Inspection on 17/10/05 for Grasmere

This inspection was carried out on 17th October 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 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

Grasmere 29/10/08

Grasmere 05/12/07

Grasmere 04/12/06

Grasmere 19/01/06

Grasmere 10/03/05

Grasmere 21/07/04

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

CARE HOMES FOR OLDER PEOPLE Grasmere 49 Grange Road Sutton Surrey SM2 6SY Lead Inspector Deborah Yapicioz Unannounced Inspection 17th October 2005 10:00 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 Grasmere DS0000007133.V258060.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. Grasmere DS0000007133.V258060.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Grasmere Address 49 Grange Road Sutton Surrey SM2 6SY 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) 020 8642 8612 020 8642 9953 Mrs Zeenat Nanji Mr Salim Nanji Mrs Sandra Sawyer Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Grasmere DS0000007133.V258060.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10/03/05 Brief Description of the Service: Grasmere is registered with the Commission For Social Care Inspection to provide personal care for twenty-five older people. The home is situated in south Sutton and is within reasonable walking distance of shops and public transport. The original building has been extended over recent years and a number of the single rooms lead directly onto the garden. Many of the rooms have ensuite facilities and there are also sufficient numbers of bathroom and toilet facilities conveniently located throughout the home. There is also a well-equipped kitchen and a separate laundry room The garden is used by residents in suitable weather and can easily be accessed by those whose mobility is restricted. There are three communal rooms including the dining room and a shaft lift. Residents have regular access to services of healthcare professionals such as district nurses, dentist and opticians as well as chiropodists. Grasmere DS0000007133.V258060.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 took place on the morning of 17th October 2005. The home was inspected under the National Minimum Standards Care Homes for Older People. The home is registered with the Commission for Social Care Inspection to provide residential care for up to twenty-five service users. The inspector would like to thank the home manager, the homeowner the staff team and the service users, for their time and willingness to facilitate the inspection process. Methods of inspection included a tour of the premises, observation of contact between staff and service users and a discussion with the registered manager and homeowner. Records examined included the service users plans, complaints, staffing records, training records, Medicine Administration Record Sheets, menus and staff meeting minutes. What the service does well: What has improved since the last inspection? The home does not admit any service user whose needs cannot be met by the staff team at the home. A needs assessment is requested from the referring care manager and the home management team also completes the in-house assessment to ensure that the home is suitable and the service users needs can be met. The home has recently undergone a planned programme of improvement. Three refurbished single rooms with ensuite facilities have been completed. Grasmere DS0000007133.V258060.R01.S.doc Version 5.0 Page 6 The management team at the home are also planning more improvements in the future. 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. Grasmere DS0000007133.V258060.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 Grasmere DS0000007133.V258060.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): 1,2,3,4,5, The home provides good information and introduction opportunities for prospective service users and their families to make an informed choice about moving to the home. A needs assessment is always completed to ensure that service users needs can be met at the home. Each of the service users is issued with an individual contract setting out the terms and conditions of the placement, which safeguards the interests of both parties. EVIDENCE: Grasmere has a comprehensive statement of purpose and a separate service user guide in place, which contained all the information required under the Care Standards Act. A copy of the homes most recent inspection report was available in the home on request. A needs assessment is requested from the referring care manager and the home management team also completes the in-house assessment to ensure that the home is suitable and the service users needs can be met. The service users files looked at during the inspection all contained assessments completed before the service users moved into the home. Grasmere DS0000007133.V258060.R01.S.doc Version 5.0 Page 9 Records seen indicated that residents are invited to view the home and to stay for a trial period before a final decision is made for the placement to be long term. Most residents have involved relatives who also participate in this process. Each of the service users has a personal contract, specifying the terms and conditions of their occupancy that included periods of notice, fees charged, and the cost of ‘extras’ not covered by the basic cost of the placement. This home does not offer intermediate care therefore standard six does not apply. Grasmere DS0000007133.V258060.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10, The service users have individual care plans, which are regularly updated to ensure the service users changing needs are met. Personal care is carried out in a way that residents prefer so that dignity and choice are maintained. EVIDENCE: The home has a policy on the receipt, recording, storage, handling, administration and disposal of medication. Records examined showed that all medicines administered are recorded on Medicine Administration Record Sheets. On the day of the inspection there were some gaps in the medication records. The home must ensure all medication records are filled in correctly. Grasmere DS0000007133.V258060.R01.S.doc Version 5.0 Page 11 A sample of plans was inspected. A commercially produced, “Standex system” is in use at the home. These were comprehensive and indicated that residents’ individual needs were identified, action was taken to meet these and they were reviewed once a month. The home operates a risk management strategy. Service users at the home have individual risk assessments depending on their needs. The service users are all registered with a local General Practitioner The manager assured the inspector that there had been no incidents of pressure sores in the home since the previous inspection and that the home had good communication with district nurses who is able to offer advise on pressure sore prevention. Service users are weighed on a monthly basis and appropriate records maintained. The home also arranges for ‘gentle ‘ keep fit sessions for those service users who choose to participate. The manager informed the inspector that chiropodists, opticians and dentists visit the home on a regular basis. The service users preferred term of address is also recorded on their file and used by the staff team. There are curtains in shared bedrooms for screening when personal care is being given. The manager stated that all new members of staff receive as part of their structured induction training in how to treat service users with respect and dignity at all times. During the inspection the staff team were observed to treat the service users with respect and kindness. Grasmere DS0000007133.V258060.R01.S.doc Version 5.0 Page 12 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): 12,13,14,15 The service users at the home are offered the opportunity to engage in various activities that satisfy their social, cultural, religious and recreational interests and needs. The daily routines and house rules promote residents’ rights and encourage independence. The home has an open visitors policy to ensure family links are maintained. Dietary needs are catered for with meals that are nutritionally well balanced and clearly based on the service users food and drink preferences, providing them with daily variation and healthy eating options. EVIDENCE: On the day of the inspection the homes daily activities and the lunchtime meal choices were all conspicuously displayed on the homes notice boards. Information about the homes recreational activities were on easy to read posters attached to the homes notice boards around the home. The activities included gentle exercise, quizzes, guitar sing-a-longs and bingo sessions. The home also has a good supply of large print books. The home manager also arranges for the service users to go out on various outings including trips to the coast, up to London to see the lights. The home manager has arranged for a theatre group to come to the home to do a Pantomime at Christmas for those service users who are unable to go out much. The local church will also be doing a carol concert at Christmas. Grasmere DS0000007133.V258060.R01.S.doc Version 5.0 Page 13 There is an open visitors policy and families are welcome to visit at any time, although the service users can choose who they wish to see. The visitor’s policy is included in the service user guide. Visitors can be seen in any part of the home including bedrooms. The home invites relatives and families to any social events. The home recently arranged a garden/Jazz party and photographs of the event were placed in communal areas. Personal items including furniture can be brought into the home if service users wish (if it is appropriate). This is recorded on the service users property file. Service users are on the electoral register and have postal votes. The service users are offered three meals a day as well as morning and afternoon tea’s. The manager stated that service users have a choice of where to eat their meals. Having examined a random sample of menus, it was clear that a wide variety of well-balanced, nutritional food was available. The service users agree the homes menus at the service users meetings. Medical needs are taken into account when planning menus. Any dietary needs are recorded in the service users care plan. Grasmere DS0000007133.V258060.R01.S.doc Version 5.0 Page 14 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): 16,17,18 There is complaints policy and procedure, which facilitates good access to the complaints system for the residents, their family or their representatives. The home has the appropriate policies in place to ensure the protection of vulnerable service users. EVIDENCE: Grasmere has a complaints procedure, which outlines how a complaint is dealt with and timescales for action. The home keeps a record of any comments or complaints made about the service. There has been one anonymous complaint since the last inspection, which was sent directly to the Commission for Social Care Inspection. The complaint was investigated by the Commission for Social Care Inspection and not upheld. The home has in place procedures for responding to suspicion or evidence of abuse, including whistle blowing, and passing on concerns to the Commission for Social Care Inspection The London Borough of Sutton’s adult protection procedures were available in the office on request. The manager assured the inspector that any allegations or incidents of abuse would be reported to the appropriate authorities, including the Commission, and appropriate records maintained, including any action taken. The home provides staff training on issues of elder abuse. A notice was on the staff room wall advising the staff team that a training session on Adult Protection issues was due to take place on 20/10/05. Grasmere DS0000007133.V258060.R01.S.doc Version 5.0 Page 15 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): 19,23,24,26 This home provides a comfortable, clean and safe environment for service users to live in. The general décor of the home is good providing a comfortable, clean and safe environment for service users to live in. Service user’s bedrooms provide privacy and reflect individual interests and preferences. EVIDENCE: The home is situated in south Sutton and is within reasonable walking distance of shops and public transport. The home provides accommodation on the ground and first floor. Access to the first floor is via stairs; a shaft lift is also available. The property has been extended on the ground floor and many of the newer bedrooms have direct access to the garden, which they look on to. The garden can also be accessed through the lounge. The home has recently undergone a planned programme of improvement. Three refurbished single rooms with ensuite facilities have been completed. There are also sufficient toilets and bathrooms situated through out the home the general standard of decoration on the day of the inspection was good. A Grasmere DS0000007133.V258060.R01.S.doc Version 5.0 Page 16 number of aids and adaptations such as bath and toilet seats, nurse call system and rails are provided at the home. On the morning of the unannounced inspection the home was warm, comfortable, bright, well ventilated and free from offensive odours. There were many “homely” touches such plants and flower arrangements. There is ample communal space through out the home. The communal areas appeared comfortable, bright and furnished appropriately with areas for service users and their visitors to meet in private. There are sufficient numbers of bathrooms and toilet facilities situated throughout the home. Service users bedrooms are pleasant and they have all been personalised by their occupants. During the inspection many of the service users said how much they liked their rooms at Grasmere. Grasmere DS0000007133.V258060.R01.S.doc Version 5.0 Page 17 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): 27,28,29, The staff team at the home have a range of skills and abilities, which enable them to meet the needs of the service users living at the home, ongoing training to build on staff skills is provided. The staff team have all had Criminal Records Check, as a safeguard to offer protection to the homes service users EVIDENCE: The home manager arranges for five staff to be on duty for both day shifts. The job descriptions for staff at the home staff clearly states what is expected of its employees in terms of their roles and responsibilities and the values that should underpin their conduct Staff files hold copies of the staff contracts, copies of passports/birth certificates, references, working time regulations forms, copies of Criminal Records Checks/POVA first checks as well as induction and training records. The Staff team have access to a range of training courses including National Vocational Qualifications, manual handling, food hygiene and first aid. Evidence of training was seen on the sample of personnel files viewed. The home holds regular staff team meetings, which are recorded. The management team at the home also have regular meetings. Posters informing the staff team of upcomoming training events were on display around the home including a flyer giving the details of a fire lecture due to take place at the end of October. The homeowner is in the process of developing a staff handbook, which includes a mission statement for the home and other staff policies. Grasmere DS0000007133.V258060.R01.S.doc Version 5.0 Page 18 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): 31,33,35,38, The management style is open and the home appears to be well run. There are clear lines of accountability, which is aimed at ensuring the interests of the service users, are safeguarded and their safety and welfare are protected. EVIDENCE: Sandra Sawyer manages the home. Mrs Sawyer has worked at the home for the past ten years and has been the manager of Grasmere for the past five years. The homeowner also has an office at Grasmere and is available to support the home manager if required. The home manager and the homeowner demonstrated a good awareness of health and safety issues. The home has a health and safety policy in place and the staff team receive training on issues such as basic food hygiene, fire and manual handling. Grasmere DS0000007133.V258060.R01.S.doc Version 5.0 Page 19 Copies of the homes policies and procedures are kept in the staff room. The home has staff meetings, which are recorded. Environmental risk assessments are in place. The fire alarm system and emergency lighting is checked on a regular basis. Fridge and freezer temperatures are taken and recorded. Records show that the frequencies of fire drills are not taking place as often as they should. A first aid box and a fire blanket are situated in the kitchen. There are fire extinguishers throughout the house. Coloured chopping boards and knives were seen in the kitchen. Grasmere DS0000007133.V258060.R01.S.doc Version 5.0 Page 20 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 3 3 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X X 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Grasmere DS0000007133.V258060.R01.S.doc Version 5.0 Page 21 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 2 Standard OP9 OP38 Regulation 17 (1)(a) Sch 3 3(i) 23. (2)(e) Requirement The home manager must ensure all medication records are correctly filled in at all times The home manager must ensure more frequent fire drills take place in keeping with good practise. Timescale for action 17/10/05 17/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Grasmere DS0000007133.V258060.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Grasmere DS0000007133.V258060.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. 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