Inspection on 13/06/08 for Grindley House Care Home

This inspection was carried out on 13th June 2008.

CSCI found this care home to be providing an Adequate service.

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

Grindley House Care Home 07/05/09

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 26/11/2008.

CARE HOMES FOR OLDER PEOPLE Grindley House Care Home Aynsleys Drive Blythe Bridge Stoke-on-Trent Staffordshire ST11 9HJ Lead Inspector Dawn Dillion Unannounced Inspection 13th June 2008 09:00 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 Grindley House Care Home DS0000067071.V365698.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. Grindley House Care Home DS0000067071.V365698.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grindley House Care Home Address Aynsleys Drive Blythe Bridge Stoke-on-Trent Staffordshire ST11 9HJ 01782 398919 01782 395221 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) Sudera Care Associates Limited Marie Elizabeth Bryan Care Home 22 Category(ies) of Past or present drug dependence over 65 years registration, with number of age (2), Learning disability over 65 years of of places age (6), Mental Disorder, excluding learning disability or dementia - over 65 years of age (4), Old age, not falling within any other category (22) Grindley House Care Home DS0000067071.V365698.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19 May 2006 Brief Description of the Service: Grindley House is a residential home that provides a service for older people. The home is located in Stoke On Trent, Staffordshire and is accessible via public transport and is in walking distance to local amenities. The home is situated in a residential area and is set within its own grounds, the property comprises of twenty-two single and two shared bedrooms situated on both the ground and first floor. Bedrooms are not equipped with en suite. However, bathrooms and toilet areas are situated in close proximity to bedrooms. The home provides three lounge areas, a dining room, kitchen and laundry. All areas of the home are equipped with essential furnishings and fitments to ensure the comfort of people who live at the home. People have access to a well-maintained garden at the rear of the property; ample car parking is provided at the front of the building. There are appropriate aids and adaptations in place to assist people with reduced mobility; facilities on the first floor are accessible via stairs or a chair lift. People who use the service have access to relevant healthcare services if and when required. Staffing is provided on a twenty-four hour basis to ensure the total supervision and support of people. The fees charged for service provided at Grindley House is from £375.00p (shared bedroom) – £390.00p (single bedroom) per week. This information applied at the time of our inspection the reader should contact the service for more up-to-date information. Grindley House Care Home DS0000067071.V365698.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 Star. This means the people who use this service experience adequate quality outcomes. The unannounced key inspection of Grindley House was conducted within eight hours. The emphasis of the inspection is to look at the outcomes with regards to people’s lifestyle and practices and procedures that promote equality and diversity. The inspection methods used to establish the quality of care provided and the effectiveness of the management of the home involved the examination of the records, relating to the home’s policies and procedures. During the inspection we talked to three people that use the service and three staff members, to gather an overview of the quality of the service provided. Information contained within the homes Annual Quality Assurance Assessment, (AQAA). The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the service. This report also includes information that we received from questionnaires that were completed by people who use the service. A tour of the property was undertaken, to ensure that the environment and systems in use were safe and suitable to meet people’s needs. The Registered Manager was not present on the day of the inspection. The Senior Care Assistant assisted us with the inspection. What the service does well: Grindley House presented a warm and welcoming atmosphere with people freely wandering around the home and engaging in pastimes of their choice. People who use the service spoke highly of the home, staff and the Registered Manager; these were some of their comments: “The manager and staff respond well when approached but matters of complaint are rare and usually understandable.” “The staff are very good, if they can help, they will.” Grindley House Care Home DS0000067071.V365698.R01.S.doc Version 5.2 Page 6 “The staff are very pleasant and accommodating with everything.” “Nothing is too much trouble for them.” “Grindley House, the manager and staff make conscientious efforts to run a good home for the residents, achieving a most acceptable degree of satisfaction.” “Its clear an effort is made to provide varied and palatable food and drinks.” What has improved since the last inspection? What they could do better: We looked at the AQAA, which told us that a number of people had sustained falls within the home. Prior to the inspection we also received ‘Notifications,’ (notifications are any accidents, incidents or any issues that may impact on the health, safety and welfare of the people who use the service). These notifications also told us about people falling in the home. We looked at three care plans that showed that there were no falls risk assessments in place; the staff we spoke to also confirmed this. In view of the number of reported falls, risk assessments should be put in place to provide control measures to reduce or eliminate the number of falls within the home to ensure people’s safety. We saw staff knocking on doors before entering rooms but we did not see any systems in place to promote the privacy of people. For example, privacy screening in shared bedrooms did not extend to the area where the washbasin was located, to preserve the person’s privacy and dignity. Privacy screening was not provided at all windows in wash areas and security locks were not fitted to bedroom doors. When we looked around the home we saw that in the store cupboard, linen was stored directly next to the light bulb, which could be a potential fire risk. A discussion with the Registered Manager after the inspection, via telephone confirmed that the shelving in this cupboard had been removed to prevent contact with the light bulb. Grindley House Care Home DS0000067071.V365698.R01.S.doc Version 5.2 Page 7 Information relating to the fire evacuation procedure was confusing, for instance, it said that one person who use the service would require the assistance of two staff and the use of the stair lift if in use. However, further information relating to this individual identified that the stair lift should not be used in the event of a fire or a fire drill. This did not give staff clear guidance about what to do in the event of a fire. Staff told us that some people who occupied rooms on the first floor have reduced mobility and in the event of a fire, the home may not be able to evacuate everyone to a safe area. The registered person should review the home’s evacuation procedure, to ensure that clear concise information is provided, so that staff are aware of what to do in the event of a fire to ensure people’s safety. 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. Grindley House Care Home DS0000067071.V365698.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 Grindley House Care Home DS0000067071.V365698.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 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People wishing to access the service are provided with information to enable them to establish whether the home could meet their assessed needs. People moving into the home can be assured that their assessed needs will be meet to promote their wellbeing. EVIDENCE: The home’s Statement of Purpose and Service User Guide was incorporated as one document and contained information relating to the service and provisions available within the home. People wishing to access the service were also given a brochure that provided additional information about the fees charged for the service. Grindley House Care Home DS0000067071.V365698.R01.S.doc Version 5.2 Page 10 We looked at one file pertaining to a person who lived at the home, which showed that they had visited the home before moving in. This enabled them to establish whether the service would be appropriate to meet their needs. Written needs assessments were not available on the day of the inspection. This is an assessment that the home carries out on people who wish to use the service, it enables the home to find out what the person’s care needs are and the level of support they will need. Staff told us that the Registered Manager undertakes a care needs assessment, before people move into the home. The AQAA also told us that assessments were carried out and a visiting relative also confirmed this. She told us that the Registered Manager visited her mother to do an assessment before she moved into Grindley House. Grindley House does not provide intermediate care therefore outcomes for national minimum standard number six was not inspected. Grindley House Care Home DS0000067071.V365698.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 adequate. This judgement has been made using available evidence including a visit to this service. Staff knowledge and understanding of peoples care needs ensure that people who use the service can be confident that their health and welfare will be promoted and maintained. People are able to take acceptable risks to promote their independence but the absence of risk assessments may not ensure they are safe to do so. EVIDENCE: We looked at three care plans; they did not give a clear guidance of what staff needed to do to meet people’s needs effectively. For example we asked a care staff about the communication skills and mobility of a person who lived at the home. The carer was aware of the person’s care needs but confirmed that this was not written in the care plan. The home was not able to show that this Grindley House Care Home DS0000067071.V365698.R01.S.doc Version 5.2 Page 12 person received the same care from all staff, because the care plan did not include written information about the support they required to ensure their care needs were being consistently met. The home’s AQAA and notifications received from the home, (notifications are any accidents, incidents or any issues that may impact on the health, safety and welfare of the people who use the service) showed that a number of people had sustained falls and had attended the Accident and Emergency Department at the local hospital. Staff told us that there were no falls risk assessments in place; therefore, staff were not aware of potential risks or actions to take to reduce the frequency of people falling. The AQAA stated, “Risks are identified, acted upon and documented.” This was clearly not the case. A staff member told us that where possible people were encouraged to participate in the development and review of their plan of care, this was evidenced where one person had signed their care plan. The AQAA confirmed that, “We encourage self-help and freedom of choice where appropriate and review the level of care required for each individual on a regular basis.” The care plans that we looked at showed that people had access to relevant healthcare professionals, such as a General Practitioner, District Nurse, Community Psychiatric Nurse and Dentist to ensure people’s physical and mental health. This was also confirmed by survey we received, from a person who lived at the home, which stated, “The doctor, chiropodist and optician visit regularly.” The care plans provided information about people’s choice, for example it told us about their preferences of clothing they like to wear and their make up, this promoted their individuality. Care files contained information about ‘Do Not Resuscitate’ (DNR). There was no signed letter on file from a Medical Consultant from the Primary Care Trust, in relation to this information. To ensure the rights and protection of people who use the service, this information must be removed unless the home has signed documentation from a Medical Consultant or equivalent. The homes medication system ensured that people received their medicines as directed by the doctor. For example we looked at a number of medication administration records, this showed when staff had given out the medicines, the records were signed to confirm this. Grindley House Care Home DS0000067071.V365698.R01.S.doc Version 5.2 Page 13 One staff member told us that staff that dedicated staff responsible for giving out medicines had received medication training delivered by the Pharmacist. This helped to ensure that staff know how and when to give people their medicines. We observed that the home had a dedicated fridge for storing medicines, which was situated in a storeroom, where the freezers used for storing provisions were located. The fridge contained medicated creams and was not secured. One person who lived at the home was seen to frequently wander in and out of this storeroom. We asked the Senior Care Assistant about the person’s safety who then asked the Cook to ensure that the storeroom is kept secure. We saw that privacy screening was provided in the shared bedrooms, but did not extend to the washbasin area. People would benefit from having privacy screens fitted, which extend to the washbasin area so they can be confident privacy is promoted and maintained when carrying out personal care tasks. Privacy screens should also be fitted to the window in the toilet and shower rooms. We observed staff knocking on doors before entering private rooms. Grindley House Care Home DS0000067071.V365698.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service can live a lifestyle of their choice and have the opportunity to engage in social and religious activities to promote individuality, equality and diversity. EVIDENCE: We observed the daily routine to be relaxed and saw people freely wandering around the home and engaging in various pastimes such as listening to music and conversing with other people who used the service. Some chose to stay in their bedroom. The AQAA told us; “Staff endeavour to spend a little quality time with individual service users to help them feel valued and important.” Grindley House Care Home DS0000067071.V365698.R01.S.doc Version 5.2 Page 15 Information contained in the home’s Statement of Purpose identified that social activities available in the home included armchair exercise, music therapy, bingo, card games and religious practices. One person who used the service told us that they moved to Grindley House six weeks ago, “I haven’t been out since living here but there is always places to go if you want to.” We received a survey from a person that lived at the home, which stated, “This is the only areas one might say that more could be done for residents still within their faculties.” Two people told us they were able to have visitors at anytime. We spoke to two visiting relatives who told us, they were able to visit at anytime and were always made welcome by staff. We looked at a number of people’s bedrooms and could see that they were able to personalise their rooms to reflect their interests and character. For example rooms were decorated with pictures, family photographs and ornaments. At lunchtime we dined with people that lived at the home. Information about meals available for the day was displayed on the menu board in the dining area. People were given a choice of meals; we observed that drinks were readily available throughout the day. The Cook told us that menus were developed on a monthly basis and people were given three or four choices each day to reflect their likes and dislikes. People with health problems who needed a special diet, such as diabetes were catered for and their meals were seen to be as appetising as the other meals served. One person told us, “The meals are good but I don’t eat a lot.” Another person said, “The food is alright.” Information obtained from a survey stated, “Its clear an effort is made to provide varied and palatable food and drinks.” Grindley House Care Home DS0000067071.V365698.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are able to express their concerns/complaints and their safety and protection is assured. The format of the complaint procedure may impinge on people’s understanding of how to make a complaint to ensure their rights. EVIDENCE: The AQAA stated, “Grindley House has a clear and accessible complaint procedure, which is explained to new service users and their families upon their admission.” We looked at the homes complaint procedure, which was not entirely clear, for example it stated that, “The complaint should be made to an appropriate person designated by the service.” However, it did not identify who that person was. The complaint’s procedure showed that any complaints would be responded to within twenty-eight days. Further information on how to make a complaint was included in the home’s Statement of Purpose. Grindley House Care Home DS0000067071.V365698.R01.S.doc Version 5.2 Page 17 The complaint’s procedure was published in English; the staff we spoke to was not aware whether this procedure was available in any other format, such as Braille, large print or any other languages to promote the understanding of people. A survey completed by someone who used the service stated, “The manager and staff respond well when approached but matters of complaint are rare and usually understandable.” We spoke to two visiting relatives who said that if they had any complaints they would speak to the Registered Manager, and that any problems were usually sorted out swiftly. One person who lived at the home told us, “The staff are very good, if they can help, they will.” Since the last inspection visit to the home, we have received one complaint about Grindley House relating to the standard of care provided to one person. This complaint was referred to the home for them to investigate. The home had a safeguarding policy. This is to ensure that people that use the service are safeguarded from abuse. One staff member told us that they had not received any training on safeguarding, but explained that if there were an issue of abuse she would tell the Registered Manager or the Registered Provider. The AQAA stated, “All staff are very aware of service users’ rights and choice and are able to recognise signs of distress and/or neglect and will act promptly to address these concerns.” The AQAA also identified that people who live at the home have access to a self-advocacy service. This provided independent support to people. Staff files were not available for us to look at. The AQAA stated, “New staff are subject to a Protection of Vulnerable Adults (PoVA 1st) and Criminal Record Bureau (CRB) check prior to commencement of employment.” The previous inspection report said that references and checks are undertaken before people start working in the home and that people work on a trial basis before being offered a permanent job. One staff member told us that all new staff have the appropriate safety checks before they start working in the home, to ensure the protection of people who use the service. Grindley House Care Home DS0000067071.V365698.R01.S.doc Version 5.2 Page 18 Grindley House Care Home DS0000067071.V365698.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, 21, 22 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The design and layout of the home is suitable to meet the needs of people, to ensure their comfort and welfare. People benefit from appropriate aids and adaptations that promote their independence. EVIDENCE: Grindley House is located in Stoke On Trent, Staffordshire. The large mature detached property is situated within its own grounds in a quiet residential area. The home is accessible via public transport having regular bus service and a train station nearby. Grindley House Care Home DS0000067071.V365698.R01.S.doc Version 5.2 Page 20 The property consisted of eighteen single and two shared bedrooms situated on both the ground and first floor. A chairlift was in place to enable people to access all the facilities within the home. There were three lounge areas and a dining room equipped with essential furnishings and fitments to promote people’s comfort. En suites were not provided however, all bedrooms were equipped with a washbasin and bathrooms and toilets were situated in close proximity to bedrooms and communal areas. We observed that the bathroom on the first floor was out of order; staff told us that this was due to the wooden frame of the window coming away leaving the glass edge exposed, which would be a health and safety issue for people accessing the bathroom. It is of concern that no action had been taken to address this problem, to ensure that people, who accommodate the first floor, have close access to bathing facilities. One staff member told us that no one had authorisation to commission work in the absence of the Registered Manager. People whose bedroom was on the first floor, had to use the bathroom on the ground floor. The home had recently fitted new carpets in the corridor and the bedrooms of people on the ground floor to promote people’s comfort. Aids and adaptations were available within the home; grab rails were situated throughout the building to assist people with limited mobility. Ramp access to the home was also available, and assisted bathing facilities were also in place. Nurse call alarms were installed in bedrooms. One person who lived at the home informed us, “The staff are very good, they come quickly when I press the buzzer.” The AQAA stated, “We provide any additional special needs equipment, that may make life more pleasant and comfortable for our service users and that may enhance and prolong their ability to remain as independent as possible.” The property also had a commercial kitchen and a laundry. People had access to a well-maintained garden. Access to the home is via an un-adopted road the surface was uneven, which could pose a problem for people who have limited mobility. Car parking was available at the front of the property. The hygiene and cleanliness of the home was good. Comments we received from surveys confirmed that the home was always fresh and clean. Grindley House Care Home DS0000067071.V365698.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 good. This judgement has been made using available evidence including a visit to this service. People benefit from having their needs met by sufficient numbers of experienced and trained staff. Staff recruitment procedures safeguard the people who use the service. EVIDENCE: We did not have access to staff training records. However, the home’s brochure stated, “The home is committed to developing its staff by ensuring that all care staff have minimum of, or are training towards, National Vocational Qualification Level 2.” The AQAA identified that eight of the eighteen staff employed had achieved the National Vocational Qualification level 2 in care and a further four were working towards the award. A staff member told us that she had received the following training: Moving and Handling, Fire Awareness, Control of Substances Hazardous to Health Grindley House Care Home DS0000067071.V365698.R01.S.doc Version 5.2 Page 22 (COSHH) and Dementia Awareness. She also told us that she was currently undertaking the National Vocational Qualification level 2 in care. We looked at staff rotas and spoke to the staff about the staffing arrangements. They told us that sufficient care hours were provided, to meet people’s needs. One person told us, “The staff are very good, they come quickly when I press the buzzer.” A comment from a survey received from a person who lived at the home stated, “They answer the bell when I call.” As previously identified within the report, we did not have access to staff files, to see what checks were carried out prior to people commencing employment within the home. The AQAA confirmed that new recruitments were subject to a Protection of Vulnerable Adults (PoVA 1st), Criminal Record Bureau clearance and that references were documented. A survey from a person that lived at the home stated, “The staff are very pleasant and accommodating with everything.” “Nothing is too much trouble for them.” Grindley House Care Home DS0000067071.V365698.R01.S.doc Version 5.2 Page 23 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 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service benefit from a management style that ensures their rights are promoted. Health and safety management may have a negative impact on people’s safety in the event of a fire. EVIDENCE: Grindley House Care Home DS0000067071.V365698.R01.S.doc Version 5.2 Page 24 The Registered Manager was not present on the day of the inspection. Information contained in the Statement of Purpose identified that she had eighteen years experience in the care of the elderly and had obtained a National Vocational Qualification Level 4 in Care. The home actively seeks feedback from people about the quality of the service. Questionnaires were distributed to people to ascertain their views and opinion. Reports about information received from these questionnaires were not made available to us. The home had received very positive comments from relatives whose family members lived at the home, such as: “Thanks is not enough for all the things you do for X caring so kindly and treating her so precious.” “I wish to express my sincere thanks for your care and kindness to my mum.” Information obtained from a person who used the service stated, “Grindley House, manager and staff make conscientious efforts to run a good home for the residents, achieving a most acceptable degree of satisfaction.” One person who lived at the home told us that, “I would recommend living here they are very obliging.” The AQAA was submitted to us within the identified timescale and provided good information relating to the service provided in the home and plans to promote the quality of the service delivery in the future. The AQAA stated, “Financial records, contracts, insurance and registration documents are current and available. We did not have access to records about the home’s system and practices for the management of peoples’ financial affairs. This area will be closely examined at the next inspection visit. We also observed that the homes Public Liability Insurance had expired dated 26 May 2008. There was a hand written message on the policy stating, “Awaiting new certificate.” The Fire Safety Officer carried out an inspection of the homes fire safety appliances and systems on 12 December 2007, subsequent to this inspection a number of recommendations were identified to ensure the safety of people who use the service. A few days after the inspection of the service, we spoke to the Registered Manager by telephone and she confirmed that a number of Grindley House Care Home DS0000067071.V365698.R01.S.doc Version 5.2 Page 25 the recommendations included in the last inspection report had been addressed. We saw that the fire extinguisher situated in the cellar and where the laundry facilities are located had not been serviced at the same time as the other fire fighting appliances. This may place people who use the service at risk, as they cannot be confident the appliance is fit for purpose. Risk assessments relating to the evacuation process was not thorough, for example, information about the support a person would require in the event of a fire, showed that they would need two staff and the use of the stair lift. However, further information relating to this person also said the stair lift should not be used. The information held did not provide staff with clear instruction as to what action they should take in the event of a fire. Staff told us that four people who occupied rooms on the first floor had reduced mobility and that the home may not be able to evacuate them to a safe area in the event of a fire. We saw that linen was being stored very close to a light bulb, which could present as a potential fire hazard. Discussions with the Registered Manager via telephone after the inspection confirmed that the top shelf had been removed to prevent the linen making contact with the light bulb. We raised concerns about the clutter in a corridor, which we believed posed a potential tripping hazard and could obstruct the escape route in the event of a fire. A wheelchair, hoist, rotary ironing board, carpet cleaner, suitcase and continence supplies were located in this corridor. A staff member told us the home had just received a delivery of continence supplies but made no reference to the other equipment stored in the corridor. Grindley House Care Home DS0000067071.V365698.R01.S.doc Version 5.2 Page 26 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 2 Grindley House Care Home DS0000067071.V365698.R01.S.doc Version 5.2 Page 27 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 OP7 Regulation 13 Requirement Timescale for action 01/10/08 2. OP8 3. OP38 Individual risk assessments must be carried out for people who are identified as being at risk of falls. The outcome of the risk assessments must be used to inform care planning so that people can be confident, their needs will be met and any risk identified minimised. 01/10/08 13(1)(a)( Healthcare decisions must be b) made within a multi-disciplinary framework and include medical consultation. Staff must not make independent ‘Do Not Resuscitate’ decisions on behalf of the people who use the service so that people can be confident their right to autonomy is respected and their health and welfare promoted and maintained at all times. 23(4)(c)(ii Fire exits must be free from 01/10/08 i) obstruction, so that in the event of fire people are able to leave the building swiftly and safely. Grindley House Care Home DS0000067071.V365698.R01.S.doc Version 5.2 Page 28 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 OP7 OP10 Good Practice Recommendations Care plans should reflect the care needs of people and provide a clear guidance to staff on how to meet peoples needs effectively. Consideration should be given to the provision of suitable privacy screens so that people can be confident their privacy and dignity is promoted and maintained at all times The complaints procedure should be reviewed to provide up to date information. Consideration should also be given in publishing the procedure in other formats, such as larger print, Braille and other languages if and when required. To ensure that the Public Liability Insurance is renewed. All recommendations identified by the Fire Safety Officer should be addressed to ensure the safety of people who access the service. To ensure that the fire extinguisher located in the cellar is serviced in line with the other fire fighting appliances. The fire evacuation plan should be reviewed to ensure that staff have a clear directive of what action should be taken in the event of a fire. 3. OP16 4. 5. 6. 7. OP38 OP38 OP38 OP38 Grindley House Care Home DS0000067071.V365698.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands Office West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Grindley House Care Home DS0000067071.V365698.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!