Inspection on 08/03/06 for Grisedale Croft

This inspection was carried out on 8th March 2006.

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

Grisedale Croft 12/11/08

Grisedale Croft 07/11/06

Grisedale Croft 22/08/05

Grisedale Croft 16/03/05

Grisedale Croft 28/07/04

Grisedale Croft 15/03/04

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

CARE HOMES FOR OLDER PEOPLE Grisedale Croft Church Road Alston Cumbria CA9 3QS Lead Inspector Mrs Margaret Drury Unannounced Inspection 8th March 2006 10:10 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 Grisedale Croft DS0000036586.V280151.R01.S.doc Version 5.1 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. Grisedale Croft DS0000036586.V280151.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Grisedale Croft Address Church Road Alston Cumbria CA9 3QS 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) 01434 381221 www.cumbriacare.org.uk Cumbria Care Ms Sandra Shepherd Care Home 19 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (19) of places Grisedale Croft DS0000036586.V280151.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service must at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The home is registered for a maximum of nineteen service users to include: - up to 19 service users in the category of OP (Older people not falling within any other category) - up to 2 service users in the category of DE(E) (Dementia over 65 years of age) The staffing levels for the home must meet the Residential Forum Care Staffing Formula for Older Adults. When single rooms of less than 12sqm usable floor space become available they must not be used to accommodate wheelchair users, and where existing wheelchair users are in bedrooms of less than 12sqm they must be given the opportunity to move to a larger room when one becomes available. This registration includes a total of 6 residents accommodated as follows: Flat 1 - 1 Resident Flat 2 - 1 Resident Flat 3 - 1 Resident Flat 4 - 1 Resident Flat 6 - 2 Residents The manager has no responsibilities, other than in an emergency for any other flats or accommodation attached to the home. 22nd August 2005 3. 4. 5. 6. Date of last inspection Brief Description of the Service: Grisedale Croft is a care home offering accommodation and care for up to 19 older people, two of whom may have varying forms of dementia. Cumbria Care, an internal business unit of Cumbria County Council, operates the home, which is run on a day-to-day basis by Ms Sandra Shepherd. Grisedale Croft is situated on two floors, the upper being served by a passenger lift and a stair lift. All the rooms are for single occupation, six of them having a small kitchen and toilet. There are bedrooms on the ground floor, together with a lounge/diner, smoking lounge, a bathroom and toilets. On the first floor there are bedrooms, a lounge/diner, bathroom and toilets. The six rooms with the kitchen and toilet are situated on the mezzanine floor Grisedale Croft DS0000036586.V280151.R01.S.doc Version 5.1 Page 5 that is accessed by a short flight of stairs and the stair lift. There are well kept gardens and car parking at the front of the building. Grisedale Croft DS0000036586.V280151.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the home and took place over one morning. It was the second inspection of the annual cycle and those standards not assessed on this occasion were inspected and met during the last visit on 22nd of August 2005. During the inspection, time was spent with the manager and supervisor on duty discussing documentation to do with the care of the residents and care practices in the home. Residents were spoken with either in the lounge/diners or in their own rooms. The inspector was also able to speak to visiting healthcare professionals. Some parts of the home were looked at. What the service does well: What has improved since the last inspection? As the care provided by the home is of a high standard the only improvements to note during this inspection were those relevant to the environment. The decorators were working in the large lounge on the first floor and one of the bedrooms on the same floor. A bathroom and separate communal toilet is also being redecorated and new carpet is about to be laid in one of the bedrooms. Grisedale Croft DS0000036586.V280151.R01.S.doc Version 5.1 Page 7 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. Grisedale Croft DS0000036586.V280151.R01.S.doc Version 5.1 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 Grisedale Croft DS0000036586.V280151.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 The home’s statement of purpose and resident guide provide prospective residents and/or their families with sufficient information to enable them to make an informed choice about moving into the home. EVIDENCE: The home’s statement of purpose and other information outlining the facilities on offer at the home is made available to all prospective residents and/or their families. There are also copies on display in the hall. All residents are given a contract and terms and conditions. The manager has recently updated the statement of purpose to show how the extra staffing hours allocated to accommodate the second signatory on the medication records have been utilised. The information available allows prospective residents to make an informed decision about moving into the home. Grisedale Croft DS0000036586.V280151.R01.S.doc Version 5.1 Page 10 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): 9 The healthcare needs of the residents are understood and well met. Medication and records are well maintained to ensure the protection of the residents. EVIDENCE: The arrangements for storing and administering medication in the home are safe and well organised, and residents receive their medication as prescribed, with records up to date and correctly completed. Discussions with the manager evidenced that the staff in the home have a good working relationship with their local chemist who is usually available for help and advice. The pharmacist carries out medication audits every six months. The home was allocated extra staffing hours to allow for the implementation of a second signature on the medication records. The manager has used these hours wisely for the benefit of the residents and care staff, The pharmacist at the local GP practice completes an annual medication review for each resident. Grisedale Croft DS0000036586.V280151.R01.S.doc Version 5.1 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): 14 There is a warm, sociable atmosphere in the home and the residents who spoke with the inspector were happy with the daily routines. EVIDENCE: The manager organises residents’ meeting every quarter and these are generally well attended. Topics discussed range from changes in the menus to activities and summer outings. One of the care support workers is responsible for arranging in-house activities, which include, talking books, bingo every fortnight and outings into Alston for coffee or to go to the library. Trips out into the surrounding area are arranged in the warmer weather One of the residents told the inspector she was one of four friends who enjoyed playing dominoes each evening after tea. Grisedale Croft DS0000036586.V280151.R01.S.doc Version 5.1 Page 12 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): All these standards were assessed and met at the last inspection. EVIDENCE: Grisedale Croft DS0000036586.V280151.R01.S.doc Version 5.1 Page 13 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): All these standards were assessed and met during the last inspection. EVIDENCE: Although no specific environmental standard was inspected on this occasion the inspector did look at some parts of the home on both floors. The decorators have started some redecoration work that should be completed in the near future. Grisedale Croft DS0000036586.V280151.R01.S.doc Version 5.1 Page 14 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): 28 Staff are well trained to ensure they have the competencies to meet residents’ needs. EVIDENCE: The staff team is both qualified and experienced in the care of older people. Cumbria Care provides an annual training plan and individual training needs are identified through staff supervision. Training courses completed include, infection control, in-house medication procedures, food hygiene, emergency planning, care planning and health & safety. Eight members of staff are already qualified to NVQ level 2 and another one is due to start the course at the beginning of April. This will mean that 50 of the care staff will have completed their NVQ level 2 award. Grisedale Croft DS0000036586.V280151.R01.S.doc Version 5.1 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 & 38 There is a strong sense of leadership, ensuring that the staff team is well directed to deliver good quality care to those living in the home. EVIDENCE: The registered manager has over twenty years experience in the care of older people and is currently working towards the Registered Manager Award. She is also a qualified NVQ assessor. Discussions with the supervisor on duty and visiting healthcare professionals evidenced that she provides good leadership to the staff team and her attitude towards the residents was warm, friendly and supportive. The home has a complete set of health and safety policies in place provided by Cumbria Care with the manager and supervisors responsible for health and Grisedale Croft DS0000036586.V280151.R01.S.doc Version 5.1 Page 16 safety procedures. There is an annual audit completed by Cumbria Care’s health and safety officer. All risk assessments are in place and these are updated on a regular basis with extra ones completed when required, for example if a resident goes out into the community. Grisedale Croft DS0000036586.V280151.R01.S.doc Version 5.1 Page 17 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 x X X X X X X X x STAFFING Standard No Score 27 X 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 3 Grisedale Croft DS0000036586.V280151.R01.S.doc Version 5.1 Page 18 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. 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 Grisedale Croft DS0000036586.V280151.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP 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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