CARE HOMES FOR OLDER PEOPLE
Groby Lodge 452 Groby Road Leicester Leicestershire LE3 9QB Lead Inspector
Kim Cowley Unannounced Inspection 26th October 2005 11:00 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 Groby Lodge DS0000063629.V260704.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Groby Lodge DS0000063629.V260704.R01.S.doc Version 5.0 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 Care Home 12 Category(ies) of Old age, not falling within any other category registration, with number (12) of places Groby Lodge DS0000063629.V260704.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 9th August 2005 Brief Description of the Service: Groby Lodge is situated on the A50 close to Glenfield Hospital. 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. Groby Lodge DS0000063629.V260704.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on a weekday. When undertaking inspections the Commission for Social Care Inspection (CSCI) focuses on the outcomes for residents living in a home. In order to do this, the inspector ‘case tracked’ three residents. This means the inspector checked their care records and met with them. In addition the inspector talked to two other residents, two carers, and the Owner. Further care and other records were examined. The Owner is commended for his role at the home, and the staff training programme is also commended. Two recommendations were made. What the service does well: What has improved since the last inspection?
The Accident Procedure has been reviewed and updated and staff have signed to say they have read and understood it. This means that staff will be able to act swiftly and appropriately should an accident occur. There is a new key worker system in place so each resident has a designated worker to oversee their care.
Groby Lodge DS0000063629.V260704.R01.S.doc Version 5.0 Page 6 The garden has been tidied up and contractors have cut trees back to improve the appearance of the area. Following a recommendation from the home’s pharmacist the medication trolley has been secured to a wall in office. Medication record keeping has improved. 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. Groby Lodge DS0000063629.V260704.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Groby Lodge DS0000063629.V260704.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were inspected at the last inspection on 9.08.05. Groby Lodge DS0000063629.V260704.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were inspected at the last inspection on 9.08.05. Groby Lodge DS0000063629.V260704.R01.S.doc Version 5.0 Page 10 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): EVIDENCE: These standards were inspected at the last inspection on 9.08.05. Groby Lodge DS0000063629.V260704.R01.S.doc Version 5.0 Page 11 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): 16, 18 Residents said they were happy to speak out if they had any concerns. The complaints procedure and the adult protection procedure need updating. EVIDENCE: The complaints procedure and the adult protection procedure were examined. Both need updating in order to meet Standards 16 and 18. The Owner said he would do this promptly. The complaints procedure is sent out to interested parties with the initial information pack about the home. A copy is also taped inside all residents’ wardrobes, and displayed in the entrance hall. The adult protection procedure is available in the procedures manual in the office. Staff at the home are asked to read two policies/procedures each week and sign when they have done so. The Owner said that once he has updated the complaints/adult protection procedures they would be a priority for staff to read. One resident commented, ‘The Owner told me that I could always tell him if there was anything wrong.’ Another said ‘If I had any complaints I’d speak out.’ Groby Lodge DS0000063629.V260704.R01.S.doc Version 5.0 Page 12 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): EVIDENCE: These standards were inspected at the last inspection on 9.08.05. Groby Lodge DS0000063629.V260704.R01.S.doc Version 5.0 Page 13 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29, 30 Sound recruitment procedures are in place to protect residents. The Owner supports the staff team by offering then good training opportunities. Residents are pleased with the staff team. EVIDENCE: Staff are advertised for locally and have an equal opportunities interview with the Owner prior to commencing work. The Owner insists that staff have two satisfactory written references and a CRB check before they start work permanently in the home. If they start without these they work under supervision at all times, have a telephone or fax reference, and sign a criminal records declaration. Staff have a four weeks probationary period and all staff have a contract. The Owner and Deputy have devised a new training programme for staff. All new staff now receive a thorough induction with each competency assessed and signed off by a senior member of staff. NVQs have been introduced and six staff registered for Level 2. A series of short certificated courses has been booked including Health and Safety, Dementia Awareness, and Equality and Diversity. The staff training programme is commended. All residents interviewed praised the staff and the following comments were made: ‘I’ve never had any problems with the staff.’
Groby Lodge DS0000063629.V260704.R01.S.doc Version 5.0 Page 14 ‘The staff are very kind and they treat us well.’ ‘The staff know what they’re doing.’ ‘The staff work very hard.’ Groby Lodge DS0000063629.V260704.R01.S.doc Version 5.0 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): 33, 35, 38 The home is run in the best interests of residents and their financial interests are safeguarded. Good systems are in placed to maintain the health and safety of residents and staff. EVIDENCE: In discussions the Owner said he aims to run the home in the best interests of residents and consult them when any changes are proposed. He said ‘When I first took over I met with all the residents and explained my plans for the premises to them. I also wrote to them and their relatives about the improvements I intended to make. Since then I have involved them in all major decisions about the home including décor, menus and activities.’ The Owner keeps in contact with relatives via a monthly letter, and said he is intending to hold regular residents meetings and carry out six monthly surveys
Groby Lodge DS0000063629.V260704.R01.S.doc Version 5.0 Page 16 to give staff, residents, and relatives to opportunity to comment on how the home is running. Both staff and residents praised the Owner. One carer said ‘If we need Dinesh he’s there in an instant, at the drop of a hat.’ Residents’ comments included: ‘Dinesh goes out of his way to help us and to get things for us. If we want anything special to eat he gets it. Anything you ask for is there the next day.’ ‘I’ve never had or heard a cross word from Dinesh.’ ‘The new Owner’s nice. He comes here a lot and he talks to us all every time he comes.’ The Owner is commended for his role at the home. Residents’ finances are handled by the residents’ themselves, or their representatives. Staff said that if any concerns arise about residents’ access to their own monies social service are informed. There is a range of policies and procedures in place to maintain health and safety in the home. Good records are available to show the home is properly maintained, and in discussions the Owner demonstrated his commitment to maintaining a safe environment for residents and staff. In May 2005 the Fire Officer carried out an inspection of the home. He made a number of recommendations, which the Owner said have been met. Groby Lodge DS0000063629.V260704.R01.S.doc Version 5.0 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 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 4 X 3 X X 3 Groby Lodge DS0000063629.V260704.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP16 Good Practice Recommendations The complaints procedure needs updating to meet Standard 16. The adult protection procedure needs updating to meet Standard 18. 2 OP18 Groby Lodge DS0000063629.V260704.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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