Inspection on 17/07/07 for Grenville Court

This inspection was carried out on 17th July 2007.

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

Grenville Court 30/05/06

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

CARE HOMES FOR OLDER PEOPLE Grenville Court Horsbeck Way Horsford Norwich Norfolk NR10 3BB Lead Inspector Mrs Jenny Rose Unannounced Inspection 17th July 2007 09:15 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 Grenville Court DS0000066022.V346222.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. Grenville Court DS0000066022.V346222.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grenville Court Address Horsbeck Way Horsford Norwich Norfolk NR10 3BB 01603 893499 01603 893694 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) Alpha Care Management Services Limited Position Vacant Care Home 64 Category(ies) of Dementia - over 65 years of age (44), Old age, registration, with number not falling within any other category (20) of places Grenville Court DS0000066022.V346222.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th May 2006 Brief Description of the Service: Grenville Court is a home for older people with 64 rooms accommodating up to 20 people with age related difficulties and 44 people with symptoms associated with dementia. Accommodation is grouped into 5 units across two floors, each unit having bathing and dining areas of its own. Rooms are spacious, with en suite facilities. The home is of modern design and is purpose built. It is situated in a residential area of Horsford, a village north of Norwich. There is ample car parking to the front of the building and a secure garden area to the rear. Grenville Court DS0000066022.V346222.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care Services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out, by using information from previous inspections, information from the Providers, the residents and their relatives, as well as others who work in or visit the Home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and the current judgements for each outcome group. This was a key unannounced inspection, which took place over 8 hours on a weekday, 17th July 2007 and was carried out as part of a routine inspection plan. There were 62 people living in the Home on the day. The recently registered Manager and her Deputy were present throughout the inspection and were helpful and supportive during the inspection process. An Annual Quality Assurance Assessment self assessment document had been received from the Home beforehand, giving much information. The inspection took the form of a tour of the premises, examination of care plans, staff files and other records. Seven comment cards had been received from relatives, and one from a resident, with positive comments overall. There were individual discussions with the Manager and the Group Audit Manager, four visitors; several members of staff, (four in private); and with several residents, (three in private). The information from comment cards and from the people spoken to is incorporated in the report. What the service does well: • The Home is purpose built and of modern design, grouped into two units. It is located in a village situation, near Norwich, close to amenities and public transport. There is a welcoming atmosphere and the Home is comfortable, pleasantly decorated and furnished. One resident’s comment was: “I am happy here and well cared for.” Care plans are produced in line with the needs and wishes of the people living in the Home and are signed by the residents and/or their relatives, if appropriate. The privacy and dignity of individuals are respected and promoted. Relatives and visitors are welcomed into the Home at any time and are involved with decisions regarding their relative’s care, if appropriate. DS0000066022.V346222.R01.S.doc Version 5.2 Page 6 • • • Grenville Court • Good management systems, record keeping and continuous improvement guided by the best interests of the people living in the Home are being developed. The meals are varied and nutritious and can be taken in a choice of dining areas or in residents’ rooms. Finger foods and fresh fruit are available in addition to meals and pictorial menus especially for those people with Dementia Care needs. There are three rooms designated for Recall and Reminiscence containing a wide variety of furniture and artefacts from the early 20th century. There is a newly appointed Activities Organiser and scope for the activities programme to be developed further. A relative’s comment card said that Grenville Court’s attributes are: ”..cleanliness, separate rooms, activities and pleasant, friendly staff” • • • What has improved since the last inspection? • The Manager has recently been registered. She and the Group Audit Manager are experienced and committed, with the Providers’ support, to improving standards in the Home. The Home has a full time Administrative Assistant and they have produced an evidence file for the Home corresponding to the National Minimum Standards. Steps have been taken in monitoring the incidence of falls and measures taken to reduce their occurrence by deploying staff in particular areas of the Home, changes in staff breaks and through the employment of further care staff. There are three-monthly residents’ and relatives’ meetings, regular open day clinics and one-to-one meetings with the Manager. Suggestions from these meetings are carried through in the continuous improvement of the Home. Several improvements required at the last key inspection and a random inspection have been made and reviewed. These include: o The refurbishment of two assisted bathrooms. • • • o All staff undergo training in Infection Control, as well as in Safeguarding Adults and Health and Safety. Grenville Court DS0000066022.V346222.R01.S.doc Version 5.2 Page 7 o Additional care and domestic staff have been employed; training programmes developed, including induction training for all members of staff, staff supervision and appraisals. o Recruitment checks are in place prior to staff commencing work. o People have their private rooms identified by photographs and a sign with their name of choice. Communal rooms are identifiable by picture signs. o Informal comments, complaints and compliments are audited and transferred to individual files as appropriate. Staff wear name badges and photographs of senior members of staff are displayed in the hall for ease of identification. New systems for the accounting of the residents’ Amenities Fund and residents’ individual monies have been introduced. • There are textured pictures in corridors for residents to touch, as well as photographs of movie stars of black and white movies, which are conversation topics for residents. The Home has recently been successful in obtaining a grant to re-landscape one enclosed garden with ramps, raised beds and sensory planting areas to be completed in 2008. • What they could do better: Good Practice Recommendations: • There should be a more easily supervised area for people living in the Home who wish to smoke and more suitable arrangements for staff who wish to smoke during their breaks. The present activities programme could be developed in line with the present residents’ needs, wishes and life histories. A review of verbal communication training between staff and residents, especially when residents are being moved in wheelchairs or hoisted, would be beneficial for residents. There could be further development of the keyworking system, especially for those people with Dementia Care needs. The Medication Administration Record (MAR) sheets should be secured in the Medication File to prevent discrepancies and to further protect residents. DS0000066022.V346222.R01.S.doc Version 5.2 Page 8 • • • • Grenville Court • The written views of the residents’ care from Healthcare Professionals who visit the Home should be sought as part of the Quality Assurance process to further ensure that the Home is run in the best interests of the people who live there. 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. Grenville Court DS0000066022.V346222.R01.S.doc Version 5.2 Page 9 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 Grenville Court DS0000066022.V346222.R01.S.doc Version 5.2 Page 10 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): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed assessments are made prior to admission and the people living in the Home are having their assessed needs met. The Home no longer offers intermediate care. EVIDENCE: Five care plans were examined and there were detailed individualised assessments which form the basis of the care plans. There was evidence that the pre-assessment procedure included visits by the Management, followed by a visit to the Home, with relatives/carers, if possible and appropriate. In addition, information was obtained from other healthcare professionals. One relative spoken to said he visited the Home and several others, in order to ascertain that this particular Home would meet his relative’s needs. All the comment cards revealed that the relatives had received sufficient information before admission and the Home provides advocacy information to both residents and carers on admission. There is a policy that unplanned admissions are avoided, except in an emergency. Grenville Court DS0000066022.V346222.R01.S.doc Version 5.2 Page 11 The Home no longer provides intermediate care, as it is considered too disruptive for permanent residents. Grenville Court DS0000066022.V346222.R01.S.doc Version 5.2 Page 12 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. People living in the Home and their relatives are happy with the way that staff deliver their care and respect their dignity. EVIDENCE: The comment cards overall were positive regarding care in the Home. For example: “..recently our relative had a chest infection and the Doctor was called in to check her very quickly and they informed me by telephone”. “The care and support is second to none”. Five care plans were examined. These all included a photograph of the resident, if permission had been granted for this, and comprehensive details necessary to enable staff to deliver the particular care needed. A new member of staff spoken to confirmed this. The plans are focussed on the individual’s personal preferences in numerous ways, including particular aspects of medication administration and the resident’s right to refuse this. Life histories are being gathered, but there is a good practice recommendation made regarding these being audited and linked to the activities programme in order to provide a more holistic view in the care plan. (see Daily Living). Grenville Court DS0000066022.V346222.R01.S.doc Version 5.2 Page 13 There was evidence showing the involvement of Healthcare Professionals, the GP, District Nurse, Occupational Therapist, Physiotherapist and Continence Advisor, amongst others. There was evidence in one care plan of a meeting between the Occupational Therapist and Physiotherapist for the following week to discuss the use of a reclining chair for one resident. The resident and/or relatives sign care plans, if appropriate. These were regularly reviewed, well kept and up to date. There was only one resident with a long term history of pressure areas being treated by the District Nurse, which may be due to the fact that the care plans and reviews contain analysis of tissue viability and action to be taken to maintain vulnerable areas. There are risk assessments for particular issues in residents’ care, including falls and the use of bedrails, for example. There was evidence these were discussed with residents and relatives, if appropriate. The Home has introduced a monitoring programme to analyse the effectiveness of their procedures. Observation of the medication round demonstrated that the administration of medication appeared to be appropriately and safely carried out. The senior carer administering the medication on the day had completed training and she explained the system for double-checking signatures on the MAR sheets, which she needed to employ on the day. Following issues regarding minor discrepancies in PRN medication in boxes in the lockable medication trolley, the Home has instituted a weekly audit for this. There is also a recommendation that the MAR sheets should be securely fastened in the file, in order to avoid discrepancies and to further protect residents. Medication is stored in a spacious, tidy and secure area and the Controlled Drugs were seen to be appropriately stored and recorded. There was no one in the Home who wished to administer their own medication, but there are lockable drawers in residents’ rooms, should this be the case It was observed, and residents and relatives spoken to, confirmed that they were treated with respect and their privacy was protected. Two residents spoken with were very satisfied with the way their dignity was promoted by staff during personal care tasks. Grenville Court DS0000066022.V346222.R01.S.doc Version 5.2 Page 14 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): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the Home have choice and have the opportunity to take part in some activities within the Home and to maintain links with the local community, and family and friends. EVIDENCE: Comment cards and a resident spoken with confirmed that people living in the Home were satisfied with the lifestyle in the Home and with the choices in their day to day lives. Some residents choose to stay in their rooms, having some or all of their meals there. Others preferred to spend their time in the communal areas. Residents said they could go to bed and get up when they choose and were also encouraged to be as independent as possible. As a result of a recent residents’/relatives’ meeting, the breakfast times had been staggered by request. There was evidence that there are activities 5 days a week, musical entertainment every month, with the Library Service visiting on a personal basis. The day before the inspection, residents had made a fruit salad in a cooking session and on the day of the inspection, the newly appointed Activities Organiser was visiting residents on a one-to-one basis. There is a reminiscence room furnished with artefacts from the early 20th century, which is also used as a craft area, results of which are displayed around the Home. One resident spoken to chose not to participate in these group activities, but Grenville Court DS0000066022.V346222.R01.S.doc Version 5.2 Page 15 was looking forward to a bus trip later in the week. Another resident also preferred not to participate in group activities, but enjoyed doing crosswords in her room. Church services are held for those who wish to attend. There is a shop facility for residents to use if they wish to. For those less able a shopping trolley is provided weekly or more frequently if requested. For those residents with Dementia Care needs, there are menus with pictures of food, a picture of cutlery and a plate to denote the Dining Room and also textured pictures in the corridors. The new Activities Organiser records activities and the names of the residents taking part, in a communications book, which can be seen by residents and relatives. There is a recommendation that this record could be expanded and the activities programme also linked to details of people’s life histories and interests in the care plans. Keyworkers at present are responsible for updating the care plans with these details and there is a recommendation for a review of the keyworkers’ role, particularly in relation to those with Dementia Care needs to give a more holistic picture of residents’ needs and wishes. There was no resident living in the Home without contact with family, friends or advocate. One particular relative spoken to confirmed that he was closely involved with his relative’s care and informed of changes of medication, or in his relative’s health, if appropriate. Comment cards were positive overall concerning the meals. On the day of the inspection, staff were observed asking residents for choices and meals were served individually taking into account likes and dislikes. The chef, who has catering qualifications, confirmed that he was using fresh vegetables and there was a vegetarian option on the menu that day. The deputy chef is embarking on the NVQ in catering. A visitor confirmed that finger foods, snacks, fresh fruit and drinks are available whenever wished and special diets are catered for. Residents choose where they would like to eat. One resident spoken to was particularly satisfied that she could have sandwiches in her room to eat in the evening, if she wished. She felt that there was sufficient choice of the main meals. There are nutritional assessments in care plans and special diets are catered for, particularly for those people with Diabetes. Residents requiring assistance with eating were helped discreetly by staff, who also gave residents time to eat. Grenville Court DS0000066022.V346222.R01.S.doc Version 5.2 Page 16 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the Home and their relatives felt that complaints and concerns would be listened to and acted upon and the Home’s policies and procedures help ensure that residents are protected from abuse. EVIDENCE: There is a complaints procedure and details of this are made available to everyone coming to live in the Home, as well as to their relatives. The complaints file was seen and a complaint of November 06 had been satisfactorily dealt with. A recommendation from the previous key inspection that informal comments and complaints are recorded, audited and transferred to individual files as appropriate, had been implemented. A compliments book was also kept in the Reception areafor visitors to see. The Manager said they were committed to taking all concerns and comments seriously and take action immediately on relative’s and residents’ comments in person or by questionnaires. There are regular relatives’ meetings and Open Day clinics for residents and relatives. There is an “open door” policy to speak to the Manager in the first instance and regular questionnaires to residents and their families in order to address concerns. As a result of several expressed concerns, the arrangements for dealing with laundry were reviewed and further staff employed. Advocacy information is displayed in the front entrance hall. Grenville Court DS0000066022.V346222.R01.S.doc Version 5.2 Page 17 Policies and procedures for safeguarding adults are in place. All staff will have received training in the issues surrounding the protection of vulnerable adults by September 2007 and training has also taken place in Dementia and dealing with Challenging Behaviour. There was evidence of keeping accurate records of any incidents. Auditing of accidents and incidents is carried out on a regular basis . Comment cards, residents and two visitors spoken to said they would know how to make a complaint, if necessary, but they had had no cause. Grenville Court DS0000066022.V346222.R01.S.doc Version 5.2 Page 18 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): 19,21 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the Home enjoy comfortable accommodation, which is clean and well maintained, with access to appropriate facilities and equipment. EVIDENCE: This is a purpose built Home and all the bedrooms are ensuite and comfortably furnished. Residents are encouraged to bring their own furniture, if they wish and rooms seen were personalised. There is ongoing maintenance and decoration, a schedule of which was seen. There was evidence from the staff training programme that care and domestic staff have undertaken training in Infection Control, following the requirement of the previous key inspection. During a tour of the building it was seen that new baths have been fitted in two bathrooms, new carpets in some bedrooms, an increase in communal space and plans to arrange the larger Dining Room into smaller areas. The Home has recently received a grant to make a secure, sensory garden, easily accessible to residents and wheelchairs overlooked from the larger Dining Room. Grenville Court DS0000066022.V346222.R01.S.doc Version 5.2 Page 19 Signs are in place on residents’ doors with their name of choice, together with photographs of residents, to enable them to more easily identify their rooms. In addition, there is a textured picture sign for the large Dining Room and a large print calendar also showing the weather is displayed in the Reception Area. A bedside lamp in one resident’s room, which was missing at the last key inspection, has been provided. There are appropriate laundry facilities and the number of designated laundry staff has been increased, with three members of staff working full time throughout the day. Two members of staff spoken to were aware of the importance of taking care with residents’ clothes and they evidently took pride in their work. There has been an increase in domestic staff. Carpet cleaning takes place daily and was taking place on the day of inspection in communal areas and bedrooms, according to a schedule and where necessary. All areas of the Home seen smelled fresh and clean and this was borne out by the comment cards. A smoking area still has not been identified, although one resident spoken to was satisfied with being able to smoke in the summer in a small garden area outside the front door. However, this would not be feasible in winter weather. Staff are required to move away from the building if they wish to smoke during their breaks. The recommendation is therefore repeated for consideration to be given to a more easily supervised and covered area for smoking. Grenville Court DS0000066022.V346222.R01.S.doc Version 5.2 Page 20 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the Home are satisfied with the care they receive, that it meets their needs, delivered by a trained staff team. EVIDENCE: Overall the comment cards were positive about staffing. One said, “the staff are excellent”, another “the staff are always helpful”. Those members of staff spoken to said they enjoyed working in the Home and felt they worked well together in caring for the residents. They also felt they were well supported by the management and with training opportunities. The Manager and the Group Audit Manager said that since the last key inspection there had been an increase in staff numbers, both care and domestic staff, and, as a result of falls monitoring, staff are deployed in areas and at times when incidents of this nature are likely to occur. Staff breaks have also been changed in order that sufficient staff are available at peak times. Staff rotas were seen and on the day of inspection there were twelve staff on duty in the morning, one more than were on duty at the time of a random inspection in September 2006, and eleven in the afternoon and five at night. The Manager confirmed that she and the Deputy Manager also work “hands on” and staff are supervised working, as well as by interview at regular intervals. Extra staff are on shift when training is taking place. Job descriptions have been reviewed and roles and responsibilities more clearly Grenville Court DS0000066022.V346222.R01.S.doc Version 5.2 Page 21 defined. The care staff are supported by additional domestic, catering and administrative staff, including increased numbers of designated laundry assistants. As a result of the last key inspection, a training development programme for the Home and for individual staff has been produced. Evidence from this shows that 60 of care staff have NVQ2 or above and 40 are working towards NVQ2 or above. Many of the overseas staff have professional qualifications in their own country, which equate with NVQ3. Induction training has now taken place, not only for new staff, but also for staff employed before the change of ownership. In September all members of staff will have received training in Safeguarding Adults and Infection Control. One staff member spoken to confirmed that the Management were very approachable and he had been offered training opportunities in Dementia and Continence and that training was always being updated. Domestic staff receive training in COSHH, Infection Control, Moving and Handling, as well as Adult Abuse. The Manager reported that a good relationship had been built up with the local college and the NVQ Assessor visited the Home for assessments. Overseas staff are also offered the opportunity to improve their English at the College, which two members of staff spoken to had taken advantage of. During the inspection a resident fell in the Dining Room. Staff demonstrated their knowledge of how to act in this situation and all behaved appropriately. However, there is a recommendation that a review takes place regarding staff communicating verbally with residents, especially during moving and handling procedures. Five staff files demonstrated that CRB checks are completed prior to commencement of work. POVA first checks are carried out initially and if satisfactory staff can work under supervision. From two staff files seen staff employed from overseas have not been employed without written assurances/certification from the country of origin confirming identity and satisfactory CRB or equivalent. It is now the Home’s policy that if new care staff are employed without an NVQ2 qualification, they should agree to train towards an NVQ2 when they start employment. Staff spoken to confirmed that there were regular staff meetings and that staff could raise matters for the agenda. They also confirmed that there were good handovers for the Seniors before the beginning of shifts and then for other care staff at the start and end of shifts. Grenville Court DS0000066022.V346222.R01.S.doc Version 5.2 Page 22 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): 31,33,35,36,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the Home and their representatives feel their interests are safeguarded by the management approach of the Home. The auditing of the Quality Assurance system will hopefully further ensure that the service continuously improves in the best interests of the people living there. EVIDENCE: The Manager has recently been registered following her successful completion of the NVQ4. She has many years’ experience of working in the care of elderly people and is responsible for the day to day running of the Home. In this she has support of the Group Audit Manager and they show a commitment to improving standards in the Home. In this, they have the support of the Group Operations Director and the full time support of an Administrative Assistant who is undertaking her NVQ3 qualification. Grenville Court DS0000066022.V346222.R01.S.doc Version 5.2 Page 23 There is a clear line-management structure with the appointments and job descriptions for two Unit managers, a team of Seniors and Care Assistants operating a keyworker system. All members of staff wear identification badges and there are photographs of Managers and the staff team in the main reception area and on the Oak and Ash Units. An open management style is being fostered by relatives and residents’ meetings held in the evening and open day clinics, as described elsewhere in this Report (Standard 16 and 18). The Annual Quality Assurance Assessment had been satisfactorily completed for the Commission and in house Questionnaires on aspects of Living in the Home had been completed on 20th June 07, and were in the process of being analysed. Some of the Questionnaires seen were very complimentary. Regular residents/relatives, management and staff meetings and the production of a newsletter placed in every room assist in aiding communication. Although staff at present ask Healthcare Professionals for feedback concerning their opinion of the residents’ care, there is a recommendation that these views should be gathered by written questionnaires, in order to be recorded and form part of the Quality Assurance process to further ensure that the Home is run in the best interests of the people living in it. There is a new system for the administration residents’ personal monies, for small items of shopping, etc and auditing of the Amenities Fund which had been audited the day before the inspection and were seen to be audited monthly. From a random sample of records of completed supervision sessions, staff supervision is now being carried out on a regular basis both on-the-job and by interview and this was confirmed by staff members spoken to. Staff sign a supervision agreement. Yearly appraisals are now being carried out, grouped at six monthly intervals, the first group having taken place on 5th December 06 and the second on 22nd March 07. There has been a variety of new audit tools introduced to the managing of the Home since the last key inspection and all records seen were well kept and up-to-date, and all now reflect the present ownership of the Home. Records were seen for Fire drills, Nurse call system, showers, outside lights, gas certificates, to name some, and demonstrate that health, safety and welfare of the residents and staff are promoted. The Operations Manager has responsibility for health and safety matters in the Home and oversees staff training in this area for the Homes in the organisation. Incident forms are sent to the CSCI on a regular basis and are audited. There is regular auditing of the facilities and the Accident Book and the latter has resulted in the monitoring of falls and preventative action being taken. (see elsewhere in this Report). Grenville Court DS0000066022.V346222.R01.S.doc Version 5.2 Page 24 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 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 X X X X 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 3 X 3 Grenville Court DS0000066022.V346222.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 OP26 Good Practice Recommendations The home should consider a more easily supervised area for smoking. This recommendation is repeated MAR sheets should be secured in the Medication File to prevent discrepancies and further protect the people living in the home. Consideration should be given to reviewing the role of the keyworker, particularly in relation to those people with dementia care needs, in order that their needs, choices and rights are known, protected and promoted. Consideration should be given to developing the present activities programme in line with the residents’ needs, wishes and life histories. 2. OP9 3. OP13 4. OP14 Grenville Court DS0000066022.V346222.R01.S.doc Version 5.2 Page 26 5. OP28 Consideration should be given to reviewing verbal communication training between staff and residents, especially during Moving and Handling. Consideration should be given to surveying the views of Healthcare Professionals who visit the Home by written questionnaires to further ensure that the Home is run in the best interests of the people who live there. 6. OP33 Grenville Court DS0000066022.V346222.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 - 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!