Inspection on 19/01/06 for Grasmere

This inspection was carried out on 19th January 2006.

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

Grasmere 29/10/08

Grasmere 05/12/07

Grasmere 04/12/06

Grasmere 17/10/05

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 19th January 2006 11:30 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 Grasmere DS0000007133.V282563.R01.S.doc Version 5.1 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.V282563.R01.S.doc Version 5.1 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.V282563.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th October 2005 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.V282563.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes second inspection for the year 2005/6. The inspection was unannounced and took place at on 19th January 2006. The home was inspected under the National Minimum Standards Care Homes for Older People. A previous inspection took place on 17th October when most of the standards that the Commission for Social Care Inspection considers as key standards were inspected. Methods of inspection included meeting with the service users, a partial tour of the premises, and observations of contact between staff and service users, and talking with members of staff. The inspector would like to thank the service users and the staff team for their help in facilitating the inspection. Overall the inspection confirmed that the home continues to provide a good standard of care to the people living there. What the service does well: What has improved since the last inspection? What they could do better: Grasmere DS0000007133.V282563.R01.S.doc Version 5.1 Page 6 It is the homes policy that all medicines administered are recorded on Medicine Administration Record Sheets. On the day of the inspection the medication records were incomplete. This was a requirement of the previous announced inspection and will be monitored at the next inspection. It was also noted that correction fluid has been used to the Medicine Administration Record Sheets This is not good practise and should be discouraged by the home manager. 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.V282563.R01.S.doc Version 5.1 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.V282563.R01.S.doc Version 5.1 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 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. EVIDENCE: Grasmere has a statement of purpose and a Service users guide in place, which, are given to any prospective service users. The homes latest report is available 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. 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. The home is in the process of admitting two new service users. Assessments for both the service users have been completed and visits to see the home have taken place. Grasmere DS0000007133.V282563.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,9 The service users have individual care plans, which are regularly updated to ensure the service users changing needs are met. Medication records at the home are not filled in correctly which could potentially place service users at risk. EVIDENCE: The home has a policy on the receipt, recording, storage, handling, administration and disposal of medication. It is the homes policy that all medicines administered are recorded on Medicine Administration Record Sheets. On the day of the inspection the medication records were incomplete. This was a requirement of the previous announced inspection and will be monitored at the next inspection. It was also noted that correction fluid has been used to the Medicine Administration Record Sheets This is not good practise and should be discouraged by the home manager. The home has care plans in place that carries on from the original care plan and assessment. Residents’ individual needs were identified and the actions to be taken to meet the requirements. The care plans are reviewed regularly and the staff team at the home monitor the plans and make regular entries to record daily activities and any areas of concern. Grasmere DS0000007133.V282563.R01.S.doc Version 5.1 Page 10 Service users are asked about issues around death and dying before admission to the home, this includes any cultural or religious wishes. Grasmere DS0000007133.V282563.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 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. EVIDENCE: The home provides a variety of activities and social events that service users can participate in. The service users spoken to during the inspection enjoyed the Christmas activities, which were organised by the home over the Christmas period. This included a Christmas pantomime, Christmas dinner and a trip to see the lights in London. The staff team at the home are hoping to arrange a theatre trip to see “My Fair Lady”. 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. Visitors can be seen in any part of the home including bedrooms. The home invites relatives and families to any social events. Service users are on the electoral register and have postal votes. The service users informed the inspector that they liked the staff team at the home and they had been able to bring in some of their own possessions and furniture when they moved in. Grasmere DS0000007133.V282563.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 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: The home has a complaints procedure, which outlines how a complaint is dealt with and timescales for action. The complaints procedure is included in the service uses guide. The home keeps a record of any comments or complaints made about the service. The home has an Abuse policy and any concerns would be referred in line with the Vulnerable Adults Procedure. The home has a copy of the local authority Adult Protection Policy on site. The staff team have access to training on Adult Abuse. Grasmere DS0000007133.V282563.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24 The general décor of the home is good providing a comfortable, clean and safe environment for service users to live in. EVIDENCE: The home is situated in a residential area of south Sutton and is within reasonable walking distance of shops and public transport. 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. During the inspection many of the service users said that they liked their rooms. 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 number of aids and adaptations such as bath and toilet seats, nurse call system and rails are provided at the home. Grasmere DS0000007133.V282563.R01.S.doc Version 5.1 Page 14 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): 27,30 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. EVIDENCE: The staff members spoken to during the inspection made positive comments on their experience of working at the home. The Staff team have access to a range of training courses including National Vocational Qualifications, manual handling, food hygiene and first aid. Attendance certificates are kept on staff files The home holds regular staff team meetings, which are recorded. The home manager arranges for five staff to be on duty for both day shifts. At night two staff are on duty. 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 Grasmere DS0000007133.V282563.R01.S.doc Version 5.1 Page 15 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): 31,38 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: Mrs Sandra Sawyer manages Grasmere. Mrs Sawyer has worked at the home for the past ten years and has been the manager for the past five years. The homeowner also has an office at Grasmere and is available to support the home manager if required. There are clear lines of accountability within the home and staff members spoken to were clear about the roles of the management team. Grasmere DS0000007133.V282563.R01.S.doc Version 5.1 Page 16 Members of the staff team spoken to during the inspection felt supported by the home manager. Several members of the team said that they would be happy to speak to the manager if they had a concern. The home has a health and safety policy in place. A first aid box and a fire blanket are situated in the kitchen. There are fire extinguishers throughout the house. Coloured chopping boards were seen in the kitchen. Fridge and freezer temperatures are taken and recorded. Fire drills are not taking place as often as they should and will be checked at the next inspection. Grasmere DS0000007133.V282563.R01.S.doc Version 5.1 Page 17 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X X STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 2 Grasmere DS0000007133.V282563.R01.S.doc Version 5.1 Page 18 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 OP9 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 30/05/06 2. OP38 30/05/06 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 OP9 Good Practice Recommendations The home manager must ensure that correction fluid is not used on the Medicine Administration Record Sheets. Grasmere DS0000007133.V282563.R01.S.doc Version 5.1 Page 19 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.V282563.R01.S.doc Version 5.1 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!