Inspection on 21/09/05 for Greville House

This inspection was carried out on 21st September 2005.

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

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

Other inspections for this house

Greville House 19/06/08

Greville House 15/11/06

Greville House 27/04/05

Greville House 09/11/04

Greville House 28/05/04

Greville House 02/03/04

Greville House 04/02/04

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

CARE HOMES FOR OLDER PEOPLE Greville House 40 Streetly Lane Sutton Coldfield West Midlands B74 4TX Lead Inspector Kath Strong Unannounced Inspection 21 September 2005 09:45 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 Greville House DS0000016771.V252732.R01.S.doc Version 5.0 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. Greville House DS0000016771.V252732.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Greville House Address 40 Streetly Lane Sutton Coldfield West Midlands B74 4TX 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) 0121 308 8304 0121 308 8304 Mrs Christina Sally Howard Mr Jonathan Keith Howard Pamela Thompson Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Greville House DS0000016771.V252732.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The category of registration is OP (older people, over 65). The maximum number is 22 and the type of home is care home only. The registered manager develops and implements adult protection procedures for Greville House that incorporates Birmingham`s MultiAgency Guidelines and those of Walsall MDC. Mrs Thompson must provide evidence of completion of a Management qualification at NVQ level 4 or equivalent at the earliest opportunity or before April 2005. One named person may be accommodated and cared for in this home for reason of Mental Illness (OP 21, MD 1) 27th April 2005 3. 4. Date of last inspection Brief Description of the Service: Greville House occupies premises, which are approximately a century old; many of the original features have been retained. The home is located in a residential area to the north of Birmingham, overlooking Sutton Park and is within a short drive or bus ride of Sutton Coldfield, Mere Green and Streetly. The building is a large, extended and attractive residential property, which is surrounded by gardens that provide a pleasant and secluded outlook from most bedrooms. There is sufficient off road parking to the side of the premises for eight vehicles and the main drive can accommodate a further vehicle. Bedroom accommodation is provided on the ground and first floors; the upper floor is accessed via a stair lift. All bedrooms are single status, sixteen of which have en-suite facilities. There are two lounges situated on the ground floor and a separate exceptionally well appointed dining room. The registered manager and two of the senior staff are trained nurses who between them provide cover during the weekends as well as weekdays. The home provides a comprehensive and interesting internal and external activities programme. Residential care is provided for up to 22 persons of 65 years of age or above but the home cannot accommodate wheelchair users. Greville House DS0000016771.V252732.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the visit was to conduct an unannounced inspection; the outcome was determined by a variety of methods. In depth discussions were held with the registered manager as well as individual discussions with five residents. Dialogue took place with the cook who also provides management input one day per week. Relevant documentation was examined including two care plans, this included case tracking to ensure that all identified needs were being met. A partial tour of the premises was carried out and the serving of lunch was observed. The three requirements generated from the previous inspection were reviewed. At the conclusion verbal feedback was given to the registered manager. In order to obtain a comprehensive overview of the services provided this report should be read in conjunction with the report from the April 2005. Inspection. What the service does well: What has improved since the last inspection? The bathroom situated on the first floor has recently been refurbished to a high standard. The landing curtains have been replaced. Greville House DS0000016771.V252732.R01.S.doc Version 5.0 Page 6 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. Greville House DS0000016771.V252732.R01.S.doc Version 5.0 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 Greville House DS0000016771.V252732.R01.S.doc Version 5.0 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 Appropriate pre-admission assessments are carried out by a senior member of staff in order for the home to determine its ability to meet the identified needs. EVIDENCE: The home completes an enquiry form at the initial contact stage, which progresses to a comprehensive pre-admission assessment being carried out prior to a placement being offered. Standards 4, 5 and 6 were fully met at the last inspection. Greville House DS0000016771.V252732.R01.S.doc Version 5.0 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 and 10 The is a clear and consistent care planning process in the home that provides staff with appropriate guidance of care needs and evidence of a proactive approach to the involvement of external professionals. Medication is well managed promoting good health. Resident’s privacy and dignity is respected. EVIDENCE: The care plans of two recent admissions were examined and found to contain details regarding past and present conditions and care needs. Staff had identified and produced a strategy for dealing with a problem regarding a residents sleep pattern, the situation was being monitored and documented. Files included records of monthly monitoring of residents weights and rationale and outcome of the involvement of external multi-agency professionals. Staff are not permitted to administer medications until they have undertaken an accredited training course. Most staff have also completed a further in depth course provided by Solihull Technical College. The system for administration of medications was determined to be safe. Greville House DS0000016771.V252732.R01.S.doc Version 5.0 Page 10 By means of observations and by talking to residents it was evident that staff are friendly and supportive towards residents and use their preferred term of address. All personal care is delivered in the privacy of the resident’s bedroom or a bathroom. Greville House DS0000016771.V252732.R01.S.doc Version 5.0 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 and 15 Recreational activities are comprehensive, varied and well managed meeting residents social and leisure aspirations. Residents are encouraged and supported in maintaining relationships with relatives and friends and in accessing the local community. Residents are regularly consulted about the day-to-day running of the home. EVIDENCE: Residents meetings are held and minuted every three months and individual daily contact is offered with a senior member of staff. The recreational programme has recently been reviewed and changed in order to comply with the wishes of the current client group. As with previous inspections there is strong emphasis on provision of an interesting internal and external programme that includes visiting entertainers. On the day of inspection a 90th birthday was being celebrated, which included a gift, the resident choosing the menu for the day and an evening buffet with staff, relatives and friends being invited by the resident. The dining room was being decorated in preparation for the festivities. Photographic collections of various internal and external events are on display in communal areas. Upon the inspectors arrival at the home at 09.45am residents were observed finishing breakfast in the dining room. The breakfast menu is extensive with Greville House DS0000016771.V252732.R01.S.doc Version 5.0 Page 12 all requests being catered for. The dining room is of an exceptionally high standard in décor, furniture and layout. Lunch was served from a hostess trolley by the cook and a carer with other carers in attendance to serve at the tables and provide discreet assistance. Observations revealed that the cook had a good knowledge of individual’s likes/dislikes and preferred portion sizes. Meals at Greville House are of a very high standard with evidence that choices of alternatives were being offered. Encouragement and support is provided for residents to go on outings with relatives and friends and to access the local community such as attendance at a Women’s Institute. Greville House DS0000016771.V252732.R01.S.doc Version 5.0 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): 18 Arrangements for protecting residents from abuse are satisfactory. EVIDENCE: The home has a written policy that covers all relevant aspects of adult protection, which is complimented by the No Secrets document issued by the Department of Health. The home has a rolling programme of staff training in respect of dementia care and adult protection. Standard 16 was fully met at the last inspection. Greville House DS0000016771.V252732.R01.S.doc Version 5.0 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 and 26 The overall quality of accommodation is of a high standard providing a warm, safe and comfortable environment. All areas of the home are well maintained and very hygienic and do not pose a risk to residents in respect of health and safety. EVIDENCE: The layout of the home is attractive. Soft furnishings and furniture are of a high standard and well maintained. All communal areas are aesthetically pleasing including the secluded garden. The main lounge and dining room are utilised for recreational pursuits and those who do not wish to participate are able to frequent the small lounge or their bedroom. All bedrooms offer single accommodation, sixteen of which include en-suite facilities. Cleanliness throughout is exceptionally high, staff practices observed indicated facilitation of the hygiene levels. Standards 19, 20, 22, 24 and 26 were fully met at the last inspection. Greville House DS0000016771.V252732.R01.S.doc Version 5.0 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): 29 and 30 Staff recruitment practices are robust ensuring the protection of residents. Staff are appropriately trained to carry out their roles effectively. EVIDENCE: Prospective employees undergo a full recruitment programme and all relevant checks are carried out prior to a post being offered. A full induction is provided and care staff also undertake further induction, which reflects the contents of the TOPSS induction programme. The home has developed a rolling programme of all mandatory staff training and other relevant training that assists staff in meeting the needs of the current client group. The registered manager has recently achieved a trainers certificate in manual handling and carries out all in-house training of staff. The system also has the additional benefit of ongoing observations of staff practices to ensure that techniques deployed are acceptable. Standards 27 and 30 were fully met at the last inspection. Greville House DS0000016771.V252732.R01.S.doc Version 5.0 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): 35, 33 and 38 Personal monies of residents are adequately maintained thus safeguarding their interests. EVIDENCE: Transactions in respect of personal monies are maintained by the individual resident, their relatives or if requested by the home. Personal monies are stored individually and securely with full documentation and retention of receipts where possible. The home has now completed the process of the quality assurance system with the development of an annual report and resultant action plan with timescales. All aspects of health and safety were examined and fully complied with at the last inspection with the exception of Regulation 37. It was determined at this Greville House DS0000016771.V252732.R01.S.doc Version 5.0 Page 17 inspection that the home now notifies CSCI of any untoward incidents that affects the health and well being of residents. Standards 31, 36, and 37 were fully met at the last inspection. Greville House DS0000016771.V252732.R01.S.doc Version 5.0 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 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 4 13 4 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 x 3 X X 3 Greville House DS0000016771.V252732.R01.S.doc Version 5.0 Page 19 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. Refer to Standard Good Practice Recommendations Greville House DS0000016771.V252732.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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