Inspection on 19/05/05 for Grosvenor Hall Care Home

This inspection was carried out on 19th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Grosvenor Hall Care Home 02/08/07

Grosvenor Hall Care Home 10/04/06

Grosvenor Hall Care Home 26/10/05

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

CARE HOMES FOR OLDER PEOPLE Grosvenor Hall Care Home Newark Road Lincoln Lincs LN5 8QT Lead Inspector Dawn Podmore Unannounced 19 May 2005 @ 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Grosvenor Hall Care Home C53 C04 S 61942 Grosvenor Hall V225204 190505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Grosvenor Hall Care Home Address Newark Road Lincoln Lincs LN5 8QT Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01522 528870 Mr K Ravivaruman To be determined Care Home 31 Category(ies) of OP Old Age 25 (twenty five) registration, with number DE Dementia 6 (six) of places Grosvenor Hall Care Home C53 C04 S 61942 Grosvenor Hall V225204 190505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: An application for the registration of a manager must be received by CSCI within three months. Mr Ravivaruman must also submit confirmation of the management arrangements for the home in the absence of a registered manager within one week of becoming the registered provider. A manager has been appointed and her application is currently being processed by the Commission therefore once completed this condition will be removed from the registration certificate Mr K Ravivaruman undertakes training specifically tailored to adult abuse within three months of registration and dementia care training within six months of registration. Mr Ravivaruman has completed the required training therefore this condition will be removed for the registration certificate. Mr Ravivaruman must comply with his action plan, dated 27th August 2004 and the agreed timescales. Date of last inspection 03/01/05 Brief Description of the Service: Grosvenor Hall is a large two storey Victorian listed building. It is situated on a main road, south of the city of Lincoln and is within walking distance of local shops. Public transport is available to the city amenities.The home is set in its own grounds and gardens. Currently the gardens are not accessable due to the lanscaping of the grounds taking place, but it is anticipated that this will be completed by the summer. Car parking is available to the front of the building. Accommodation is provided on the ground and first floor in single and shared rooms. A lift gives access to the first floor. The home provides personal and nursing care for persons age sixty-five years and over with specific emphasis focussing on dementia care for five service users. The home has recently changed ownership. The new owner, Mr Ravivaruman, has begun to renovate and refurbish the home. A new manager, Mrs Angela Lacy, was appionted in February, an applicaion to register her with the Commission is currently being processed. Grosvenor Hall Care Home C53 C04 S 61942 Grosvenor Hall V225204 190505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over 7 hours and the owner of the home was present throughout the visit. A tour of the premises was conducted, and care records were inspected. Three staff, six residents, three relative and the manager were interviewed. Questionnaires were also used by the Commission to gain residents and relatives’ views. What the service does well: What has improved since the last inspection? The renovation and refurbishment of the home was underway with minimum disturbance to the residents. The refurbished bedrooms and lounge areas greatly improved the general atmosphere in the home and residents and staff said that it made the home a much nicer place to be. Staff recruitment procedures were being followed which meant that appropriate checks had been carried out before staff were allowed to work at the home. There had been an increase in the provision of staff training including subjects such as dementia. New uniforms have been provided for staff, they said that these made them feel smarter and more valued. Residents said it also made it easier for them to recognise who was a member of the staff team. The records detailing residents care needs had been improved and further development was planned. The home had introduced an activities programme, which residents said that they enjoyed taking part in, it included dominos, drawing and manicure sessions. Grosvenor Hall Care Home C53 C04 S 61942 Grosvenor Hall V225204 190505 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Grosvenor Hall Care Home C53 C04 S 61942 Grosvenor Hall V225204 190505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Grosvenor Hall Care Home C53 C04 S 61942 Grosvenor Hall V225204 190505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 & 4 The home has a satisfactory assessment process in place to ensure that it can meet the needs of the people admitted to the home. Residents and relatives are on the whole happy with the care provided and feel that their needs are being met. EVIDENCE: Records contained detailed needs assessments, these had been completed prior to the resident being admitted to the home. Staff and residents confirmed that assessments had taken place prior to planned admissions. One file, for a resident who was admitted as an emergency admission, contained information provided by social services. Staff had then completed the home’s care needs assessment within 72 hours of admission. The files of 2 new residents contained letters confirming that the home could meet their needs and the admission details. Staff demonstrated a good knowledge of the needs of the residents. Residents and relatives spoken with said that the home was meeting their needs. Grosvenor Hall Care Home C53 C04 S 61942 Grosvenor Hall V225204 190505 Stage 4.doc Version 1.30 Page 9 Comments included: ‘I am happy here, they treat me very well’, ‘the care is good, they see to you promptly and are very kind’ and ‘it’s nice here, I have no problems’. Seventeen questionnaires were returned to the Commission from residents and relatives, eleven of which said that they were completely happy with the care provision however 2 said that they were not aware of the complaint procedure and another said that they would like more activities. Additional comments included: ‘I like the way families can come and have a meal with their relative’ and ‘overall it is a well run and friendly home, my mother is happy here’. Grosvenor Hall Care Home C53 C04 S 61942 Grosvenor Hall V225204 190505 Stage 4.doc Version 1.30 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 standard(s) 7 & 8 Care plans did not identify all areas of need or provide detailed care instructions for staff; this may lead to residents needs not being met. Input from outside agencies was not fully documented in care plans. EVIDENCE: Each service user has an individual plan, which contains information relating to their care needs. Care plans seen had been recently rewritten demonstrating that the care needs of the residents had been reassessed. Although there had been an improvement in the documentation of care needs further development was required. Areas not fully addressed included nutritional assessment and completion of body maps to identify any skin damage. Although pressure risk assessments completed showed that some residents were at risk of developing pressure damage, plans had not always been formulated to instruct staff on what action they needed to take to minimise the risk of this happening. Individual residents medical conditions and personal likes and dislikes were not documented in sufficient detail. Care plans had been evaluated monthly with additional evaluations if the resident’s needs or prescribed care had changed. Grosvenor Hall Care Home C53 C04 S 61942 Grosvenor Hall V225204 190505 Stage 4.doc Version 1.30 Page 11 Residents’ health needs were being met. Visits by doctors and district nurses were recorded in residents files, however care plans did not detail all the nursing care being provided by the district nurses in detail. Grosvenor Hall Care Home C53 C04 S 61942 Grosvenor Hall V225204 190505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 & 15 The home provides a regular activities programme but this could be expanded to include more variety. Meals provided offer variety and choice. EVIDENCE: The home has introduced an activities programme, which includes dominos, drawing, movement to music and manicures. Currently there is no activities coordinator employed at the home so care staff are providing daily activities. Participation in activities was recorded either in the activities book or on residents’ files. Residents said that they were happy with the introduction of the activities programme but one relative said that they would like to see more entertainment such as sing a longs and visiting entertainers. People also commented that they would like outings in the summer. Staff said that a pub evening held at the home over the bank holiday had been a great success. On the day of the visit one member of staff was painting residents fingernails and talking to them, while another played tunes on a mouth organ. It was recommended that the programme be expanded to include a more varied choice of activities, especially for people with dementia and that individual preferences be clearly documented. Grosvenor Hall Care Home C53 C04 S 61942 Grosvenor Hall V225204 190505 Stage 4.doc Version 1.30 Page 13 The activities room was still being used for storage while the remodelling of the home was taking place, however residents were happy with the temporary arrangement of activities being provided in the lounge area. The meal on the day of the visit was nutritionally balanced and well presented. It consisting of chicken pie or liver and onion gravy, followed by chocolate sponge served with a chocolate sauce. Residents said that they enjoyed the food provided, comments included ‘the food is very nice and you always get a choice’, ‘I am happy with everything’ and ‘it’s nice, I have no complaints’. Grosvenor Hall Care Home C53 C04 S 61942 Grosvenor Hall V225204 190505 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 The home has robust procedures for handling allegations of adult abuse, and staff were clear on the action to take in the event of this occurring. EVIDENCE: The home’s adult protection policy was in line with current local guidelines. Staff spoken with had a good knowledge of the types of abuse that could occur and the actions that they must take if they had any concerns. The acting manager had a good understanding of procedures to follow regarding reporting any suspected abuse to the Commission and social services. Staff said that adult protection training had taken place and attendance had been recorded in training files. Grosvenor Hall Care Home C53 C04 S 61942 Grosvenor Hall V225204 190505 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 21, 23, 24 and 26 The standard of the environment had greatly improved since the last inspection. Residents living at the home live in a clean, comfortable and homely environment. EVIDENCE: Since the new owner took over the home he has commenced a major refurbishment and redecoration programme. A tour of the building showed that the programme was well underway. Ten bedrooms had been decorated and refurbished with ensuite facilities being added to 6 of these rooms. The downstairs lounge had been redecorated, new furniture had been purchased and a new carpet fitted. A large room upstairs had been made into a lounge/dining room, which included renovation of the high ceiling and the purchase of appropriate furnishings. Other work completed included replacing the roof tiles, installation of a new nurse call system and the fitting of a sluice machine. The addition of a ramp at the front of the building made access to the home easier. Grosvenor Hall Care Home C53 C04 S 61942 Grosvenor Hall V225204 190505 Stage 4.doc Version 1.30 Page 16 The garden area could not be used due to the building work, but the owner said that landscaping, which will include an enclosed patio area, would be completed by the summer. A new hoist had been fitted in one of the bathrooms. The laundry had been relocated to a more convenient location and new equipment purchased. As part of the refurbishment programme locks are to be fitted to all bedroom doors. This programme had not been completed and there was no evidence of residents being consulted on this issue. People who were spoken with said that they were very happy with the refurbishment of the home. Residents said that they liked their rooms and felt that they had everything they wanted. Staff said that the refurbishment work had made the lounge airy and light, and a much nicer environment to work in. The home was clean and tidy with no offensive odours. Grosvenor Hall Care Home C53 C04 S 61942 Grosvenor Hall V225204 190505 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30 Adequate staffing levels are provided. The procedures for recruitment of staff were robust and therefore offered protection for people living at the home. Additional training is required to ensure staff can meet all the needs of the residents. EVIDENCE: Staff duty rotas demonstrated that the home was providing adequate staffing levels. One nurse and 3 carers are on duty during the day and at night one nurse with 2 care staff care for the 19 residents currently living at the home. Since the last inspection the shift pattern has been changed to allow for a handover period to ensure that all relevant information is passed on. Residents said that they felt that there were enough staff to care for them but 2 relatives said that they felt that there was not enough staff on duty. A recently employed member of staff described how they had been recruited, this included completion of an application form, face to face interview, supplying 2 references and undertaking a C.R.B. (Criminal Records Bureau) check; records confirmed this. Documented induction training had been provided but it did not cover all the necessary subjects in any depth. Records and staff comments confirmed that training had been provided, this included; adult protection, manual handling, fire safety, health and safety, dementia, aggression management and basic food hygiene. Not all staff had attended the training sessions and it was recommended that staff training files Grosvenor Hall Care Home C53 C04 S 61942 Grosvenor Hall V225204 190505 Stage 4.doc Version 1.30 Page 18 be audited to provide a clear record of which staff still required essential training. Grosvenor Hall Care Home C53 C04 S 61942 Grosvenor Hall V225204 190505 Stage 4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 & 32 With the appointment of the new manager and regular visits by the owner, there is sufficient leadership, guidance and direction to staff to ensure residents receive consistent quality care. EVIDENCE: A manager was appointed at the end of February and an application for her to become the Registered Manager is currently being processed by the Commission. Mrs Lacy is a qualified nurse with experience in care home management. Residents and staff said that they found Mr Ravivaruman and Mrs Lacy approachable and available to discuss any issues. Mr Ravivaruman is regularly available at the home were he is coordinating the refurbishment programme and providing support to Mrs Lacy. At the last inspection in January Mr Ravivaruman was required to complete a monthly report detailing his findings at the home, these reports have not been Grosvenor Hall Care Home C53 C04 S 61942 Grosvenor Hall V225204 190505 Stage 4.doc Version 1.30 Page 20 completed and although, according to staff and service users, he was spending a significent amout of time at the home there was no documentary evidence of his visits. Grosvenor Hall Care Home C53 C04 S 61942 Grosvenor Hall V225204 190505 Stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x 2 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 2 3 x x x x x x Grosvenor Hall Care Home C53 C04 S 61942 Grosvenor Hall V225204 190505 Stage 4.doc Version 1.30 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 15[1] 15(2)(b) Requirement Care plans must contain more comprehensive information. They must set out in detail the action that care staff need to take to ensure that their individual needs are met. The programme for upgrading the premises must be completed. Residents must be consulted regarding the fitting of locks to bedroom doors and their opinions documented. Training must be provided to all staff in both manditory and specialist subjects. This must include subjects such as diabetes. The previous timescale for this was 31/12/05 and although some staff have attended appropraite training others have not. Visits must be made and documented in accordance with regulation 26. The previous timescale for this was 28/2/05 and although staff and service users say that the owner visits the home regularly there was no documentation to support this. Timescale for action August 1st 2005 2. 3. 19 24 23[b] 12[4][a] September 1st 2005 July 1st 2005 September 1st 2005 4. 30 18 (1) 5. 37 26[1][4] [5] July 1st 2005 6. Grosvenor Hall Care Home C53 C04 S 61942 Grosvenor Hall V225204 190505 Stage 4.doc Version 1.30 Page 23 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 8 Good Practice Recommendations The healthcare needs of service users should be maintained and additional information should be recorded in care plans in relation to oral healthcare, and continence assessments The activites programme should be expanded to include appropriate activites for all residents including those with dementia. The designated activities room should not be used as a storage facility. Staff training files should be audited to identify which staff require essential training. 2. 3. 4. 12 12 30 Grosvenor Hall Care Home C53 C04 S 61942 Grosvenor Hall V225204 190505 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Unity House Weaver Road, off Whisby Road Lincoln LN6 3QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Grosvenor Hall Care Home C53 C04 S 61942 Grosvenor Hall V225204 190505 Stage 4.doc Version 1.30 Page 25 - 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. 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