Inspection on 19/12/05 for Grasmere House

This inspection was carried out on 19th December 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 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 House 10/06/06

Grasmere House 14/06/05

Grasmere House 27/10/04

Grasmere House 13/05/04

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

CARE HOMES FOR OLDER PEOPLE Grasmere House 33 Cargate Avenue Aldershot Hampshire GU11 3EZ Lead Inspector Pat Griffiths Unannounced Inspection 19th December 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 House DS0000012106.V273918.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 House DS0000012106.V273918.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Grasmere House Address 33 Cargate Avenue Aldershot Hampshire GU11 3EZ 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) 01252 328 052 Mrs Ramtohal Mrs Ramtohal Care Home 9 Category(ies) of Dementia - over 65 years of age (9), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (9), Old age, not falling within any other category (9) Grasmere House DS0000012106.V273918.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th June 2005 Brief Description of the Service: Grasmere House is a large house in a residential area of Aldershot. The home is a short walk from the local shops and close to the main shopping centre of Aldershot. The home is registered to provide care for nine older people including those with dementia. The home provides accommodation on two floors, with one shared and seven single bedrooms. There is a large lounge and separate dining room. There are gardens to the front and back of the home, with paved seating areas for the residents. Grasmere House DS0000012106.V273918.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second of two statutory unannounced inspections for the inspection year 2005/06. The inspector was able to tour the home, talk to staff and residents, review care plans and staff files and read policies and procedures. The inspector was unable to obtain comments or opinions from most of the residents because of health-related communication problems. Through observation it was apparent that the residents were happy and had a good relationship with the staff. What the service does well: What has improved since the last inspection? 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 House DS0000012106.V273918.R01.S.doc Version 5.1 Page 6 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 House DS0000012106.V273918.R01.S.doc Version 5.1 Page 7 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): 3 The assessment of potential residents prior to their move into the home ensures that their need can be met Standard 6 does not apply to this service EVIDENCE: The manager or the senior carer undertake pre-admission assessments on all potential residents to ensure that the home can meet their needs. They are also invited to spend a day in the home and meet the other residents, to ensure that the home also meets their expectations. Several care plans were examined and the pre-admission documentation was found to contain relevant information such as medical history, mental state, mobility and dietary preferences. The home does not provide intermediate care, but will occasionally provide respite care if there is a bed available. Grasmere House DS0000012106.V273918.R01.S.doc Version 5.1 Page 8 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 and 9 Arrangements ensure the residents needs are identified and set out in a care plan. The homes medication policies and procedures protect the residents. EVIDENCE: The inspector saw several personal care plans, which showed that all sections of the plan were completed and reviewed and updated as appropriate. Recent photographs of all residents have been included in their files. The plans included information about healthcare needs, daily activities, their likes and dislikes such as what time they liked to go to bed and how they wish to be addressed by the staff. Visits by healthcare professionals such as the GP and chiropodist are also recorded in the care plans. The residents personal care plans are reviewed and updated regularly, the manager told the inspector that residents or their nominated representatives could be more involved in the process if they wished. The inspector examined the MAR sheets (Medication Administration Record) and found they had been correctly completed, drugs received into the home are now recorded for each resident in their medication record. Grasmere House DS0000012106.V273918.R01.S.doc Version 5.1 Page 9 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 and 14 Arrangements ensure a choice of activities. Residents are encouraged to exercise choice and control in their lives and their visitors are encouraged. EVIDENCE: Residents are encouraged by the staff to maintain contact with family and friends and the home has an open visiting policy. They can entertain their visitors in the communal rooms or in the privacy of their bedrooms. Activities in the home include music and movement, crossword puzzles, knitting and sewing. Staff said that several residents have been out with relatives to do their Christmas shopping in the nearby town and Christmas activities included the local church visiting the home for some carol singing. During the tour of the home the inspector noted that the bedrooms had been personalised with the residents own possessions, such as pictures, ornaments and small pieces of furniture. Residents are encouraged by the staff to make choices in their daily life and these choices include choosing which clothes they will wear and what time they get up and go to bed, this information is contained in the care plans Grasmere House DS0000012106.V273918.R01.S.doc Version 5.1 Page 10 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): 18 The home has a satisfactory adult protection procedure in place but staff training is erratic. EVIDENCE: The home has policies and procedures in place regarding adult protection and abuse. Training information and certificates in the staff files show that staff have not received training in adult protection during the last year. There are no plans available to indicate that any training or up-dates on training are planned for the staff. The need for up-to-date training in adult protection for all staff was discussed with the manager. The manager said that she would get a newer, up to date, copy of the Hampshire Abuse Procedure. Grasmere House DS0000012106.V273918.R01.S.doc Version 5.1 Page 11 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 The home is clean, pleasant, safe and well maintained EVIDENCE: On the day of the visit the inspector was able to tour the home, seeing all of the bedrooms, the sitting room, the kitchen and the dining room. There is also a small area at the back of the home for residents who smoke. All were clean, pleasant and free from odour. Local contractors undertake routine maintenance and there is an on-going plan of repair and decoration. There is a large rear garden, which is easily accessible for the residents and has paved areas with benches for sitting out. The home has its own laundry on site, in a building at the rear of the home. On the day of inspection a section of wallpaper was seen to be hanging down from the ceiling in one bedroom. The manager said that the ceiling would be fixed later that day. Grasmere House DS0000012106.V273918.R01.S.doc Version 5.1 Page 12 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): 28 and 30 Staff training is erratic and does not ensure staff competency EVIDENCE: Fifty percent of the staff have completed an NVQ (National Vocational Qualification) at level 2 or 3 and another member of staff has started the course. The managed said that all new staff complete induction training. The home does not have a training plan and there are no clear records of the training that has been completed during the last year. The inspector looked at training certificates and records in all eight staff files and found that training was erratic. All staff had attended a fire training session in May or June 2005 and three staff had training in adult protection at different times of the year. The manager told the inspector that some of the staff are part time, working in other homes and receive training there. The inspector and the manager discussed the need for staff training and the need to record all training sessions. Training must be regularly updated to include any changes in practice or legislation. The need for a staff training plan and training record was made a requirement of the inspection. Grasmere House DS0000012106.V273918.R01.S.doc Version 5.1 Page 13 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 An experienced manager runs the home EVIDENCE: The registered manager is a qualified nurse, who has owned and run the home for many years. She has completed her Registered Managers Award, which is an NVQ in management. The home has policies and procedures in place, which are currently being reviewed and updated. The home has a small staff group, many have been there for several years and know the residents very well. Grasmere House DS0000012106.V273918.R01.S.doc Version 5.1 Page 14 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 3 X X X X X X X STAFFING Standard No Score 27 X 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X X Grasmere House DS0000012106.V273918.R01.S.doc Version 5.1 Page 15 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 OP18 Regulation 13(6) Requirement The registered person must ensure that all staff receive upto-date training on Adult Protection The registered person must ensure that all staff training is up-to-date The registered person must ensure that a staff training record is kept. An action plan must be sent to the commission which includes the training plan and a record of all training that has been completed Timescale for action 31/03/06 2. OP30 18(1)c 31/03/06 3. OP30 18(1) c 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Grasmere House DS0000012106.V273918.R01.S.doc Version 5.1 Page 16 No. Refer to Standard Good Practice Recommendations Grasmere House DS0000012106.V273918.R01.S.doc Version 5.1 Page 17 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 House DS0000012106.V273918.R01.S.doc Version 5.1 Page 18 - 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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