Inspection on 17/10/06 for Groby Lodge

This inspection was carried out on 17th October 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

Groby Lodge 08/10/08

Groby Lodge 18/02/08

Groby Lodge 26/10/05

Groby Lodge 09/08/05

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

CARE HOMES FOR OLDER PEOPLE Groby Lodge 452 Groby Road Leicester Leicestershire LE3 9QB Lead Inspector Rehana Rashid Unannounced Inspection 17th October 2006 10:30 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 Groby Lodge DS0000063629.V316344.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. Groby Lodge DS0000063629.V316344.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Groby Lodge Address 452 Groby Road Leicester Leicestershire LE3 9QB 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) 0116 2855868 0116 2547343 Pine View Care Homes Ltd Mr Dinesh Raja Care Home 12 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (12) of places Groby Lodge DS0000063629.V316344.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To be able to admit the named person in the category PD(E) subject of variation application V22846. Service User numbers: No one falling within category DE(E) may be admitted into Groby Lodge where there are 3 persons of category DE(E) already accommodated within Groby Lodge Service User Numbers No one falling within category OP may be admitted into Groby Lodge where there are 12 persons of category OP already accommodated within Groby Lodge Service User Numbers No person to be admitted to Groby Lodge in categories OP or DE(E) when 12 persons in total of these categories/combined categories are already accommodated in Groby Lodge. 26th October 2005 3. 4. Date of last inspection Brief Description of the Service: Groby Lodge is situated on the A50 close to Glenfield Hospital. Access to Groby Lodge is via a slip road off the A50. The home is registered for twelve older people. It has 12 single bedrooms, 11 of which have ensuite facilities. Downstairs there is a large lounge/dining room, which overlooks the rear garden. There is good car parking at the front of the home and the large secluded garden has seating areas. On 18th October 2006 the registered manager stated that Groby lodges current weekly fee range is £320 to £370. Information about the service is provided via the statement of purpose. Groby Lodge DS0000063629.V316344.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out on 17th October 2006 for the duration of four hours. The main method of inspection was case tracking, which involved randomly selecting two residents and examining their care records. Case tracking is used to establish if the needs of the residents are being appropriately assessed by the home and their needs are being catered for. Indirect and direct observation of practice and interaction between staff and residents was also carried out as part of the inspection methodology. A partial tour of the building was given by the Care Manager. Documentation including health and safety records were also examined. The management of medication was partially assessed. The Registered Manager and Care manager assisted in the inspection process. Two members of staff were spoken with and three staff files were examined. Three residents were spoken with, all three spoke positively about the care received at Groby Lodge care home. The focus of the inspection was to concentrate on the key standards, which were assessed under the new methodology of Inspecting for Better Lives (IBL). What the service does well: Residents benefit from a comfortable, appropriately furnished environment, which provides specialist equipment such as hoists. Bedrooms viewed by the inspector were comfortable, clean and personalised. Groby Lodge provides a homely atmosphere to the residents. Staff were observed to be respectful towards the residents and good relationships were observed. Three residents were spoken with one resident stated, “life is wonderful at Groby Lodge.” Another commented that “I have no complaints and I am happy here”. Whilst another resident said, “staff are very good and they are all very kind.” Residents also commented that the food was very good. Groby Lodge DS0000063629.V316344.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Groby Lodge DS0000063629.V316344.R01.S.doc Version 5.2 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 Groby Lodge DS0000063629.V316344.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3,5,6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective residents individual aspirations and needs are assessed prior to moving to the home, which provide assurances that their needs can be met. Intermediate care is not provided by the home. EVIDENCE: Procedures were in place to ensure prospective residents and relatives were given the opportunity to visit the home prior to admission. Case tracking confirmed that pre-admission assessments are completed for all prospective residents, and provided reassurances that their individual needs can be met. Documentation supported that prospective residents were assessed prior to them moving into the home. The registered manager advised that the care manager carries out pre- admission assessments on all prospective residents and obtains any relevant information from social services. Groby Lodge DS0000063629.V316344.R01.S.doc Version 5.2 Page 9 Discussion with a residents confirmed that their relatives viewed the home prior to them moving in, to ensure the home was suitable for them. Prospective residents are able to visit Groby Lodge prior to admission, as are their relatives and friends. They are able to visit for the day or stay for a couple pf hours, so they are able to make an informed choice about moving into the home or not. Groby Lodge DS0000063629.V316344.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7.8.9,10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users health, personal and social care needs are set out in an individual plan of care, but must be need reviewed regularly. Service users health care needs are met. Service users feel they are treated with respect and their right to privacy is upheld. EVIDENCE: The records of two residents were viewed, which contained detailed care plans clearly identifying resident’s personal care and health care needs. Residents care plan and risk assessment documentation showed that these are not reviewed at the regular interviews as stated in the national minimum standard seven. Care plans should be reviewed on a monthly basis and updated to reflect changing needs. However where needs are constantly changing more frequent reviews maybe required. Risk assessments are in place but did not identify actions to be taken by staff to minimise the risks identified. Groby Lodge DS0000063629.V316344.R01.S.doc Version 5.2 Page 11 The files indicated that residents health needs are addressed and when appropriate or necessary the home seek input from local health care professionals such as the GP or District Nurse. Visits by health professionals are recorded within the daily communication records. On the day of the site visit a District Nurse was visiting one of the residents. Residents files viewed confirmed they had been registered with a GP. Policies and procedures were in place with regards to the administration of medication. Medication is stored in a lockable trolley, which is secured to the wall. Medication records for two residents were examined, no gaps were found in the entries. Medication is administrated by senior care staff. Through observation it was clear that staff communicated well with the residents. Resident’s comments included that “staff are respectful towards us” and “nothing was too much trouble for staff.” Residents spoken with stated personal care is carried out in private in a dignified manner. One of the residents spoken with stated they are able to deal with their own correspondence which they receive unopened. Groby Lodge DS0000063629.V316344.R01.S.doc Version 5.2 Page 12 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): 12,13,14,15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service Users find the lifestyle experienced in the home matches their expectations and preferences. The home arranges social activities for the service users. They maintain contact with family, friends and exercise control over their lives. Service users receive a balanced diet. EVIDENCE: Residents spoken with stated they are happy with the level of social activities. Details of social activities were displayed in the lounge area; activities include bingo, skittles and a visit from the hairdresser. During the inspection some residents were in the lounge watching television, speaking with fellow residents or snoozing. One resident stated there are social activities “I can join in the social activities but prefer spending time in my own room.” Two residents spoken with stated that the staff are very welcoming and polite to their visitors. One resident commented “during the weekend I go and spend time with my family.” Another resident said that there are no restrictions when you go to bed or wake up. Groby Lodge DS0000063629.V316344.R01.S.doc Version 5.2 Page 13 Groby Lodge have a four weekly menu, which contain nutritional and wellbalanced meals. Three residents spoken with said that the food in the home was very good. Residents spoken with stated if they did not like a meal they are offered an alternative choice. Residents made positive comments about the meals provided: “Food is perfect.” “I enjoy the meals, they are very good.” “Meals are very good, you get more than enough.” Food probing temperatures were viewed a couple of gaps were identified. These temperatures should be taken regularly and documented. This is to ensure food is served to residents at the correct temperature. Storage and supplies of food stocks were satisfactory Groby Lodge DS0000063629.V316344.R01.S.doc Version 5.2 Page 14 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): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users have access to the complaints procedure and are confident complaints will be listened to and acted upon. Service users are protected from abuse. EVIDENCE: Residents are provided with the Complaints Procedure at the point of admission to the home. The complaints procedure is displayed in the entrance. Since the last inspection the Commission for Social Care Inspection have not received any complaints. Records kept of complaints showed minor complaints had been received by the registered manager since the last inspection and had been resolved. Residents spoken with stated they had no complaints. All were confident that any concern and complaint made would be addressed promptly. Groby Lodge has a whistle blowing policy in place. A copy of the “No Secrets” Multi-Agency Policy and Procedures for the Protection of vulnerable adults from abuse was not seen at the site visit. A copy at the home would be good practice ensuring staff follow local procedures in the event of abuse or suspicion of abuse. This was raised with the registered manager who stated he does have a copy. Groby Lodge DS0000063629.V316344.R01.S.doc Version 5.2 Page 15 Two members of staff were spoken with one stated she had not received any training in adult protection, whilst the other staff member stated she had previously received this training. All staff must receive training in adult protection, which will ensure staff recognise and understand their role in the protection of vulnerable adults. Furthermore this will ensure residents are protected from abuse. Groby Lodge DS0000063629.V316344.R01.S.doc Version 5.2 Page 16 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): 19,26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users live in a safe, well-maintained environment. Groby Lodge Care Home is clean and pleasant. EVIDENCE: Groby Lodge Care Home offers its residents a clean and well-maintained environment. The garden is situated at the rear which is very well maintained with plants and seating for the residents. Inspection of toilet facilities, bedrooms and communal areas such as the lounge and kitchen were found to be suitable for residents. The toilet facilities viewed were in a good state of condition. They were also clean and free from odour. The kitchen was clean and well maintained. Three bedrooms viewed were personalised with resident’s personal possessions including photographs, ornaments. Radiators viewed in the bedrooms were not fitted with radiator covers. This was raised with the registered manager Groby Lodge DS0000063629.V316344.R01.S.doc Version 5.2 Page 17 who stated risk assessments were in place, these were not viewed during the inspection. Residents are able to keep their own furniture in their rooms to make them more personalised and homely. Residents spoken with stated they liked their rooms and they were comfortable. The home has a passenger lift. Groby Lodge Care Home provides its residents with specialist equipment to meet their needs, which includes grab rails in the toilet facilities, hoists and raised toilet seats. The laundry facilities included industrial washer with sluicing facilities and a drier. The care staff are responsible for cleaning the home. The home was clean and pleasant. Paper towel dispensers in the two ground floor toilets and kitchen viewed contained no paper towels. In order to minimise risk of cross infection it is recommended that paper towels be provided. Groby Lodge DS0000063629.V316344.R01.S.doc Version 5.2 Page 18 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): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are in safe hands. The homes recruitment practices need to be robust ensuring residents are protected. Staff are trained and competent to do their jobs. EVIDENCE: The registered manager stated recently it has been problematic recruiting staff. On the day of the inspection the rota stated three staff should be on duty, but there were only two staff on duty, which included the Care Manager and the Senior Carer. During the day three staff are on duty, two carers in the evening and one waking in carer at night. At night there is an on call system to support the carer. Care staff are responsible for domestic tasks including cleaning and cooking. Two staff members were spoken with who stated the staffing levels are adequate to meet the current needs of the residents. However if the needs of the residents increased they felt staffing levels will need to increase to meet the needs of the residents. Residents spoken with reported they felt there were enough staff on duty to meet their needs; they also said that the staff were kind, caring and considerate. Groby Lodge DS0000063629.V316344.R01.S.doc Version 5.2 Page 19 Recruitment practices at the home need to be more robust offering protection to the residents. Three staff files were viewed; one file viewed showed that a Criminal Records Bureau (CRB) check was in place after the staff member had commenced employment. No evidence was seen to confirm that a Protection Of Vulnerable Adults (POVA) check had been carried out prior to the member of staff commencing employment. The registered manager must ensure that new staff do not commence work in the home until all the necessary recruitment checks have been carried out which include POVA first check and a satisfactory CRB disclosure. One staff file did not contain two references as specified in schedule 2 of the care homes regulations 2001, the file only had one reference. No evidence was seen to confirm staff members had received training in adult protection; the Registered Manager stated staff had attended in house training. From the three staff files viewed two contained certificates confirming staff had received training in First Aid, Moving and Handling and medication administration. The registered manager stated five staff members are currently working toward National Vocational Qualification (NVQ) in care level 2 and two staff members had achieved NVQ level 2. One staff member spoken with stated she was to attend a medication management course the following day. Groby Lodge DS0000063629.V316344.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a home, which is managed well, and their financial interests are safe guarded. Groby Lodge is run in the best interest of the service users. The health, safety and welfare of service users are promoted and protected. EVIDENCE: The registered manager sated he was currently undertaking the registered managers award. A member of staff spoken with stated the manager is very supportive and approachable. Residents spoken with stated they were happy at the home and felt that the manager is helpful. One resident stated, “On the whole I enjoy being at Groby Lodge.” Groby Lodge DS0000063629.V316344.R01.S.doc Version 5.2 Page 21 Residents at Groby Lodge are given the opportunity to contribute to the running of the home through residents meetings, and quality assurance systems. Residents meetings take place every six-month, where issues are raised and suggestions are made. The quality assurance systems operated by the registered manager also include questionnaires to resident’s families or representatives. The registered manager stated that most of the residents handle their own finances, or handled by relatives. Currently the home manages the personal allowance for one resident. Records of transactions were not seen, as they were not available at this inspection. A range of records relating to health and safety were examined. Files were well organized and easily accessible. Records for equipment servicing for the hoist and lift and other health and safety records including portable appliances testing were observed and were found to be carried out at the required intervals. On the day of the inspection records viewed regarding fire testing showed that some issues had been identified with regards to some fire checks not taken place at regular intervals as advised by the fire officer. The health and safety checks must take place at regular intervals to ensure the safety of residents and staff. Records were seen which showed that there are some gaps in food probing temperature recordings. Groby Lodge DS0000063629.V316344.R01.S.doc Version 5.2 Page 22 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 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 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Groby Lodge DS0000063629.V316344.R01.S.doc Version 5.2 Page 23 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 15 Requirement The registered person shall keep service user plans under review. (Ensure care plans are reviewed and updated to reflect changing needs in respect of their health and welfare.) Care plans to be reviewed at least once a month. The registered manager must ensure that new staff do not commence work in the home until all the necessary recruitment checks have been carried out which include POVA first check and a satisfactory CRB disclosure. The registered person must ensure the health and safety of residents and staff, by making sure fire testing takes place at regular intervals as advised by the fire officer. Timescale for action 17/01/07 2. OP29 19 17/11/06 3. OP38 23 31/10/06 Groby Lodge DS0000063629.V316344.R01.S.doc Version 5.2 Page 24 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. 3. 4. 5. Refer to Standard OP18 OP26 OP29 OP35 OP38 Good Practice Recommendations The registered person should ensure all staff have received training in adult protection. The registered person should provide paper towels in the kitchen and toilet facilities to minimise risk of cross infection. The registered person must ensure all staff files contain information as set out in schedule 2 of the care homes regulations 2001. The registered person should ensure secure facilities are provided for the safe keeping of money on behalf of service users. The registered person should ensure that food probing temperatures are taken regularly and documented. To ensure food is served to residents at the correct temperature. Groby Lodge DS0000063629.V316344.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Groby Lodge DS0000063629.V316344.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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