Inspection on 29/06/05 for Gratia Limited

This inspection was carried out on 29th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Gratia Limited 20/07/06

Gratia Limited 11/10/05

Gratia Limited 11/11/04

Gratia Limited 14/07/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Gratia Limited 472 Groby Road Leicester Leicestershire LE3 9QD Lead Inspector Everton Osbourne Unannounced 29 Jun 2005 11:00 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Gratia Limited C51 C01 S58192 Gratia V233226 290605 STAGE 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Gratia Limited Address 472 Groby Road Leicester Leicestershire LE3 9QD 0116 2311640 0116 2332724 None Gratia Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Mathew Smith Care home only 21 Category(ies) of LD Learning disability (21) registration, with number LD(E) Learning disability - over 65 (9) of places Gratia Limited C51 C01 S58192 Gratia V233226 290605 STAGE 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1) The maximum number of service users who can be admitted to the home at any one time shall not exceed 21. 2) That the home is registered to accommodate a maximum of 1 service user with LD/PD; 9 service users with LD(E); and 4 service users with LD/DE. Date of last inspection 11th November 2004 Brief Description of the Service: Gratia Care Home cares for 21 younger adults who have learning disabilities which may include up to 9 older persons with learning disabilities. The premise is located on the main Groby Road leading to the city of Leicester where residents have access to a variety of shops and other amenities. The home is easily accessible by public and private transport. The premise consists of two floors for residents use which is accessible by use of the passenger lift or stairs. There are a variety of aids and adaptations throughout the home based on residents assessed care needs to support them to be more independent. The home have nineteen single bedrooms eight with ensuite facilities. There is one double bedroom without ensuite facility. An adequate number of toilet and bathroom facilities are situated on both floors for residents use. A garden area is situated to the rear of the building. Gratia Limited C51 C01 S58192 Gratia V233226 290605 STAGE 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took four hours to complete. With the exception of issuing one Immediate Requirement Notification and making two Recommendations, the outcome of this inspection was positive. Two residents spoken with indicate that they are satisfied with the care provided in the home. A tour of the premises took place, which indicated that the premises are maintained to high standards creating a homely environment. One care staff member, the assistant manager and registered manager were spoken with as part of the inspection process. 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. Gratia Limited C51 C01 S58192 Gratia V233226 290605 STAGE 4.doc Version 1.40 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Gratia Limited C51 C01 S58192 Gratia V233226 290605 STAGE 4.doc Version 1.40 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3 and 4. The admission procedure is good. There is adequate information about the services provided in the home which is given to prospective residents and their relatives. Satisfactory assessment processes are in place for the protection and care of residents. EVIDENCE: The Statement of Purpose was examined. Adequate information about the care provision is contained in the document. Two residents spoken to indicate that they were given a copy of this document prior to moving into the home. Two residents’ assessments were inspected and conversation held with these residents indicated that the information contained in the documents accurately describes their care needs. Two residents’ daily care records seen indicate that they made a number of trial visits to the home before they moved in, which was confirmed by verbal statements made by the two residents. Gratia Limited C51 C01 S58192 Gratia V233226 290605 STAGE 4.doc Version 1.40 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8 and 10. Residents care plans are written in detail in order to ensure that they receive the care they need. There is no evidence to indicate that residents are involved in the care plan process. Giving residents freedom to make choices about their daily lives is managed well. EVIDENCE: Detailed examination of two residents’ care plans indicated that all aspects of personal and health care needs including recreational needs are recorded in the documents. Care plan records seen and discussion held with one staff member and the assistant manager indicated that the documents are reviewed on a regular basis. No resident or their relatives’ signature was seen on the document to indicate that they were involved in the care plan process. The registered person should obtain residents or their relatives’ signature to show that they are involved in the care plan process. Two residents spoken with indicate that they make plans about their daily activities with support from the staff team. Staff members were seen offering a choice of daily activities to residents. Two residents’ care plans seen indicate that recreational and educational activities form part of the care process. Gratia Limited C51 C01 S58192 Gratia V233226 290605 STAGE 4.doc Version 1.40 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 13, 14 and 17. Good opportunities are given to residents so that they can engage in educational or occupational activities as part of their day care activities. Variable and balanced meals are given to residents to meet their nutritional care needs. EVIDENCE: Two residents’ care plans and activities records seen indicated that residents attend day care as part of the care process. Two residents spoken with indicated that they have a choice to participate in recreational activities. Two residents spoken with indicated that they maintain contact with their family and friends by receiving visitors to the home or by making visits away from the home. Observations made and the lunchtime meal seen indicated that meals are varied and wholesome. Two residents spoken with gave positive responses regarding the meals. Gratia Limited C51 C01 S58192 Gratia V233226 290605 STAGE 4.doc Version 1.40 Page 10 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 and 21. Suitable processes are in place to ensure that residents receive good healthcare provisions. The medication procedure works well in general but information displayed on one resident’s medication record has the potential of giving staff members’ incorrect information concerning safe medication practice. EVIDENCE: Two residents spoken with indicated that sufficient support is given by staff members to ensure that their hygiene care needs are fully met, which is recorded in both residents’ care plans and their daily care records. Detailed inspection of two residents’ care records indicated that healthcare professionals such as Community Nurses and General Practitioners form part of the care process. Two residents spoken with indicated that they access doctors and other professionals located in the community as part of their ongoing care. The medication policy seen contains sufficient information for staff members’ guidance regarding safe medication practice. One resident’s medication record seen had medication listed that was no longer required as prescription for the resident. An Immediate Requirement Notification was issued requiring the home to maintain medication records in accordance with relevant written guidance. Gratia Limited C51 C01 S58192 Gratia V233226 290605 STAGE 4.doc Version 1.40 Page 11 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. Robust processes are in place so that residents or their relatives can access the complaint process if required. There is an adult protection procedure in place to respond to suspicion or allegation of abuse for residents’ protection. EVIDENCE: Detailed examination of the written complaint process indicated that good guidance is given to residents and their relatives on how to make a complaint. The complaints logbook seen indicated that there has been one complaint since February 2005, which appear to have been resolved with positive outcomes. The adult protection process was inspected. Clear guidance is written for staff members regarding protecting vulnerable adults. One staff member spoken with gave good verbal responses concerning the protection of vulnerable adults. Two residents spoken with indicated that they feel safe residing in the home. Gratia Limited C51 C01 S58192 Gratia V233226 290605 STAGE 4.doc Version 1.40 Page 12 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 27, 28 and 30. The home is maintained to excellent standards with a strong emphasis on creating a homely environment. Adequate communal space and facilities are provided in the home for residents’ comfort. The home is clean and hygienic for residents’ safe use. EVIDENCE: An inspection of the flooring, walls and fixtures throughout the home indicated that the premise is being maintained to high standards. Two residents indicated that they are satisfied with the décor within the home. Two residents spoken with indicated that they feel satisfied with the communal space provided namely the dining room and lounge space which they feel is large enough for their leisure activities. An inspection of the premise indicated that it is clean and hygienic in appearance. Two residents spoken with indicated that they are satisfied with the cleanliness of the home. Gratia Limited C51 C01 S58192 Gratia V233226 290605 STAGE 4.doc Version 1.40 Page 13 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33. The care hours and staffing numbers provided in the home are sufficient for the provision of residents’ care and protection. EVIDENCE: Information provided by the registered manager prior to the inspection and observations carried out during the inspection indicated that suitable skill mix and staffing hours are provided on a daily basis. Two residents’ spoken with indicated that they are satisfied with the staffing compliment in the home. Gratia Limited C51 C01 S58192 Gratia V233226 290605 STAGE 4.doc Version 1.40 Page 14 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 40, 41 and 42 The home makes a good effort in adhering to good record keeping although some gaps are evident. Written policies and procedures are adhered to for residents’ protection. EVIDENCE: All policies seen during the inspection indicated that adequate information is written in the documents for staff members’ guidance on how to safeguard residents in the home. One medication record seen did not have the resident’s date of birth listed. The registered person should have residents’ date of birth listed on all medication records. Fire records examined and dates seen on fire extinguishers indicated that suitable checks of fire safety equipments are being made on a regular basis. Two staff members spoken with which included the assistant manager indicated that safe care practices are being maintained in the home. For example one care staff member spoken with gave good demonstration on proper hand washing techniques and gave good verbal responses on how residents’ care needs must be met appropriately. Gratia Limited C51 C01 S58192 Gratia V233226 290605 STAGE 4.doc Version 1.40 Page 15 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 x 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 3 3 x 3 Standard No 11 12 13 14 15 16 17 3 x 3 3 x x 3 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Gratia Limited Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score x x x 3 2 3 x C51 C01 S58192 Gratia V233226 290605 STAGE 4.doc Version 1.40 Page 16 No Are there any outstanding requirements from the last inspection? 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 20 Regulation 13(2) Timescale for action The registered person shall make Immediate arrangements for the recording 29.06.05 of medicines received into the home. In this instance, medication that is not prescribed for a resident must not be listed on the medication records. Requirement 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 6.10 Good Practice Recommendations The care plan should be written and reviewed with the service users involvement and a representative if appropriate. In this instance, the service user or representatives should sign the care plan to show that they have been involved in the care planning process. Records required for the protection of service users and for the effective running of the business are maintained, up to date and accurate. In this instance, residents date of birth should be listed on medication records. 2. 41.1 Gratia Limited C51 C01 S58192 Gratia V233226 290605 STAGE 4.doc Version 1.40 Page 17 Commission for Social Care Inspection The Pavilions, 5 Smith Way Grove Park, Enderby Leicester LE19 1SX 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. 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