Inspection on 23/10/07 for Grevill House

This inspection was carried out on 23rd October 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

Grevill House 15/08/06

Grevill House 14/02/06

Grevill House 20/07/05

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

CARE HOMES FOR OLDER PEOPLE Grevill House 279 London Road Charlton Kings Cheltenham Glos GL52 6YL Lead Inspector Ms Eleanor Fox Key Unannounced Inspection 09:30 23 and 24th October 2007 rd 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 Grevill House DS0000064592.V342752.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. Grevill House DS0000064592.V342752.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grevill House Address 279 London Road Charlton Kings Cheltenham Glos GL52 6YL 01424 512964 01242 224278 manager.grevill@osjctglos.co.uk 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) The Orders of St John Care Trust Mrs Joy Rosemary Warren Care Home 65 Category(ies) of Old age, not falling within any other category registration, with number (65) of places Grevill House DS0000064592.V342752.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Temporary Variation - One named service user under the age of 65 years. The home will revert to the original service user category when the named service user no longer resides at the home. Temporary Variation - One named service user under the age of 65 years. The home will revert to the original service user category when the named service user no longer resides at the home. Temporary Variation - One named service user under the age of 65 years. The home will revert to the original service user category when the named service user no longer resides at the home or reaches 65 years of age. 15th August 2006 Date of last inspection Brief Description of the Service: Grevill House is a purpose built Care Home, providing nursing and personal care to 50 residents over 65 years of age. The home is managed by the Orders of St John Care Trust. Grevill House is situated in the village of Charlton Kings, approximately 2 miles from Cheltenham Town centre. The home has 50 single rooms, with comfortable homely communal accommodation on both floors. A shaft lift has been installed for easy access to the upper floor. Although only two of the rooms have en suite facilities, there are several assisted bathrooms and separate toilet facilities throughout the home. Some of the bedrooms at the front of the property have the benefit of a small balcony. An additional superb independent facility known as the Ashley Intermediate Care Centre provides intermediate care for 15 service users. All the large comfortably furnished bedrooms have en suite facilities and the service users have the benefit of sunny open plan communal rooms. They have access to full rehabilitation support services during their short stay in the unit. The property is surrounded by landscaped gardens. The provider supplies information about the home, including the most recent CSCI report in a file at the entrance of Grevill House. Current fees range from £539 to £742. Hairdressing, chiropody and any personal items are charged extra; costs are provided on request. Grevill House DS0000064592.V342752.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the home and to the intermediate care centre and takes into account the views and experiences of people using the service. Three random inspections of Grevill House were undertaken in November and December 2006 to investigate a complaint from the relation of resident, raising concerns about a number of care issues. When these investigations had been completed, the inspector concluded that the home had not breached any of the Care Homes Regulations. One inspector undertook this unannounced inspection of Grevill House over the course of two days in October 2007. The inspector checked the home’s compliance with any outstanding requirements made by the Commission for Social Care Inspection. On this occasion, she chose the care of four of the residents in the main home for particular scrutiny. She also selected two service users who were staying in the intermediate care centre. The inspector spoke to each of these people, visited their bedrooms, read all their relevant care records, and, where possible, observed their interaction with members of staff and their participation in various activities. The inspector also looked at the medication administration processes, particularly with reference to those people who had been selected for case tracking. She observed the medication storage arrangements and the protocols in place for self-medication. She also examined the processes for recording medications, which had been administered and the management of controlled drugs. The inspector walked around the two properties, and observed the service of the mid day meal during the course of the visit. She also observed the residents’ participation in a variety of activities, meeting the activities coordinator and discussing her role at the home. She checked that residents were able to exercise choice and to maintain social contacts. The inspector also looked at the processes in place to protect the residents from any risks. Arrangements for and records relating to the maintenance of equipment were examined. Grevill House DS0000064592.V342752.R01.S.doc Version 5.2 Page 6 The inspector read selected personnel and recruitment records and looked at the opportunities provided for training. Finally, she spoke to the registered manager, to the unit manager and to the administrator, particularly in relation to general management issues and other responsibilities of their roles. The inspector extends her thanks to all the staff that provided assistance during the inspection processes. Prior to the inspection, CSCI surveys were distributed to residents, staff and relatives of those living at Grevill House and staying at the Ashley Intermediate Care Centre. Six were returned from residents and service users; five responses were sent in from relatives and advocates and five from Health Professionals who had experience of the home. Twenty-two members of staff also returned completed questionnaires. Many of the written opinions are reflected in the content of this report. What the service does well: Service users requiring short-term rehabilitation care have the benefit of a very comprehensive service provided in comfortable homely surroundings. People accommodated in both premises are treated with courtesy and respect by the staff. Those that spoke to the inspector strongly confirmed their appreciation for the care they were receiving. One lady said, “They are the kindest carers you could wish to meet.” A varied and stimulating programme of activities has been developed for the residents’ entertainment. However, at present there is only minimal one to one stimulation for those people with short-term memory loss. This shortfall is now being addressed. People are also provided with a reasonable choice of food. Any complaints or concerns are addressed promptly and, if required, full investigations are undertaken. People accommodated in these units live in a comfortable environment, which has been furnished to suit their needs. Observation of the records shows that careful recruitment processes are followed. Throughout their employment staff have the opportunity to attend training appropriate to their work. They also receive good guidance on dealing with abuse issues. Although the whole home has just one registered manager, both units have the advantage of experienced and well-qualified nurses to manage the service. Grevill House DS0000064592.V342752.R01.S.doc Version 5.2 Page 7 Quality assurance is managed well in this home. 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. The summary of this inspection report can be made available in other formats on request. Grevill House DS0000064592.V342752.R01.S.doc Version 5.2 Page 8 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 Grevill House DS0000064592.V342752.R01.S.doc Version 5.2 Page 9 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): 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with good information so that they may make an informed decision regarding their admission. They may also be assured that their needs will be met, as there is an effective assessment process in place. Service users are given good opportunities to develop independent living skills when they are admitted to the Ashley Intermediate Care Centre. EVIDENCE: Since the last inspection the Statement of Purpose and Service User Guide have been fully reviewed and updated to reflect the changes at the home. A copy of the new documentation is displayed in the front hall of Grevill House. Grevill House DS0000064592.V342752.R01.S.doc Version 5.2 Page 10 Each person living in the home is also provided with a personal copy of the ‘Residents Guide’. The registered manager has been requested to add just one more sentence to the information providing details about people who may be admitted to Grevill House. Detailed assessments are undertaken of each person wishing to be considered for admission to Grevill House. The information is recorded and maintained on file for use in the admission processes. In some cases, members of staff also have the benefit of further details provided by other health and social care professionals previously involved in the care of these elderly people. It has been identified that on a few occasions in the past, inappropriate admissions have been arranged at the Ashley Intermediate Care Centre. However in recent months, these issues have not arisen and the anomalies appear to have been resolved. There is a dedicated 15-bed intermediate care unit in the grounds of the home where service users are accommodated for approximately six weeks to develop the necessary skills to live independently in the community. They receive care from a multi-disciplinary team of staff and have access to well designed facilities and equipment to meet their different needs. Grevill House DS0000064592.V342752.R01.S.doc Version 5.2 Page 11 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, and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People accommodated in both areas may be assured that all their care needs will be met appropriately and in a manner that respects their privacy and dignity. EVIDENCE: Grevill House: Four examples of care planning documentation were looked at in detail on this visit. In each case specific care plans had been prepared based on a thorough assessment of care needs. On the whole, these provided clear and appropriate guidance to staff and appeared to reflect the resident’s current condition. Some had been pre-printed but had been personalised to be appropriate to the named resident. Detailed risk assessments, particularly in relation to the risk of developing pressure sores and other identified issues had been undertaken. Where necessary, associated care plans had been prepared. Grevill House DS0000064592.V342752.R01.S.doc Version 5.2 Page 12 Observation of the residents in question showed that they appeared to be receiving the care as instructed. Ashley Intermediate Care Centre: Two examples of care planning documentation were examined. Once more individual care plans had been prepared to address each person’s care needs, based on an overall assessment. Records relating to the Doctors’ visits and care provided by the Occupational Therapist and Physiotherapist were also maintained in the files. One isolated shortfall in the documentation has now been amended. In both units, there were clear records in the files to show that people receive care from other healthcare professionals as required. One person had had support from the Speech and Language Therapist, Psychiatrist, Tissue Viability Nurse and Continence Advisor. Another had recently had chiropody treatment and another had visited the hospital for an appointment with the Ophthalmic Surgeon. Grevill House: The medication administration systems relating to the four selected residents were checked on this occasion. Medication storage and the management of controlled drugs were also assessed. Photographs had been provided for the residents to assist identification It was observed that all the medication storage cabinets were securely locked, including the dedicated refrigerator. Drugs were administered and stored correctly; controlled medications were also managed appropriately. Records were maintained accurately. Medication policies are readily available and a recent copy of a medication reference book is provided for staff information. Ashley Intermediate Care Centre: The majority of service users are supported to self medicate their drugs on the basis of risk assessment processes. Appropriate lockable storage is provided in each room for their use. Care staff monitor the service users closely to ensure that medications are managed safely On no occasion throughout the inspection did the inspector see any example when residents’ privacy and dignity were not respected. Staff appeared polite and friendly in their approach, ensuring that the residents and service users had adequate time and opportunity to move from room to room and giving them assistance and encouragement as required. One person commented to the inspector, “The girls have given me my confidence back. I feel so much more positive now”. Grevill House DS0000064592.V342752.R01.S.doc Version 5.2 Page 13 Grevill House DS0000064592.V342752.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. Some of the residents are given the opportunity to take part in a number of interesting and entertaining activities, and the majority benefit from a varied and nourishing diet. EVIDENCE: Since the last inspection a dedicated activities coordinator has been employed, working 14 hours a week. After discussion with residents and staff she has developed a varied programme of activities. During the inspection, she arranged a quiz, which was attended by seventeen people. Each person was taking part, as far as they were able and appeared to enjoy the event. She also arranges external entertainers and trips out in the minibus when possible. Records of each person’s participation in any form of activity are maintained for reference purposes. One resident wrote, “I enjoy the activities we do now – they brighten up the day”. Grevill House DS0000064592.V342752.R01.S.doc Version 5.2 Page 15 However, at present there is only minimal one to one stimulation for those people with short-term memory loss despite the number of residents with early dementia. Further development in this area is required. One person spoken to in the Ashley Intermediate Care Centre did comment that he was lonely much of the time at the Centre; he missed all his friends at home. This was reported to the Unit Manager for further attention. Another person accommodated there had joined residents in Grevill House to take part in the quiz. Friends and family are free to visit people in both properties so long as the resident/service user is happy to see them. Efforts are also made to ensure that visitors are fully aware of any planned events or specific news. A newsletter is produced on a regular basis. One relative commented, “They make visitors feel welcome here”, and the wife of another person said, “They are a friendly group”. Residents, who spoke to the inspector, confirmed that they were able to choose when they wished to get up and go to bed; they were given choice in their meals and were able to spend their days where and how they preferred. Information is provided on how to source advocacy, if it is required. The service of the mid day meal was observed on this visit. Most of the residents in Grevill House sat in the large sunny dining room. Service Users in the Ashley Intermediate Care Centre ate their food in the pleasantly furnished dedicated dining area. Some people preferred to remain in their bedrooms and were served there. Hot trolleys have been provided to keep food warm when transported to other areas. People living in the home were given a good choice of food and helpings were adapted, as appropriate. Those residents requiring assistance to eat their food were helped in a patient and sensitive manner by the majority of staff. One isolated incident was reported to the manager and was addressed. Plate guards and adapted cutlery were provided as needed. The inspector did observe that vegetables brought in for one resident were cooked for him in the kitchen at the request of his wife. Three people did speak positively about the food provided with one person saying, “You can’t fault the food here – it is very good.” Another person did consider that, “It’s a bit bland” but nevertheless he enjoyed his meal. The kitchen appeared clean and well organised. Grevill House DS0000064592.V342752.R01.S.doc Version 5.2 Page 16 Grevill House DS0000064592.V342752.R01.S.doc Version 5.2 Page 17 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. Residents living at Guild House and accommodated in the Ashley Intermediate Care Centre may be assured that they can expect to live in a safe environment and that any concerns they raise will be promptly and appropriately addressed. EVIDENCE: A clearly explained Complaints Procedure has been prepared for Grevill House. A copy of the document is provided to each prospective resident and/or relatives with other information about the home. The details are also displayed within the home and in the Ashley Intermediate Care Centre. The complaints records were provided for inspection. These showed that any complaints or concerns had been addressed promptly, investigated and, where necessary, remedial action taken. One relative wrote, “The manager does her best to address issues when I make her aware of them.” A resident said, “The carers are very good and sort out any problems we have. I don’t have any complaints about this place.” Another said, “All the staff are very approachable”. Grevill House DS0000064592.V342752.R01.S.doc Version 5.2 Page 18 The home provides a fully documented policy to address all forms of abuse. The policies are readily available for staff to read. Abuse issues are covered in the Induction Programme, which each newly appointed member of staff undertakes. Some have also had further formal training on the subject. There are no records of any abuse issues occurring in the home or in the Ashley Intermediate Care Centre since the last inspection. One member of staff who was questioned on the subject showed that she had a good understanding of her responsibilities if an allegation of abuse is made. POVA (Protection of Vulnerable Adults) legislation is correctly followed at Grevill House. Grevill House DS0000064592.V342752.R01.S.doc Version 5.2 Page 19 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, 20 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents living in the home and service users in the Ashley Intermediate Care Centre are accommodated in a reasonably clean and comfortable environment, which has been furnished and equipped to suit their needs. EVIDENCE: On this occasion, the inspector walked around the buildings, visiting the bedrooms of all those selected for case tracking and observing the communal rooms. Both properties were in reasonable decorative condition and the majority of the furnishings were satisfactory and appeared to meet the needs of the people living there. Grevill House DS0000064592.V342752.R01.S.doc Version 5.2 Page 20 A well-stocked fish tank has been placed in the front hall of Grevill House; three residents pointed out some particular favourites to the inspector and explained that they enjoyed watching the fish during the day. Service users accommodated in the Ashley Intermediate Care Centre have the benefit of a particularly well-equipped environment, which has been designed to give them adequate space and opportunity to undertake rehabilitation activities. Two people commented on how nice the unit is. The inspector was aware of some malodours along one corridor on the upper floor of Grevill House. However, the area had been cleaned and windows were left open to freshen the atmosphere. One relative did comment in the survey, “The upstairs smells of urine whenever I visit.” The laundry area was tidy and well organised. Clean and soiled items were all segregated correctly and staff appeared to be observing good health and safety protocols. Each resident appeared to be wearing fresh and well-presented clothing. Grevill House DS0000064592.V342752.R01.S.doc Version 5.2 Page 21 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 adequate. This judgement has been made using available evidence including a visit to this service. People living in this home receive care from a competent workforce, which would benefit from some isolated improvements in recruitment procedures. EVIDENCE: Grevill House: On the first day of the inspection there were fifty residents living in the home. The deputy manager, who is also a trained nurse plus another two trained nurses were on duty with twelve carers to look after the residents. The administrator, the activities coordinator, the handyman, two cleaners, the laundry assistant, cook, and two kitchen assistants were also working that day. Two nurses, seven carers and a kitchen assistant were scheduled to be on duty in the evening with a nurse and four carers working overnight. There was an additional carer working overnight who was providing one to one care for one resident. Despite some adverse comments about staff shortages on the staff questionnaires returned to the inspector, the home does appear to provide very adequate staffing levels to meet the residents’ needs. Grevill House DS0000064592.V342752.R01.S.doc Version 5.2 Page 22 Ashley Intermediate Care Centre: There were fifteen service users accommodated in the Ashley Intermediate Care Centre. That morning the Unit Manager, one care leader and two carers were on duty. A care leader and two carers were due to be working in the evening, with one care leader and a carer working overnight. There was also one cleaner allocated to this area. Other members of the multidisciplinary team work in the unit as and when required. It was confirmed that these numbers were adequate to meet the service users’ needs. The home is making good progress towards ensuring that at least 50 of the staff have achieved a National Vocational Qualification in Care; however this standard has not quite been met. Grevill House: Twenty-seven new members of staff have been recruited to the home since the last inspection. Personnel files relating to five of these people were selected at random and read on this occasion. In each case, the prospective employee had completed an application form, normally providing a full employment history. In two cases, however, only the most recent employment history had been included. Records had been maintained of the interview processes and POVA (Protection of Vulnerable Adults) and CRB (Criminal Record Bureau) screening had been completed. Two written references were provided for each applicant. However in two cases previous colleagues and not the employer had provided these documents, raising some doubts about their authenticity. Consideration should be given to ensuring that references are obtained from named employers, not colleagues working alongside applicants. There was also no recorded evidence to show that one nurse’s current registration status had been verified. Ashley Intermediate Care Centre: Two additional members of staff had joined the care team in the Ashley Intermediate Care Centre. In both cases correct recruitment procedures had been completed. There were records to show that staff employed in both areas had been fully inducted to their roles. One member of staff described the induction processes she had experienced when she started at the home. Staff are given the opportunity to attend a good variety of training; clear records are maintained of their attendance. In the Ashley Intermediate Care Centre a rolling programme of training is being introduced to cover topics such as, respiratory care, stoma care, diabetes and other specialist issues. Grevill House DS0000064592.V342752.R01.S.doc Version 5.2 Page 23 Grevill House DS0000064592.V342752.R01.S.doc Version 5.2 Page 24 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 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents may be reassured that there are robust management systems in place at this home to ensure that they are fully protected. EVIDENCE: The Registered Manager, a trained nurse, is well experienced in the care of older people. She has also undertaken additional management training. She is well supported in her role by her deputy, also a trained nurse and the administrator. The Unit Manager in the Ashley Intermediate Care Centre is also a trained nurse and has recently undertaken advanced education in the care of elderly people. Grevill House DS0000064592.V342752.R01.S.doc Version 5.2 Page 25 There are a number of quality monitoring systems in place at Grevill House. Residents/relatives satisfaction surveys are distributed annually and action taken to address any issues raised. The inspector was shown the outcomes of the most recent audit undertaken in the summer. There were issues relating to care, food, environment and activities identified. All these are now being addressed. The medication administration systems have been monitored throughout this year. Accidents, incidents and complaints are also audited once a month and the results monitored corporately. The home was assessed for the ISO 9001 quality award in 2006 and will be subject to an internal company quality audit in November 2007. ‘Peer audits’ by managers of other care homes have just been commenced. These will be conducted on a monthly basis. The home has also been awarded two stars by the Environmental Health Department following an assessment of the catering services, including food hygiene and safety procedures, an assessment of the structure of the establishment and confidence in management, plus an assessment of the control systems in place. The home continues to take responsibility for the personal monies for many of the residents; the records relating to the four residents selected for case tracking were checked on this occasion. It was observed that individual secure storage is provided and that records are maintained accurately. Residents’ status in relation to ‘Power of Attorney’ is also now maintained on file. Service users accommodated in the Ashley Intermediate Care Centre normally take responsibility for their own finances and are provided with lockable storage for any valuables. Where possible, they are requested to limit these as far as possible. There are records to show that the majority of the employees have had an appraisal during 2007 and most have also been supervised at least once or twice during the year. However it is recommended that supervision processes should be conducted six times a year for any staff involved in care. Records were provided to show that maintenance of equipment is undertaken in line with manufacturers’ recommendations. Records relating to the maintenance of hoists, maintenance of shaft lifts, safety of electrical equipment and water management were checked on this visit. Grevill House DS0000064592.V342752.R01.S.doc Version 5.2 Page 26 The Fire Risk assessment in place is currently being reviewed and updated. However, staff are receiving regular training in fire safety and prevention. The most recent Environmental Health inspection report provided following a visit in March 2007 identified that there had been some issues relating to cleaning, storage and hazard management. These have now been addressed. Any accidents or incidents are recorded appropriately. Grevill House DS0000064592.V342752.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x x 3 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 2 x 3 Grevill House DS0000064592.V342752.R01.S.doc Version 5.2 Page 28 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. 1. Standard OP29 Regulation 19(1c) Requirement The home must be satisfied on reasonable grounds as to the authenticity of the references of supplied for each candidate. Each applicant for a post at the home must provide a full employment history. A record must be maintained of each nurse’s current registration status and that this has been verified. Timescale for action 31/12/07 2. 3 OP29 OP29 Schedule 2.6 Schedule 2.9 31/12/07 31/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard OP12 OP12 Good Practice Recommendations Consideration should be given to developing further specialist activities for those people with short-term memory loss. More dedicated activities should be developed for those people accommodated in the Ashley Intermediate Care Centre so that they do not feel isolated and lonely. DS0000064592.V342752.R01.S.doc Version 5.2 Page 29 Grevill House 3. 4 5. OP28 OP29 OP36 At least 50 care staff should be trained to National Vocational Qualification, Level 2 in Care or equivalent. Consideration should be given to ensuring that references are obtained from named employers, not colleagues working alongside applicants. Supervision processes should be undertaken six times a year. Grevill House DS0000064592.V342752.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue BS1 4UA Bristol 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 Grevill House DS0000064592.V342752.R01.S.doc Version 5.2 Page 31 - 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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