Inspection on 16/08/06 for Gresley House Care Home

This inspection was carried out on 16th August 2006.

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

Gresley House Care Home 23/06/08

Gresley House Care Home 15/10/07

Gresley House Care Home 12/02/07

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

CARE HOMES FOR OLDER PEOPLE Gresley House Care Home Market Street Church Gresley Swadlincote Derby DE11 9PN Lead Inspector Vanessa Davies Unannounced Inspection 16th August 2006 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 Gresley House Care Home DS0000067515.V309019.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. Gresley House Care Home DS0000067515.V309019.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gresley House Care Home Address Market Street Church Gresley Swadlincote Derby DE11 9PN 01283 212094 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) Mrs Judith Dena Griffin Stewart Westley Barker Mrs Roberta April Stringer Care Home 27 Category(ies) of Dementia - over 65 years of age (11), Old age, registration, with number not falling within any other category (14), of places Physical disability (2) Gresley House Care Home DS0000067515.V309019.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 2 places within the total of 27 can be used for (PD) either sex aged 50 - 65 yrs. Plus one (1) day care placement not regulated by Commission for Social Care Inspection. An additional PD place for CW - This person is named in the noticed of proposal (CW) this agreed place will cease on the termination of this person. For the home to accommodate one named person in the notice of proposal (PS) this agreed place will cease on the termination of this persons care at the home. New Registration Date of last inspection Brief Description of the Service: Gresley House care home provides personal care and accommodation for up to 27 people aged 65 years and over, including 2 places for persons 50 - 65 years and 1 day care place. Gresley House is situated in Church Gresley town centre, close to shops and local amenities; the home does not have a car park. Residents have access to a well-set out garden area. The home is situated on 2 floors and has 25 single rooms and 1 double room. Access to the first floor is by stairs and a stair lift. The home has 4 lounge and dinning areas. Gresley House Care Home DS0000067515.V309019.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first Key Inspection of this service since the new providers took over in June 2006. The previous inspection in April highlighted a number of requirements, as the Registered Manager is the same the requirements not addressed at that inspection have been copied to this report and must be addressed within the timescale set in order to prevent further action being taken by the Commission. Information for this report was gathered before and during the visit. The manager was not available during the inspection. The Deputy Manager, Provider and a Manager from a sister home within the new organisation, were present, all providing various pieces of information for this report. Information was also gathered by reading records and speaking with residents. What the service does well: The new provider is very keen to make a large number of positive changes within the home, making herself available to residents, relatives and staff. The home assists residents and relatives to maintain contact, there are no unnecessary restrictions on visiting. Staff have built good positive relationships with residents and those spoken with stated that the staff ‘are lovely’. Activities are varied and meet the needs of the residents. The home is very clean and pleasant and residents bedrooms seen were personalised. The majority of the staff team have achieved NVQ 2 or above in Care. There is a low staff turnover, the staff team is established and appear to work well together. Staff have attended all mandatory training and confirmed that since the new provider had taken over further training was planned. The new provider is implementing a detailed quality audit document, this will ensure that all care provided is audited regularly and changed accordingly. Gresley House Care Home DS0000067515.V309019.R01.S.doc Version 5.2 Page 6 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. Gresley House Care Home DS0000067515.V309019.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 Gresley House Care Home DS0000067515.V309019.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is poor. Limited information within the care files prevents needs being met and potentially puts service users at risk. This outcome has been made from evidence gathered before and during the visit to the service. EVIDENCE: 4 service users files were examined during the visit. Each of the files had an assessment of need in place, however all of the assessments were very poor and provided very little information. This was highlighted at the previous inspection and requirements were set but have not been addressed. The new provider stated that she was in the process of implementing new assessments and care plans. The home does not provide intermediate care. Gresley House Care Home DS0000067515.V309019.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is poor. Lack of detail within the assessment of need and care plans prevents the manager from establishing whether needs can be met and how they will be met. This outcome has been made from evidence gathered before and during the visit to the service. EVIDENCE: Residents spoken with stated that the staff respected their privacy and dignity and this was observed during the inspection. Staff completed a combined assessment and care plan for resident’s, however it did not detail how all needs were being met. A clear care plan was not set out detailing the action which needed to be taken by care staff to ensure that all aspects of resident’s health, personal and social care needs were met. Where moving and handling, tissue viability and falls risks were identified, a care plan was not in place setting out measures taken to minimise further Gresley House Care Home DS0000067515.V309019.R01.S.doc Version 5.2 Page 10 risks. These issues were highlighted with the Registered Manager at the previous inspection in April 2006 but have still not been addressed. Residents spoken with felt that their health needs were being met, although this was not evidenced within the files examined. The new Provider assured the inspector that she was implementing new paperwork, which would ensure that all work with residents is evidenced. Arrangements were in place to enable residents to be seen by an optician and chiropodist on a regular basis, and a dentist as required. All contact/visits from G.P.s, optician and chiropodist were kept on separate files, although again the provider stated that this was to be changed. All staff who administer medication have received training. As highlighted at the previous inspection there were still gaps in the recording of the administration of medication, an immediate requirement was left at the previous inspection to address this, however the manager has still not addressed it. The manager does not keep a clear record of medication received in to the home, the provider stated that this was to change too. Gresley House Care Home DS0000067515.V309019.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. Contact with family and friends is encouraged, ensuring residents maintain contact with their community, assisting in the promotion of choice and independence. This outcome has been made from evidence gathered before and during the visit to the service. EVIDENCE: Residents and staff confirmed that contact with family and friends is supported. Residents said that family and friends can visit at any reasonable time and are made to feel welcome in the home. Residents said that the staff were lovely, one resident stated that she missed the previous provider but liked the new provider. Discussions with residents and observations showed that residents are helped to exercise choice and control over their lives, where possible. Residents said that the daily routines are flexible. Residents spoken with said that they were satisfied with the level of activities provided in the home, and said that there personal interests were supported. A number of residents were playing dominoes during the visit. A couple of Gresley House Care Home DS0000067515.V309019.R01.S.doc Version 5.2 Page 12 residents attended local centres, and one resident was involved in an advocacy group in the community. Residents stated that the food was lovely and that they had a choice, if they did not want what was on the menu an alternative would be provided. The home keeps a record of food offered. The menu appeared to offer a varied and healthy diet. Gresley House Care Home DS0000067515.V309019.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is poor. Poor complaints record-keeping and the Registered Managers lack of knowledge around adult protection, potentially puts residents at risk of harm. This outcome has been made from evidence gathered before and during the visit to the service. EVIDENCE: Residents spoken with considered that staff were approachable and that concerns were listened to and acted upon. Although the home has a complaints procedure and record, all complaints are not recorded, the inspector was made aware of a complaint from a resident which had not been recorded. The provider stated that this was being addressed and staff were aware that all complaints must be recorded. Procedures were in place to safeguard resident’s safety and welfare. However the manager needed to be told what to do following an allegation, as she did not know. There is currently an allegation of abuse within the home, which has been reported to the Adult Protection team. Although a number of staff have received training in the protection of adults, it is recommended that they receive further training due to the recent allegation. Gresley House Care Home DS0000067515.V309019.R01.S.doc Version 5.2 Page 14 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): 19,26 Quality in this outcome area is good. Clean, pleasant surroundings provide a homely environment for residents enabling them to relax and settle into the home more easily. This outcome has been made from evidence gathered before and during the visit to the service. EVIDENCE: Residents consider that the environment is homely and comfortable and is maintained to a good standard; this was apparent on the inspection. Areas of the home seen on inspection highlighted no issues relating to the environment. Arrangements were in place to ensure that the home is well maintained. Resident’s bedrooms contained personal belongings. The home was clean and free from odours at the time of the inspection. Staff reported that domestic and laundry cover is provided 7 days a week and that the hours provided were considered sufficient for the needs of the home. Gresley House Care Home DS0000067515.V309019.R01.S.doc Version 5.2 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,30 Quality in this outcome area is good. Above the recommended 50 of staff trained in NVQ2 Care ensures that staff are suitable trained to meet the changing needs of the residents. This outcome has been made from evidence gathered before and during the visit to the service. EVIDENCE: Training records confirmed that over 50 of care staff had achieved or were in the process of achieving a national approved qualification (N.V.Q Level 2 or 3), to ensure they are trained and competent to do their job. Staff and residents considered that the staffing levels were sufficient to meet residents’ needs. The home has an established staff team. The home continues to have a low turnover of staff. The deputy manager reported that new staff work under supervision of a senior member of staff and receive an induction, the induction has been introduced by the new provider and is very detailed to cover all aspects of expectations when working with older people in care. As detailed earlier within this report the provider must arrange further training for all staff and the manager in Adult Protection. Gresley House Care Home DS0000067515.V309019.R01.S.doc Version 5.2 Page 16 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): 31,33,35,38 Quality in this outcome area is adequate. Requirements continually not being addressed potentially puts residents at risk. This outcome has been made from evidence gathered before and during the visit to the service. EVIDENCE: The Inspector raised concerns with the provider about the Registered Manager not addressing previous requirements within the timescales set and the lack of knowledge around Adult Protection, the provider assured the Inspector that this was being addressed and all requirements were now being addressed. A policy and procedure is in place relating to the management of resident’s finances and money, to safeguard residents interests. The manager confirmed Gresley House Care Home DS0000067515.V309019.R01.S.doc Version 5.2 Page 17 that resident’s relatives or an independent person managed their finances and personal allowances; one resident’s allowances were paid directly into her own bank account. No one at the home was appointee for resident’s finances. Care staff confirmed that the deputy manager worked with them and supervised their work. The new provider has implemented a policy on staff supervision and care staff will now receive 1-1 formal supervision to ensure they are appropriately supervised. The deputy manager reported that staff have attended all mandatory training and confirmed that since the new provider had taken over further training was planned. The new provider is implementing a detailed quality audit document, this will ensure that all care provided is audited regularly and changed accordingly. The deputy manager informed the inspector that the fire alarm system still could not be heard from the laundry room, however it had been reported and someone had been to look at the system and a response was awaited. Fire systems are checked regularly and residents spoken with were aware of what to do in the event of a fire. Gresley House Care Home DS0000067515.V309019.R01.S.doc Version 5.2 Page 18 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 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 2 17 X 18 1 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X 3 X X 2 Gresley House Care Home DS0000067515.V309019.R01.S.doc Version 5.2 Page 19 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. 2. Standard OP3 OP3 Regulation 14 13 Requirement Residents must have their needs fully assessed on admission to the home. (previous timescales 16/6/05 & 01/06/06 not met) Risks to residents must be identified and minimised as far as possible. (previous timescale 01/06/06 not met) Care plans must set out measures taken to minimise further risks to residents. (previous timescale 01/06/06 not met) Resident’s care plans must set out how their needs are to be met.(previous timescale 16/6/05 & 01/06/06 not met) Timescale for action 15/09/06 15/09/06 3. OP3 13 15/09/06 4. OP7 15 15/09/06 5. OP9 13 Staff must administer medicines 15/09/06 in accordance with home’s procedures. (previous timescale 16/6/05 & 15/05/06 not met) A record of medication received 15/09/06 at the home must be recorded. A record of complaints must be 30/09/06 kept. All staff and the Registered 30/09/06 Manager must receive training in DS0000067515.V309019.R01.S.doc Version 5.2 Page 20 6. 7. 8 OP9 OP16 OP18 13 22.8 13.6 Gresley House Care Home 9 10 11 OP31 OP31 OP31 Adult Protection. 12, 14, 15 Detailed assessments of need 30/09/06 and care plans must be in place for all residents. 22.3, 22.8 All complaints must be detailed 30/09/06 and investigated. 43 It is an offence not to comply 30/09/06 with regulations 12,14,15, 22. 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 OP27 Good Practice Recommendations All staff and the manager should receive training in Adult Protection. Gresley House Care Home DS0000067515.V309019.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Gresley House Care Home DS0000067515.V309019.R01.S.doc Version 5.2 Page 22 - 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. 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