Inspection on 18/10/07 for Granville House

This inspection was carried out on 18th October 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Granville House 17/09/09

Granville House 11/08/09

Granville House 16/02/07

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 Key Unannounced Inspection 18th October 2007 09:30 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.V348638.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.V348638.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.V348638.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. 16th February 2007 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 is also some ancillary staff in place including cook, domestic and handyman. The home provides a service to older people with dementia. 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.V348638.R01.S.doc Version 5.2 Page 5 The homes fees range from £405.00 to £439.85 per week with no top up charges for local authority funded residents. Any charges for the following are not included in this fee: Newspapers, private telephone calls, hairdresser, chiropodist (private) dry cleaning, treatment by dentist, opticians (where applicable) and clothing. Granville House DS0000004857.V348638.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over one and a half 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 (within an AQAA – annual quality assurance assessment) 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? There have been numerous improvements within the service not least the fact that the home has addressed all the areas of concern identified within the last inspection report, this having involved improvement in: • Care planning and how care plans are documented with an increasing emphasis on the individual; • Better documentation as to when as required medications are necessary; • Ensuring prescribed creams are secure; • Better identification of areas where the service is able to improve as stated within the homes annual quality assurance assessment, this assisted by robust methods of consultation with residents, staff and other stakeholders. In addition there was improvement in the following: Granville House DS0000004857.V348638.R01.S.doc Version 5.2 Page 7 • • • In pre admission assessments and how the home communicates information to the prospective residents, Better quality foods and wider dietary choices (including West Indian cuisine), The flooring in the lounge, conservatory and some bedrooms has changed from carpet to non-slip laminate or good quality lino. 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.V348638.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Granville House DS0000004857.V348638.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 & 5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective residents have access to sufficient information to enable them to make an informed choice as to the homes suitability in meeting their individual needs. EVIDENCE: The home provides a Statement of Purpose that is specific to the individual home, and the resident group catered for. The objectives and philosophy of the service are set out and information is carried through to a service user’s guide with summary of key points in a brochure. The service user’s guide details what the prospective individual can expect and gives a clear account of the specialist services provided, quality of the accommodation, qualifications and experience of staff and how to make a complaint. All residents and/or their representatives are given copies of the guide, this evidenced by Granville House DS0000004857.V348638.R01.S.doc Version 5.2 Page 10 signature at the point they are given. Consideration has been given to the presentation of information in understandable formats for residents with dementia and the manager has created an ‘assessment folder’ that is taken out by staff when they meet residents prior to admission, this during the course of the home’s pre admission assessment. This folder contains copies of the homes statement of purpose, service users guide, brochure, key policies, last CSCI report and a wide range of photographs relating to the service provided, the facilities available and day-to-day life at the home. The manager has identified that there is need to develop this further with plans to improve the presentation of the pictures in the assessment folder and include information relating to the current service user’s views of the home. Based on the information seen within three residents case files the home does not admit people until a full needs assessment has been undertaken this involving the manager of the service and where possible care staff. People involved in the assessment are documented on the pre admission assessment forms and include the prospective resident, relatives and in some cases social workers. Where an assessment has been undertaken through care management arrangements there was evidence in case files that the home receives this prior to the individual’s admission. Admissions to the home only take place if the service is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident. The staff management team may consider the application together with other staff, before agreement is given for the admission. The homes assessment format as well as covering all those areas expected by national minimum standards was seen to focus on the individual personal requirements, preferences and choices (such as meal preferences, religious needs, cultural needs, likes and dislikes and so on) Where possible and if prospective residents wish it there is the opportunity for them to spend time in the home prior to making a decision as to their admission, the manager seeing this as a valuable time to gather information as to the individual’s needs. The manager usually makes herself available at these times, or there are other senior staff that are available to give them information and to help them understand what is available at the home. There was seen to be clearly documented evidence of some resident’s visits to the home pre admission. Where this is not possible the home invites the residents representatives to visit the home. Following the admission the placement is subject to a trial period following which there is a review to make any final decision as to the homes ability to meet the individual’s needs and assess their satisfaction with the service provided. There was seen to be records of such on all case files examined. New residents are provided with a Statement of Terms and Conditions/Contract, which this sets out the fee, what is included in this fee, the role and responsibility of the provider, and the rights and obligations of the Granville House DS0000004857.V348638.R01.S.doc Version 5.2 Page 11 individual. This is clear, jargon free, easy to understand and gives a fairly clear understanding of what residents can expect, although is currently only available in written format. Based on comparison of more recent admissions with those that had resided at the home for a while it was clear there has been some review of the terms and conditions. Feedback from questionnaires indicated that 6/8 residents felt that they received sufficient information about the home before they moved in, this backed up by comments from relatives with all saying that they always or usually had the information needed in respect of admission or changes to the service. There was one comment that indicated there had been some misunderstanding between agencies at the point of admission, although these were now resolved and there was now a good relationship between resident, relatives and the home. Granville House DS0000004857.V348638.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are identified and put into practice in accordance with individual wishes. EVIDENCE: The home is currently in the process of updating care plan formats and the case tracking of resident’s care involved sight of new and older formats. In all cases the care plans for individuals detailed the full range of needs the individual required with an emphasis on individual preferences and choices as carried through from the home’s assessments. Care plans in general were found to detail the personal and healthcare support an individual required and discussion with the residents, representatives and staff indicated that these were up to date and accurate. There was evidence of the plans highlighting the diverse needs of residents in respect of how communication with individuals Granville House DS0000004857.V348638.R01.S.doc Version 5.2 Page 13 was to be enhanced and how individual preferences are met (including dietary, cultural and religious). Information on the care to be provided drew, with little exception, on a range of risk assessments in respect of nutrition, tissue viability, falls, mobility and bathing, all which are reviewed monthly to ensure they are current. The manager has identified that there is however scope to develop the care plans so they are easier to understand for those who have difficulty with written documents. There was documented evidence that residents or their representatives had been consulted as to their involvement with the care planning process, although the manager was advised to ensure that the residents consent to their representatives signing to agree was explicit, or there was clear agreement as to their capacity in accordance with the expectations of the Mental Capacity Act. Discussion with staff and the manager showed that there was a good awareness of the care plans contents and by default the needs of residents and how these were to be met. Discussion with residents and relatives indicated that residents care needs were met by the home, this confirming comments in questionnaires received with 100 of residents replying stating they received the care and support they needed and 6/9 residents stating the home meet residents needs. There was evidence that the home is exploring resident’s wishes in respect of the gender of their carers with these choices documented within case files. Whilst there are only two male carers the manager has identified proactive recruitment to reflect the resident group as an issue for the service. Based on documentation in case files, this supported by comments from residents and relatives, the home is proactive in ensuring that residents have access to the full range of community health services including G.P, district nurse, dentist, optician, psychiatrist and so on. The home was able to evidence that referral of health issues to these agencies is both timely and appropriate. Staff awareness of health related issues in supported by a robust training programme. The home has developed an efficient medication policy; procedure and practice guidance and staff knowledge has been supported through the provision of appropriate accredited medication training. Whilst the take up of selfmedication is limited the homes policy supports residents who wish to take this option within a risk assessment framework. Medication records are seen as key to the efficient management of health care matters, and examination of these records coupled with discussion with and observation of staff confirmed that they are consistently kept up to date. This extends to the signing for prescribed creams as they are administered; these creams now kept secure when not in use. In addition the home has clear guidelines for the Granville House DS0000004857.V348638.R01.S.doc Version 5.2 Page 14 administration of ‘as required’ PRN medication although the agreement of these with the prescribing practitioner is advised. Staff in discussion gave clear examples of how they would promote the privacy and dignity of residents on a day to day basis, this building on information documented in care plans and the practices observed during the course of the inspection in the way the staff interacted with residents. Case files contained residents preferred titles and staff were heard to use these on numerous occasions. Discussion with residents confirmed the validity of these titles. Granville House DS0000004857.V348638.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. People who use services are able to make choices, sometimes with relative support, about their life style, and are supported to develop their life skills. Social, educational, cultural and recreational activities and meal provision meets resident’s expectations. EVIDENCE: Through the assessment process the home has worked hard to establish individual’s preferences and choices in respect of their lifestyle with documentation showing that this information was in the majority of cases clearly documented. Observation showed that residents were able to get up when they choose (in accordance with documented choices) and breakfast was available when they chose to have it rather than at a set time. In addition important facets of a resident’s life prior to admittance to Granville were maintained with one resident having regular access to church with her relatives assistance. Many of the residents chose not to go to bed until late or in some cases like to stop up at night and in trying to meet this preference the homes staffing has been organised so that there are more staff available at the times Granville House DS0000004857.V348638.R01.S.doc Version 5.2 Page 16 residents need them. A number of recliners have been purchased so that residents, if they chose, are able to rest in these in comfort. Comments from residents and relatives confirm the homes pro-active approach to building the homes routines around the resident’s chosen lifestyle. Activities were seen to be available during the course of the inspection and staff were seen to encourage participation within these. The recording of resident’s individual involvement in activities has improved since the last inspection and this showed that residents were able to partake in appropriate group or individual activity as wished. Contact with relatives and representatives are encouraged by the home, not least through an open visiting policy. A number of relatives were seen visiting the home during the course of the inspection, and confirmed that this was the case. The homes policies state that hospitality is to be offered to visitors and this was seen to happen in practice. Meals are available should visitors wish them. Comments from relatives also confirmed that the home kept them involved with developments in respect of the individual. Residents were seen to be able to bring in their personal possessions into the home within health and safety restrictions and there was information available to residents and their representatives as to other organisations that may assist them within the homes complaints procedure and in the reception area of the home. The home is known to have encouraged resident’s involvement with advocacy services. There are disclaimers in place in respect of some choices although in cases these were signed by relatives and it was unclear as to the actual choice made as ready typed options had not be crossed out. This led to discussion with the manager around the need to ensure that assessments are carried out in respect of resident’s capacity to make decisions in accordance with the Mental Capacity Act 2005, this so that their right to any individual decision making is fully protected. The manager has recently obtained a copy of the Department of Health documentation in respect of this legislation and stated would be familiarising herself with this in preparation for any implications this may have for the homes practices. The home was seen to have an eight-week menu and it was stated that this is reviewed at the end of every eight-week period drawing on comments made by residents through such as monthly meetings. The Meals are very well balanced and highly nutritional and cater for varying cultural (West Indian meals are available) and dietary needs of the people who use services. Sight of meal times showed these to be relaxed, portions to be of good sizes (although small portions were given where requested) and choice to be available. Staff were seen to offer residents a choice of meals beforehand, for example residents were asked midmorning what their choice was for lunch. Comment from residents on the day indicated that they felt the meals were generally good, this confirming the finding of questionnaires where all the respondents stated they enjoyed the meals. Granville House DS0000004857.V348638.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents have access to a robust, effective complaints procedure that allows them to express their concerns, and feel safe in the knowledge that they are protected from abuse. EVIDENCE: Residents and others involved with the service say that they are happy with the service provision feel safe and well supported this indicating that the service has their protection and safety as a priority. Access to the complaints procedure is facilitated by the home and residents stated that they were listened to and things were put right. Comments to us included the following: “The policies and procedures are available for friends and relatives to read. The complaint procedure was explained when I completed my fathers background details” “The staff do listen to me” “Would talk to staff and they put right” The service has a complaints procedure that is clearly written and easy to understand and is also available in large print and recently in pictorial format. Granville House DS0000004857.V348638.R01.S.doc Version 5.2 Page 18 The complaints procedure is supplied to everyone living at the home and in addition is displayed in a number of areas. Residents are also encouraged to raise any issues within monthly meetings. The home keeps a full record of formal complaints but is looking to develop a system of recording non formal concerns which are brought to the home’s attention. The home’s policies and procedures for dealing with adult protection matters are available and give clear specific guidance to those using them, supplementing the local authorities procedures that are stored in the same folder. Staff when asked knew when incidents need external input and who to refer the incident to, although in some instances were unclear as to where the procedures were kept. The manager stated that an update for the staff team in adult protection was due, although has been provided on a regular basis to staff previously. Other training around dealing with physical and verbal aggression is also made available to staff as needed. The manager in discussion understood the procedures for Safeguarding Adults and will always attend meetings or provide information to external agencies when requested. There are a low number of referrals, this seemingly due to a lack of incidents, rather than a lack of understanding about when incidents should be reported. Granville House DS0000004857.V348638.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: The home provides a physical environment that generally meets the specific needs of the people who live there and is comfortable. There was clear evidence of on going works having taken place since the last inspection and continuing during the course of this visit with redecoration of some bedrooms and the fitting of attractive non slip flooring in lounge/conservatory and some bedrooms. There has also been recent purchase of a number of recliner chairs for use by residents, these available in the homes lounges. The availability of two lounges and a conservatory allows residents to have choice as to where Granville House DS0000004857.V348638.R01.S.doc Version 5.2 Page 20 they wish to sit. Some of the furniture in bedrooms whilst adequate is dated and would benefit from replacement. The provider is well aware of this issue however and is looking to replace these items following the completion of an extension of the home when additional items would need to be purchased to furnish new rooms. The replacement of dining tables would however be beneficial as the current ones are old and have been subject to prior repair. Larger tables may in some instances be more appropriate. Comments from one resident in a double room indicated that whilst they were happy sharing they felt that there was a lack of space. This is also an issue that the provider was well aware of and plans to extend the home will result in only single rooms. There are also plans to extend the homes garden area although there was comment from a relative as to the current garden area been readily accessible and suitable for some residents. Sampling of servicing documentation for equipment and fixtures in the home evidenced that these were well maintained and a recent Fire prevention officers visit to the home raised no areas of concern. The home was found to be well lit, clean and tidy and smelt fresh and residents stated that this was usually the case. The management has a good infection control policy and know to seek advice from external specialists, e.g. infection control as needed. Staff in discussion were well aware of the steps to take to reduce the spread of any infections such as MRSA (in which case there is clear detail in care plans as to actions staff must take) and training for staff in infection control is on going. Granville House DS0000004857.V348638.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff in the home are well trained, skilled and available in sufficient numbers at the times residents need them. Staff recruitment procedures are robust and protect residents. EVIDENCE: Residents and their representatives expressed confidence in the staff team that care for them with comments made as to their being good at their `jobs’, ‘well trained’ and friendly’. This was supported by observation of the staff in practice and discussion with some staff around working practices at the home. Rotas were seen and their accuracy was confirmed. Staffing is reviewed on an on going basis to ensure that sufficient staff are available at the times residents need them, this having led since the last inspection to more staff been available at night as opposed to the day, this due to a number of residents choosing to stop up late at night. The manager was clear in discussion that staffing levels are based around delivering positive outcomes for the people using the service and not staff requirements. Seven out the eight residents that responded via CSCI questionnaires stated that staff were always around when they were needed. Granville House DS0000004857.V348638.R01.S.doc Version 5.2 Page 22 The home was seen to have a robust training programme and whilst they were a few gaps in training needed for staff these were clearly identified and were been actioned by the manager. There was evidence that the manager encourages staff to take external qualifications beyond the basic requirements, this assisted through links with a training agency that can formulate bespoke programmes to fit in with the homes requirements. The manager spoke of the training organisation currently developing a training session for staff in pool activity levels (a framework for activity based care system specifically developed for use with people who have dementia). This is to be seen as building on the accredited training in dementia care that most care staff now hold. This clearly underlines the organisations emphasis on maintaining a skilled and well-trained workforce, the benefits of which are apparent based on the outcomes from this inspection. The service was seen to have a robust recruitment procedure with these procedures followed in practice, this judgement based on examination of three staff files. The recruitment process is supported by a set interview and vetting process. Based on discussion with staff and evidence within their files there was satisfactory evidence of staff having a suitable induction, which led in the case of care staff to completion of common induction standards. Staff meetings were seen to be well documented and take place usually once a month this building on the regular one to one supervision sessions staff have with the manager. Granville House DS0000004857.V348638.R01.S.doc Version 5.2 Page 23 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 excellent This judgement has been made using available evidence including a visit to this service. The home is managed by a qualified and competent manager who with the assistance of the provider has developed robust systems for self-evaluation of the service so as to ensure that it is becoming more resident focused and better managed. EVIDENCE: The registered manager has the required qualification and experience and as such has demonstrated that she is highly competent to run the home and meets its stated aims and objectives. The manager has sound knowledge of her responsibilities in terms of the legal framework and to the provider; Granville House DS0000004857.V348638.R01.S.doc Version 5.2 Page 24 showing a keen interest in developing the service in line with resident’s best interests. The provider provides sufficient support to the manager to enable her to carry out her role effectively. The manager has a keen interest in her continued professional development and to this end is looking to commence vocational management training beyond the minimum levels expected for a registered manager. Discussion with staff evidenced that the manager communicates a clear sense of direction with staff positive as to the support they are offered in terms of supervision and training. The manager has a keen interest in ensuring the service develops its ability to offer a service that fully encompasses equality and diversity issues, examples of which were seen in practice. The views of the service users and their representatives are sought through a variety of mediums including meetings, regular questionnaires and through maintaining contact on an on going basis. The service has demonstrated that it has developed and the manager is able to easily identify other areas where there is scope to improve the service as identified in the homes annual quality assurance assessment. The manager is still conscious that the homes quality systems, in her opinion could be more robust and as such intends to develop these further. It was noted that management visits to the home whilst carried out on a regular basis are not routinely documented. The home has efficient systems to ensure effective safeguarding and management of individual’s money, with records relating to the safekeeping of monies and valuables seen to be well maintained and following spot checks accurate. Any property belonging to residents was seen to be recorded within inventories that are updated on a regular basis. The home does not act as an appointee for any resident and steps are taken to ensure there are appropriate others to undertake this role. All the working practices in the home presented as safe and there was little evidence of any accidents that were preventable. The manager does however undertake regular audits of accidents so that any trends would be easily identified. The home was seen to have a range of policies and procedures to promote and protect residents’ and employees’ health and safety, these communicated to staff via training, meetings and supervision. Discussion with staff showed that that had a good understanding of their responsibilities in respect of safe working practices and knew where the homes policies were kept for reference. The home proactively monitors its health and safety performance using the input of other statutory agencies as required. Granville House DS0000004857.V348638.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 4 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 4 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 3 X 3 Granville House DS0000004857.V348638.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 1 Requirement No statutory requirements have been made following this inspection. Timescale for action 01/11/07 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. Refer to Standard OP14 Good Practice Recommendations The registered provider should ensure that assessments are carried out in respect of resident’s capacity to make decisions in accordance with the Mental Capacity Act 2005, this so that their right to any individual decision making is fully protected. The registered provider should ensure that all disclaimers in place in respect of residents choices are clear as to the actual choice agreed where ready typed options on these are not deleted even though signed by resident or representative. The registered provider should provide new dining room tables in accordance with resident’s views on what type/size is appropriate and suitable for them. The registered provider or responsible individual should prepare a written monthly report on the conduct of the DS0000004857.V348638.R01.S.doc Version 5.2 Page 27 2. OP14 3. 4. OP19 OP33 Granville House home so that their views are available in their absence and there is evidence of on going review that supports the home quality monitoring systems. Granville House DS0000004857.V348638.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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.V348638.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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