Inspection on 04/12/06 for Grasmere

This inspection was carried out on 4th December 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 19/01/06

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 Key Unannounced Inspection 4th December 2006 08:35 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Grasmere DS0000007133.V322731.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. Grasmere DS0000007133.V322731.R01.S.doc Version 5.2 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 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.V322731.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th January 2006 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.V322731.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on 4th December at 8:35am. This was the homes first inspection for the year 2006/2007 and was an unannounced visit. All of those standards considered by The Commission to be key to the inspection process were assessed during the visit. 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. Records examined included the service users plans, complaints, staffing records, training records, Medicine Administration Record Sheets and health and safety records. The inspector would like to thank the service users, staff and management 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? Grasmere DS0000007133.V322731.R01.S.doc Version 5.2 Page 6 The homeowner Mrs Nanji has recently completed the Registered Managers Award and is “refreshing” her National Vocational Qualification assessor’s award. Since the last inspection there has been an improvement in the number of fire drills that have taken place. Five drills have been completed and all staff have had fire awareness training. The handy man also carries out weekly fire door checks as well as checks on the emergency lighting, which is all recorded. 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. Grasmere DS0000007133.V322731.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Grasmere DS0000007133.V322731.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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. 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: A statement of purpose and service users guide is available to interested parties, which outline the service and facilities available to prospective residents. Copies of both documents were seen in the reception area of the home, as well as information on advocacy services for older people. A needs assessment is requested from the referring care manager and the home manager or homeowner always completes the in-house assessment to ensure that the home is suitable and the service users needs can be met. Grasmere DS0000007133.V322731.R01.S.doc Version 5.2 Page 9 The service users files looked at during the inspection all contained assessments completed before the service users moved into the home. The service user and their family (if it is appropriate) are involved and consulted in each stage of the admission. Service users and their families are encouraged to visit the home before a decision to move is made. A meeting takes place soon after moving into the home and the manager said that there is always a member of the management team around to deal with any teething problems or misunderstandings. One service users who has recently moved to the home said that he had been invited to look around the home before he moved in. The home has a contract in place, which includes rooms to be occupied, who is liable for breech of contract, fees, complaints and the trial period. This home does not offer intermediate care therefore standard six does not apply. Grasmere DS0000007133.V322731.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users have individual care plans, which include consultation with service users and their families. Care plans 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. Service users have been consulted on their personal and cultural preferences in relation to illness, death and dying, thus ensuring their individual wishes are respected. EVIDENCE: The service user plans carry on from the original plan drawn up by the care manager and other involved professionals. The plans include risk assessments and any medical appointments or visits from other professionals. Some service users prefer to be known by a shortened version of their name and those details are recorded in their personal file. Case files looked at where updated regularly. The home manager stated that issues of respect and how to treat service users with dignity and offer choices is incorporated into the induction training of new staff. Service users spoken to during the inspection felt that the staff team are Grasmere DS0000007133.V322731.R01.S.doc Version 5.2 Page 11 nice to them and treated them well. The home has a policy and procedure on Death and Dying. Service user files looked at as part of the inspection showed that the service users are asked about issues around death and dying before admission to the home, this includes any cultural or religious wishes. The home has a policy on the receipt, recording, storage, handling, administration and disposal of medication. The service users photographs were on the files. Records examined showed that all medicines administered are recorded on Medicine Administration Record Sheets. There were four gaps in the medication administration records looked at during the inspection. The service users are all registered with a local General Practitioner and have access to visiting health care professionals including opticians, chiropodists and dentists. These visits are all recorded on the service users files and records looked at during the inspection demonstrated that service users were recently offered, “flu jabs” Grasmere DS0000007133.V322731.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 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: Grasmere DS0000007133.V322731.R01.S.doc Version 5.2 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. There are no restrictions with regard visiting times, providing there arrive at ‘reasonable’ times of the day (e.g. not late at night etc…). Visitors can be seen in any part of the home including bedrooms. The home invites relatives and families to any social events. Information about how to contact local advocacy groups is available in the lobby entrance. The inspector was informed that majority of service users families are able to represent them and offer advice as required. Service users are on the electoral register and have postal votes. Having examined a random sample of menus, it was clear that a wide variety of well-balanced, nutritional food was available. The service users can also have seasonal choices such as salads. Medical needs are taken into account when planning menus. Any dietary needs are recorded in the service users care plan 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 an aroma therapist, gentle exercise, quizzes, skittles, sing-a-longs and bingo sessions. A hairdresser also visits the home regularly. The home manager explained that the home celebrates the service users birthday. The inspection took place just before Christmas and the home manager explained that she was arranging some additional activities. These activities include carol singers and a trip to see the Christmas lights in London. The home manager said that representatives of local churches visit the home. Personal items including furniture can be brought into the home if service users wishes and the item is suitable for the purpose. Any items brought into the home would be recorded on the service users file. Grasmere DS0000007133.V322731.R01.S.doc Version 5.2 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. 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. 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 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 received three complaints in the last year, which were all appropriately recorded and investigated. 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 at the home have all had training on abuse issues. Grasmere DS0000007133.V322731.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,23,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The 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 located in a quiet residential area and the layout and design appeared suitable to meet the needs of older people. The home was clean and generally odour free on the day of the inspection. Service users bedrooms are pleasant and they have all been personalised by their occupants. The baths and showers are within close proximity to the communal areas and service users bedrooms. Some bedrooms have ensuite facilities. Grasmere DS0000007133.V322731.R01.S.doc Version 5.2 Page 16 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. Comment cards received from the family and friends of service users at the home were positive about the facilities on offer at the home and service users spoken to during the inspection liked their bedrooms. The home has appropriate laundry facilities separate from the kitchen and the preparation of food. The laundry has suitable flooring. There is a locked cupboard for the Control of Substances Hazardous to Health products. The home has policies and procedures on the disposal of clinical waste. There are “Grab rails” a call bell system, mobile hoists, and other adaptations capable of meeting the assessed needs of the majority of the service users were in evidence through out the house. Grasmere DS0000007133.V322731.R01.S.doc Version 5.2 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. 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. 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: Grasmere has an equal opportunity policy in place, which includes a recruitment procedure. Criminal Records Checks are undertaken as part of the recruitment procedure. Criminal records checks were seen on the staff files looked at during the inspection. The home has had an ongoing problem with getting a criminal records check for one long standing member of staff who was employed at the home prior to the need for the criminal records checks to be completed. The homeowner is still in negotiations with the criminal records bureau and the staff member’s solicitor. Copies of all correspondence were seen on file. The homeowner has kept the Commission for Social Care Inspection informed of the issue. Grasmere DS0000007133.V322731.R01.S.doc Version 5.2 Page 18 The home manager confirmed that there is always a minimum of three staff on duty during the day at the home, with five staff on duty in the mornings. There is also a cook, cleaners and a handy man. The job descriptions for staff at the home clearly states what is expected of its employees in terms of their roles and responsibilities and the values that should underpin their conduct. The home holds regular staff team meetings, which are recorded. The staff members spoken to during the inspection made positive comments on their experience of working at the home The staff team receive an induction when they begin at the home a record is kept on the staff file. 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 is kept on staff files. The service users spoken to during the inspection said that the staff team treated them well. Observations of the contact between the staff team and service users confirmed this. Grasmere DS0000007133.V322731.R01.S.doc Version 5.2 Page 19 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): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management style appears to be transparent with clear lines of accountability. In the main health and safety arrangements are adequate to ensure potential risks to service users health and safety are so far as reasonably possible identified and minimised, although the frequency of staff supervisions should be increased. 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 Mrs Nanji has recently completed the Registered Managers Award and is “refreshing” her National Vocational Qualification assessor’s award. Grasmere DS0000007133.V322731.R01.S.doc Version 5.2 Page 20 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. The supervision records of the staff team at the home were looked at during the inspection. The supervisions are not taking place as frequently as necessary. Annual appraisals for the staff tea should also betaking place. Since the last inspection there has been an improvement in the number of fire drills that have taken place. Five drills have been completed and all staff have had fire awareness training. The handy man also carries out weekly fire door checks as well as checks on the emergency lighting. These are all recorded. Copies of the homes policies and procedures are kept in the office and the staff members spoken to were aware of where to locate them. The home manager demonstrated a good awareness of health and safety issues. 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. The home has thermostatic control valves and the temperature is checked weekly and recorded. The home has a quality assurance system in place and the homeowner informed the inspector that the findings are used to inform the homes business plan. The standard of recording and administration in the home is good and all the information needed to evidence that standards are being met was easily accessible. Grasmere DS0000007133.V322731.R01.S.doc Version 5.2 Page 21 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 X 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 X 18 3 3 X X X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Grasmere DS0000007133.V322731.R01.S.doc Version 5.2 Page 22 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) Such 3 3(i) 18(2) Requirement The home manager must ensure all medication records are correctly filled in at all times Staff must receive regular supervision at least six times a year and this must be recorded. Staff members should also have an annual appraisal. Timescale for action 04/12/06 2 OP36 30/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Grasmere DS0000007133.V322731.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Grasmere DS0000007133.V322731.R01.S.doc Version 5.2 Page 24 - 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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