Inspection on 27/04/05 for Greville House

This inspection was carried out on 27th April 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 21/09/05

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 27th April 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 v224676 e54 s16771 greville hse v224676 270405 stage 4.doc Version 1.30 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 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 of places Greville House v224676 e54 s16771 greville hse v224676 270405 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 9th November 2004 Brief Description of the Service: Greville House occupies premises, which are approximately a century old, and 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 within a short drive or bus ride of Sutton Coldfield, Mere Green and Streetly. The building is a large , extended and attractive propery, 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 building for eight vehicles and the main drive can accommdate a further vehicle. Bedroom accommodation is provided on both the ground and first floor. The upper floor is accessed by a stair lift. All bedrooms are of single status, sixteen of which have en-suite facilites and most overlook the garden or parkland. The home has two lounges situated on the ground floor and a separate exceptionally well appointed dining room. The home employs three trainied nurses who between them provide the majority of the senior site cover including weekends and a night time on call service. One of the three nurses also has the role of registered manager. There is a comprhensive and interesting in-house and external activities programme. The home provides residential care for persons aged 65 years or more. Greville House v224676 e54 s16771 greville hse v224676 270405 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a period of 4.25 hours and focussed in the main upon a number of the core standards and the few requirements made at the last inspection. The outcome of the inspection was determined by discussions held with the registered manager, three residents and brief dialogue with three members of staff. Documentation was examined and four care plans were reviewed, this included case tracking of individuals full needs. A partial tour of the premises was carried out. What the service does well: What has improved since the last inspection? A bedroom had been refurbished; this is carried out in consultation with the respective resident. The home was in the process of replacing all water taps in bedrooms bathrooms and toilets to incorporate a lever style in order to provide ease of access for residents. Greville House v224676 e54 s16771 greville hse v224676 270405 stage 4.doc Version 1.30 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 v224676 e54 s16771 greville hse v224676 270405 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Greville House v224676 e54 s16771 greville hse v224676 270405 stage 4.doc Version 1.30 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 standard(s) 4, 5 and 6 Before a placement is offered a comprehensive pre-admission procedure is carried out to ensure that the home is able to meet the individual’s needs. Appropriate action is taken when the service is no longer able to address all of a residents identified needs. EVIDENCE: The registered manager advised that due to the changing needs of a resident, senior staff had determined that the home was no longer able to provide a service that met all of the persons needs. Relatives had been informed of the requirement to seek alternative accommodation and Social Services had been informed of the situation. The home does not accept emergency admissions because the ethos of the home centres around minimal disruption of permanent residents. There was documentary evidence of pre-admission visits made to the home by prospective residents and their relatives. They are invited to sample the food and to mingle with residents and staff before making a decision. Greville House v224676 e54 s16771 greville hse v224676 270405 stage 4.doc Version 1.30 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 standard(s) 7, 8, 9 and 11 Most residents have comprehensive care plans in place, which set out their care needs, there was no documentary evidence of assessment and care planning of the needs of the most recent admission. Health care needs of residents are well met; proactive practices are in place. The medication system is well managed promoting good health. EVIDENCE: Of the four care plans examined, three were comprehensive and covered all aspects of physical and mental health issues and took into account individuals preferences. The file concerning the latest admission had not been completed. Not all of the identified physical illnesses had been addressed; the pressure sore risk assessment and dependency profiles had not been carried out. One resident spoken with said she “enjoys living at the home very much, I have no complaints about the care”. Care plans included records of monthly monitoring of each residents weight and files included details of the input from multi-agency professionals. Greville House v224676 e54 s16771 greville hse v224676 270405 stage 4.doc Version 1.30 Page 10 The management of medication administration within the home was determined to be satisfactory for all aspects of medication. All unused medications are returned to the pharmacy after 28 days and appropriately documented. On the last occasion of a death at the home extra staff had been provided and a senior member of staff remained on the premises during the night to provide further support. Relatives of the residents were encouraged to visit at any time and spiritual needs had been met. Greville House v224676 e54 s16771 greville hse v224676 270405 stage 4.doc Version 1.30 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 standard(s) 12, 13 and 14 Social activities are comprehensive, varied and well managed meeting residents social and leisure needs. Residents are actively encouraged and supported in maintaining relationships with relatives, friends and in accessing the local community. Residents are consulted about the day-to-day running of the home and exercise control over personal aspects of their lives. EVIDENCE: Residents meetings were being held every three months; leisure preferences are a constant agenda item. Minutes had been produced in large print and displayed on the notice board and a copy is supplied to each individual. The programme found on the dedicated notice board indicated that comprehensive in-house and external activities were being provided. Various outings had been arranged and entertainers were invited to the home regularly as well as church elders. A trolley shop had been introduced every Monday and regular visits of a donkey from the local sanctuary had been well received. Photographic collections of various events and parties were wall mounted in the reception area of the home. There was no restriction on visiting and relatives regularly take residents on outings. The inspector spoke with one of the two voluntary workers who provide leisure activities and observed positive and friendly interactions between her and residents. Greville House v224676 e54 s16771 greville hse v224676 270405 stage 4.doc Version 1.30 Page 12 Two residents said that they would be using postal votes during the imminent general election and discussed their views with the inspector. Further information given by the registered manager was that those residents who wished to attend a polling station would be escorted. Greville House v224676 e54 s16771 greville hse v224676 270405 stage 4.doc Version 1.30 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 standard(s) 16 The home has a satisfactory complaints system and had evidence to indicate that resident’s views are listened to and acted upon. EVIDENCE: Since the previous inspection of November 2004 a resident had made a verbal complaint. There was documentary evidence that the home had fully investigated the allegation and taken appropriate action to minimise the risk of recurrence. The resident and relatives were satisfied with the outcome. Greville House v224676 e54 s16771 greville hse v224676 270405 stage 4.doc Version 1.30 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 standard(s) 19, 20, 22, 24 and 26 The overall quality of the furniture fixtures and fittings are of a high standard and provide a safe and warm environment. The home has an adequate supply of adaptations, which comply with health and safety requirements and meet residents needs. All areas of the home were well maintained and hygienic and did not pose a risk to residents in respect of health and safety. EVIDENCE: The layout of the home is attractive, comfortable and homely. Soft furnishings were of a high standard and aesthetically pleasing. All communal areas were clean, tidy and did not include any unnecessary obstacles that would pose a risk. The gardens extend around two sides of the building. They were interesting in design and included an abundance of plants. Potted plants had been placed outside ground floor bedroom windows. There were discreet areas with seating which residents said they enjoyed using. The home has two well appointed lounges and a separate dining room. The smaller lounge was used a quiet room and was noted to be well occupied. The Greville House v224676 e54 s16771 greville hse v224676 270405 stage 4.doc Version 1.30 Page 15 main lounge permitted sufficient central space for presentation of activities. The dining room was tastefully furnished offering an exceptional accommodation for the serving of meals. Adaptations included hoists, assisted bathing, a call system in all bedrooms, bathrooms and toilets as well as the small lounge. Staff were observed entering the main lounge regularly to respond to any requests and ensure that residents comfort was being maintained. All bedrooms offer single accommodation, sixteen have en-suite facilities and all rooms have wash hand basins. Room were decorated and furnished to a high standard and residents were consulted when decorating was due to be carried out. Rooms were personalised to the degree preferred by the occupant, they included many personal possessions and furniture. All rooms have a lockable facility and those who preferred had their own telephones. Exceptionally high levels of hygiene were evident within all areas of the home. High levels of cleanliness were being maintained in the kitchen and laundry rooms. Greville House v224676 e54 s16771 greville hse v224676 270405 stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 and 30 The home had maintained adequate staffing levels and training resulting in an enthusiastic workforce that works positively with residents to improve their quality of life. EVIDENCE: Examination of the duty rota revealed that a minimum of four care staff and a senior person were on duty during waking hours. An allocation of two waking night staff is provided each night and an out of hours on call system of senior staff. Care staff were supported to carry out their dedicated roles with the employment of cooks, housekeepers, an activities co-ordinator and part time maintenance operative. Staff training was noted to be up to date for all mandatory and refresher courses. There was also documentary evidence that all staff had completed training regarding adult protection. The inspector was advised that further training had been arranged. Greville House v224676 e54 s16771 greville hse v224676 270405 stage 4.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 36, 37 and 38 There is strong leadership, guidance and direction to staff to ensure that residents receive consistent quality care. The home had failed to inform CSCI of incidents regarding the health, safety and welfare of a resident, although other appropriate action appears to have been taken. EVIDENCE: The registered manager is an experienced nurse with a wealth of experience. The home owner, the registered manager and a senior nurse have each successfully completed the registered managers award. The inspector observed positive and professional relationships between all staff, management residents and their visitors. An open door approach was in place and residents are offered the opportunity of talking to a senior person in confidence every day. Greville House v224676 e54 s16771 greville hse v224676 270405 stage 4.doc Version 1.30 Page 18 The documentation in respect of quality assurance was comprehensive. The registered manager was advised that in order to complete the process an annual report including a resultant action plan with timescales should be collated. Improvements regarding the timings of formal staff supervision had been achieved; the system in place was determined to be satisfactory. Resident’s files were securely stored whilst permitting staff access at all times. The home had failed to report incidents regarding a resident who had a history of falls and who had been hospitalised. The home must inform CSCI of any incidents that affect the health, safety and well being of any residents. Greville House v224676 e54 s16771 greville hse v224676 270405 stage 4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 x COMPLAINTS AND PROTECTION 3 3 x 3 x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 x 2 x x 3 3 2 Greville House v224676 e54 s16771 greville hse v224676 270405 stage 4.doc Version 1.30 Page 20 One Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) Requirement The registerd person must ensure that comprehensive assessments and care planning is completed within five days for all admissions to the home. Timescale for action Within 1 week of the inspection, 6th May 2005 31st July 2005 2. OP33 24(2) 3. OP38 The registered person must complete the quality assurance process by producing an annual report including a resultant action plan with timescales. 37(1)c,d,e The registerd person must inform the Commisssion without delay of any incidents which affect the health, safety and well being of any resiednt. Within 24 hours of the inspection, 28th April 2005 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 Good Practice Recommendations Greville House v224676 e54 s16771 greville hse v224676 270405 stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Birmingham & Solihull Local 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. Extracts may not be used or reproduced without the express permission of CSCI Greville House v224676 e54 s16771 greville hse v224676 270405 stage 4.doc Version 1.30 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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