social activity and keep in contact with family and friends. Social, cultural and recreational activities meet resident’s expectations. Residents receive a healthy, varied diet according to their assessed requirement and choice. EVIDENCE: The residents stated that the routines of the home are planned around their choices; needs and preferences, with any restrictions documented in appropriate risk assessment formats and agreed with the resident’s representatives. The home encourages residents to take control of their life and they have involvement in such as three monthly resident meetings where residents have the confidence to discuss what makes them happy and comment where improvements can be made. The home takes residents feedback seriously and makes changes where possible. Granville House DS0000004857.V340234.R01.S.doc Version 5.2 Page 14 Residents said that staff listen to them and make considerable effort to provide a flexible service, which enables them to enjoy a better quality of life. The home policies, procedures and guidance reflect this approach although quality assurance systems still need further development to ensure that there is ready evidence available of practice reflecting procedure. Sufficient staff resources are available to allow time for activities and stimulation, although residents spoken to all said that they preferred a sedentary lifestyle and staff commented on the difficulties they encountered in encouraging the residents to get involved in activity. Care plans were seen in some instances to carry information as to resident’s preferred individual activities although recording and observation by the inspector did not evidence that these were provided on a frequent basis. The comments made to the inspector by residents would however indicate that this is a lack of recording as opposed to the lack of opportunity to become involved in activities, whether they are individual or group. The home operates a key worker system, which enables closer resident/staff relationships where likes, dislikes and needs are shared, and key workers have responsibility for maintaining care plans. Family and friends feel welcome and know they can visit the home at any time. Staff always makes time to talk to visitors and share information with the agreement of the resident. The design of the home provides a number of sitting areas within the communal areas of the home where residents can entertain their visitors, in addition to the privacy of their own room. Hospitality is provided to visitors. Most residents are unable to take responsibility for their own financial affairs, these usually managed by their relatives or the social services department. The home will however safe keep monies so that there is money available for any purchases they would wish to make. Staff work to a clear robust policy that protects the residents from financial abuse and clearly directs staff in their practice. There was evidence that the staff have alerted the appropriate authorities in instances where financial abuse has been suspected. The home is able to offer residents information and telephone numbers for contacting independent people who will act as advocates on the residents’ behalf where the service user prefers the help of an independent person. There have been residents at the home who have been able to take up the services of an advocate. Service users have the choice to bring a limited amount of small goods with them on admission to the home and are encouraged to keep personal items, which are important to them in their own room. There have been difficulties with the resident’s view of the food offered by the home since the time of the last inspection with questionnaires received from residents pre inspection (last year) indicating quite a lot of dissatisfaction with meals. Granville House DS0000004857.V340234.R01.S.doc Version 5.2 Page 15 The manager was however clear as to this area of provision been problematic prior to the inspection and the views of the residents spoken to at the time of the inspection indicated that there had been a significant improvement in this area. Three residents were clear that they had foods they liked and were offered choices. Staff were seen to ask residents what they wished to have for dinner well before it was served, again giving choices. Staff were seen to provide appropriate assistance at mealtimes and when spoken to were aware of how to present food so as suitable for the residents individual needs. The menu has been subject to revision recently and presents a varied choice of foods including two roasts a week. Service users do discuss meals at meetings. Residents enjoy flexible meal arrangements and are able to eat in their own room if they wish. Regular drinks are available and staff will always make a cup of tea at any time when asked, although there was some concern as to the kettle taking a while to boil when hot water was needed. Granville House DS0000004857.V340234.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 good This judgement has been made using available evidence including a visit to this service. Residents have access to a robust, effective complaints procedure and are protected from abuse. EVIDENCE: The service has a complaints procedure that is up to date, very clearly written, and is easy to understand. It is available in large print and on display in the foyer of the home so as to enable access to anyone visiting the service. The complaints procedure is available in the homes service user guide and brief details are also summarised in the contract. Residents and others associated with the home demonstrate a good awareness of who to speak to if unhappy and expressed that they felt confident to do so, and the procedure for complaints is also reinforced at residents quarterly meetings. Unless there are exceptional circumstances the service always responds within the agreed timescale. The policies and procedures regarding protection of residents are of a good quality and are regularly reviewed and updated. The service is clear when incidents need external input and who to refer the incident to, this evidenced by their response to issues that have arisen since the last inspection of the home. Granville House DS0000004857.V340234.R01.S.doc Version 5.2 Page 17 Training of staff in the area of protection is regularly arranged by the home. There are a low number of referrals made as a result of lack of incidents, rather than a lack of understanding when incidents should be reported. The staff spoken to were clear as to what abuse constituted and the action that they should take if they discovered the same. The outcomes from any referral are managed well with issues being resolved. The home makes use of body maps within case files to log any injuries to residents. There was however concern that whilst the home gained consent to restraint this agreement was based on examples of restraint that were not specific to the individual needs of the resident concerned. Any agreement to restraint, if needed (for example use of certain medication), must be specific and only applied when agreed with the resident and their representatives (including social workers, psychiatrist etc). Residents and others associated with the service state that they are very satisfied with the service provision, feel safe and well supported by an organisation that they felt had their protection and safety as a priority. Granville House DS0000004857.V340234.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): 19,20,21,23,24,25,26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables residents to live in a safe, generally well-maintained and comfortable environment, which generally meets with their expectations. EVIDENCE: The service provides a homely environment. It has a rolling programme to improve the decoration, fixtures and fittings. There is also a book to log any repairs that arise although there was concern that this was not maintained with some minor works logged but not complete, and others completed not signed off. Granville House DS0000004857.V340234.R01.S.doc Version 5.2 Page 19 There are a number of single rooms, a few double rooms, but some of the residents say that they knew when they chose the home that they would have to share and where wished single rooms are offered as soon as they become available. Residents can personalise their rooms and choose where they sit in the communal areas. The home has three communal areas these allowing residents to sit in smaller groups. An additional sitting area has been provided through the provision of a conservatory. There was discussion in respect of the sitting of the call button in the smaller lounge, and it was agreed with the provider that the resident’s ability to use this should be kept under review in light of staffing levels that maybe available at any given time of day. Residents say they are comfortable, the home is clean, warm, well lit and there is usually sufficient hot water, although there have been occasions where there has been difficulties with the later due to failure of components in the hot water system. A recognised service contractor addresses these as they arise, with a contract taken up with the same for this purpose. There are sufficient bathrooms, one additional one provided since the time of the last inspection of the home. The toilets are situated near to resident’s rooms and the communal areas. Residents spoken to were happy with their bedrooms and none stated they wished to have a key to their door or a lockable area within as they felt there was no need. The provider was however advised to consider fitting appropriate turn bolt locks to all doors (in accordance with Fire Service expectations) so that they were available as needed. The provision of lockable areas in all rooms is also advisable, as it would assist with securing prescribed creams even if a resident did not directly request such a facility. The majority of residents stated that the home is generally clean and tidy; this confirming what was seen by the inspector. Some outbreaks of infection (some following residents return from other environments) have occurred over the last year, these been managed and CSCI informed, with the home asking for advice on controlling the infection from the NHS staff where necessary. The last inspection of the home by West Midlands Fire service highlighted no cause for concern. The last visit by Environmental Services was a few years ago the home has worked to address any issues identified at this time. Despite a few areas where improvement was needed the environment was seen to generally meet with the expectations of the residents, and the manager and provider showed an awareness of areas where work was needed, despite slippage in some of the documentation related to this. What is recognised is that there has been significant improvement over the last few years. On this basis the environment is judged as good as opposed to adequate by what is a narrow margin. Granville House DS0000004857.V340234.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): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and available in sufficient numbers to allow the fulfilment of the homes aims and meet the changing needs of residents, subject to the management becoming more flexible with the allocation of staff hours as was proposed. EVIDENCE: Residents expressed confidence in the staff that care for them. The majority of residents stated that they received attention from the staff as and when it was needed. There was discussion with management in respect of staffing levels due to some concerns in respect of night staffing levels. These need to be more flexible within the hours available, without the provider having to worry about what was now an outdated condition of registration in respect of staffing. It was agreed that this condition was restrictive due to the changing needs of residents and have been referred to the Central Registration Unit for review. It is positive that issues raised by the staff team have been listened to by the manager and brought to the provider’s attention. Discussion with the provider post inspection indicated that staffing levels have now been adjusted to better meet the peak periods of demand presented by the residents needs. Granville House DS0000004857.V340234.R01.S.doc Version 5.2 Page 21 The inspector was also made aware of the home introducing a new dependency level-monitoring tool that should assist with the on-going review and monitoring of staffing levels. Management encourage staff members to undertake external qualifications with the level of NVQ level 2 qualification well beyond the minimum requirement. The manager recognises the benefits of a skilled, trained workforce. The service clearly defines the roles and responsibilities of staff through job descriptions. Residents report that staff working with them are very skilled in their role, and are consistently able to meet their needs. The service ensures that all staff within its organisation receives relevant training that is targeted and focussed on improving outcomes for residents. The service uses external providers to deliver this training if they have not got the appropriate skills within the organisation. This training can be small scale and individualised if necessary in order to promote the delivery of appropriate care. The service has a good recruitment procedure that clearly defines the process to be followed. This procedure is followed in practice with the service recognising the importance of effective recruitment procedures in the delivery of good quality services and for the protection of residents. The only issue that was highlighted to management was the need to ensure one of the references obtained for new staff was from the new employees last social care employer where this was applicable. Residents are not at present involved in the recruitment process. Staff recruited confirm that they were involved in an induction process that included a good foundation in basic caring skills, time to familiarise they selves with the job as an extra to normal staff numbers, and targeted training in areas identified as necessary such as dementia care. There is no use of any agency staff, with use of staff from the providers other home where there was a need to fill hours. Granville House DS0000004857.V340234.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. The management and administration is led by a strong and competent manager, and robust quality assurance systems have been developed and are ready to put into place. There is evidence that the manager has listened to comments about the service from users and made changes to improve the same. EVIDENCE: The manager has the required qualifications and experience and is competent to run the home. She has worked to continuously improve services and provide an increased quality of life for residents. Granville House DS0000004857.V340234.R01.S.doc Version 5.2 Page 23 There is a strong ethos of being open and transparent in all areas of running of the home as was evidenced by resident and staff comments. The manager is resident focused and leads and supports a staff team who have been recruited and trained to an acceptable standard, and are encouraged to develop further through appraisal and supervision. The manager is aware of current good practice developments nationally and is open to adopting changes that are led by the former. Comment from a visiting professional drew attention to the fact that the manager was ‘accessible’ as opposed to office based. The home generally has sound policies and procedures, which the manager and provider effectively reviews and updates, in line with current thinking and practice. The manager spoke of methods in use to assist staff to translate the homes policies into practice such as regular supervision, staff meetings and encouragement to keep up to date with written procedures. Systems to assist with monitoring staff adherence to policies and procedures during their practice are available but need further improvement, and example of this the consistency of the quality of care plans. The home works to a clear health and safety policy, with all staff having access to this, and regular random checks taking place to ensure they are working to it. Staff spoken to were aware of safety arrangements and have the knowledge to ensure safe working practices are upheld. The home has improved its record of meeting relevant health and safety requirements and legislation over the last few years. Most records are of a good standard and are routinely completed, although there are some shortcomings as identified earlier in this report. Discussion with the provider has evidenced that a quality assurance system that is robust and workable has been developed with a reputable training agency but at the time of the inspection was yet to become fully operational. When fully operational the system should help identify those shortcomings that have been flagged up within this inspection and allow the home to achieve an improve quality rating. There was evidence however that comments from residents have been heard and changes made to improve the service (for example meal provision). Comments through the use of such as questionnaires to residents and relatives are used. If they wish and are able to, residents would be helped to take responsibility for managing their own money although as previously mentioned they are not provided with facilities to keep their valuables and money safe in their rooms although do have access to a central safekeeping facility. Where the home is responsible for resident’s money it works to a very rigorous system, it maintains very clear records that are routinely kept up to date and can be used to track individual residents finances. The service understands the need to meet external requirements if it acts as agent or appointee for residents. Granville House DS0000004857.V340234.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 X 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 4 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 3 3 X 3 2 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 2 X 3 3 X 3 Granville House DS0000004857.V340234.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Care plans must consistently include reference to how the home is to address all aspects of the resident’s health and welfare based on assessments and including social and emotional care. The triggers for the administration of as needed medication (i.e. haloperidol) must be clearly detailed in care plans. Prescribed creams must be kept secure at all times. Any agreement to restraint, if needed (for example use of certain medication), must be specific and only applied when agreed with the resident and their representatives (including social workers, psychiatrist etc). Timescale for action 30/04/07 2. OP9 13(2) 30/04/07 3. 4. OP9 OP18 13(2) 12(2) 30/04/07 30/04/07 Granville House DS0000004857.V340234.R01.S.doc Version 5.2 Page 26 5. OP33 24 To continue developing the homes quality assurance system as discussed. This is a repeated requirement that was to have been met by the 31/3/06 31/05/07 6. OP33 26 The responsible individual should prepare a written report on the conduct of the home every month. 31/05/07 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 OP9 OP12 Good Practice Recommendations Staff names should be documented against their initials in the front of the homes medication record. The home should better document the activities residents are involved with on an individual as well as group basis and evidence how these would meet the resident’s social /emotional needs. The manager should encourage the staff to complete documentation formulated to assist with the assessment of a resident’s on going preferences for example daily routine records, “I can’t stand it” sheets and so on. The homes maintenance records should be better maintained so that they are accurate. The resident’s ability to access the call bell in the small lounge by the office should be risk assessed in respect of staffing available at differing times of day. The fitting of suitable door locks and lockable facilities in all bedrooms should be considered. DS0000004857.V340234.R01.S.doc Version 5.2 Page 27 3. OP12 4. 5. OP19 OP19 6. OP24 Granville House Granville House DS0000004857.V340234.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Granville House DS0000004857.V340234.R01.S.doc Version 5.2 Page 29 - 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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