Inspection on 10/10/06 for Grosvenor House

This inspection was carried out on 10th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Grosvenor House 20/12/05

Grosvenor House 07/04/05

Grosvenor House 29/11/04

Grosvenor House 04/06/04

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

CARE HOMES FOR OLDER PEOPLE Grosvenor House 11-14 Grosvenor Gardens St Leonards-on-Sea East Sussex TN38 0AE Lead Inspector Jason Denny Key Unannounced Inspection 10th October 2006 09:50 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 Grosvenor House DS0000021123.V311713.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. Grosvenor House DS0000021123.V311713.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grosvenor House Address 11-14 Grosvenor Gardens St Leonards-on-Sea East Sussex TN38 0AE 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) 01424 423831 Greensleeves Homes Trust Mrs Janet Fox Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Grosvenor House DS0000021123.V311713.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is twenty-eight (28) Service users must be older people aged sixty-five (65) years or over on admission 20th December 2005 Date of last inspection Brief Description of the Service: Grosvenor House is a care home providing personal care and accommodation for up to 28 older people. The home is owned by the Greensleeves Homes Trust, a London based charity that operates 18 care homes throughout England. Grosvenor House is located on the west promenade of St Leonards on Sea. About 1½ miles from the centre of Hastings, there are shops, pubs, and other community facilities nearby. The property forms part of a Victorian terrace and overlooks a garden area and bowling green. Service users accommodation is on four floors. The home has recently installed a new modern lift, which gives access to all floors. All bedrooms are offered as single person accommodation unless people choose to share, such as married couples. The home is currently offering services to 27 people. The extensive building work, which started in June 2005, has now finished with just minor areas to sort to satisfy building control. This work has created ensuite shower rooms in all bedrooms, substantial communal space with level access throughout, and new level access entrance area in a previously unused area of the building. Once building control sign off the work and the Commission approve the major variation to be resubmitted [first submitted August 2003], the home will be able to offer services to up to 33 people by using the 5 new bedrooms [29 single and 2 double rooms]. Information on the range of fees charged is within the homes current statement of purpose/service user guide and ranges from £375 to £563 per week. The higher rate of fee is for those who are self-funded and is based on room size and facilities. Fee’s for self funders starts from around £445 Charges for extras include personal items beyond the basics and activities provided by the home. Such items include newspapers, perfumes, chiropody, and hairdressing. Inspection reports are not routinely sent out to families and advocates after each publication although a copy is kept on display in the reception area of the home and can be obtained via the manager. A service user guide containing the most recent inspection report is sent to any interested person [or their representatives] looking to move into the home. Grosvenor House DS0000021123.V311713.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced key Inspection, which included a visit to the home which took place between 9.50am and 4.30pm on October 10,2006.This inspection focused on the key major areas such as how needs are being met. Activities, lifestyles, environment staffing of the home, along with how the home is managed, and how concerns are dealt with, was also looked at. During this inspection process, which covers the period since the last inspection December 20, 2005 and the week of the home visit, a number of relatives have been spoken with [4]. One [1] questionnaire was received from relatives, and 13 from Residents prior to the inspection, with all comments highly positive, especially about the care, the manager, and the staff. 10 residents were spoken with, along with others observed during the inspection, which also included discussion with some staff and observation of care. The focus of the inspection was looking at the four [4] of the newest Residents who have moved in since the last inspection along with the building. Some diversity and equality areas were explored in relation to lifestyles. Care records for four Residents along with health and medication needs were looked at. Discussions with management looked at progress since the last inspection. The inspector toured all communal areas of the home along with some bedrooms. Meal arrangements were examined and sampled. A record of complaints was inspected. Staffing was looked at in detail along with the homes management, including measures to ensure quality for Residents. All seven-outcome areas were assessed with six [6] outcome areas assessed as Excellent, and one [1] area assessed as Good. What the service does well: One new Resident speaking in agreement with others stated, “There is nothing here which is not good, the home suits me admirably” comments from relatives all described the home as excellent with no obvious weaknesses or areas for improvement. The main focus of the positive comments was on the management of the home the quality of staff, food, the attentive and skilled care, and the attractiveness and cleanliness of the building, along with how Residents are supported to exercise freedoms “ They balance good care with liberty”. The home was again found to do provide excellent care, excelling in a number of areas. The management of the home was found to be excellent and dedicated to supporting residents and staff. The organisation which oversees the home was found to provide excellent support with training, financial help, and regular inspections. A range of ways were seen of how well residents are fully involved in the running of the home with regular meetings and regular information. The home deals exceptionally well with concerns from residents. A meal was sampled, which in agreement with residents was found to be Grosvenor House DS0000021123.V311713.R01.S.doc Version 5.2 Page 6 exceptional, with an excellent menu with a range of choices. The home continues to offer a range of activities and maintains strong links with the community. Regular monthly summer coach trips continue to be organised along with seasonal events. Exceptional steps are taken to cater for people’s individual tastes. The provision of care and recording was found to be excellent. An excellent building has now been created for Residents who enjoy the fullest range of facilities such as en-suite shower rooms in each bedroom high amounts of communal space and a range of bathrooms. The home goes to exceptional lengths to provide prospective new Residents with full information on the home and opportunities for a number of trial visits. All other areas such as Staff training, medication, contracts [Resident agreements/ terms and conditions] were found to be good. 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. Grosvenor House DS0000021123.V311713.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 Grosvenor House DS0000021123.V311713.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, & 5. Quality in this outcome area is EXCELLENT. This judgement has been made using available evidence including a visit to this service. The home provides both prospective and existing Residents, with a good level of information with a high number of trial visits made available. Moreover, the way in which the home assesses prospective or existing residents ensures, that it currently meets needs. Contractual terms and conditions are fair, transparent and agreed. EVIDENCE: The home’s service user guide was found to be on display in the home and fully updated in April 2006 including Resident’s and relatives views as apart of report on a survey carried out in late 2005. Resident’s spoken with, were very knowledgeable about the home due to them and their representatives provided with an excellent range of clear information before they decided to move into the home. The home’s service user guide and Statement of Purpose were found to contain all necessary information in an attractive and accessible format for prospective new Residents .Two [2] of the newer residents indicated that they had at least 4 trial visits to look around, take meals and meet people Grosvenor House DS0000021123.V311713.R01.S.doc Version 5.2 Page 9 before deciding to move in. The 4 Residents files looked at showed that the home writes to prospective new residents to confirm that they could meet assessed needs prior to admittance. Pre-assessments carried out by the manager were found to be thorough with additional information from social services also obtained by the home either prior to or on admittance. These assessments accurately described the needs of the residents concerned who the inspector met with. Written records showed that the manager carries out a new assessment shortly after a new person moves in to ensure that all needs are being met. Those new Residents who could give an opinion confirmed that they and their representatives read a contract/terms and conditions before deciding to move in the home. The inspector looked at Residents files in the case mentioned and found contracts to be clear, transparent, fully explained, and signed. Each room has an advertised price /tariff of fees dependent on size, location and facilities. There is also a different fee depending on care needs and whether the person is self funded or fully funded all of which is explained along with any additional charges. Both persons are self-funidng and were found to be paying £425 per week. The home was found to be aware of amendment to Care Homes Regulations effective from September 2006 in relation to contracts. This was evidenced in recent letters which have gone out to existing Residents providing additional information to supplement their contract such as whether the fee would be different if they were social services funded and the home’s right to vary fees. Grosvenor House DS0000021123.V311713.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10. Quality in this outcome area is EXCELLENT. This judgement has been made using available evidence including a visit to this service. An exceptional level of attention is given to the care-needs of residents. Medication is soundly managed in the best interests of Residents. Residents are treated with dignity and respect with their wishes respected. EVIDENCE: Individual plans of care were inspected of four new residents and were found to be sufficiently detailed, up to date, and contained clear information to support staff to meet the needs of residents. The plans were found to be userfriendly and covered the full range of health needs, which the inspector observed during the inspection. All residents interviewed indicated the way in which their health needs were being met by the home. This was also confirmed by their relatives who stated how well informed they are and how promptly the home responds to changing health needs and supports Residents to be as independent as possible. Staff and management are fully involved in plans of care and were found to be actively involved in their regular review. Staff Grosvenor House DS0000021123.V311713.R01.S.doc Version 5.2 Page 11 spoken with showed a good knowledge of care-plans and the key issues to be aware of in relation to new residents. All relatives and Residents spoken with described the staff as well trained, dedicated, attentive and caring. The home was found to be particularly mindful of how to prevent the risk of falls or pressure sores with a high level of ongoing risk-assessment and clear guidance to staff. The home undertakes a full six-month review of each care-pan with a review meeting involving social services and relatives along with the resident. A. Plans benefit from detailed pre-assessments, including detailed risk assessments, which are carried out before someone moves in and which form the basis of the care-plan. The manager was observed to be in discussion with socials services ensuring that all support was in place before she considered taking in a new Resident. The inspector looked at medication stocks, record keeping, training records and observed trained staff dispensing medication all of which was found to be in order. The manager discussed the range of checks carried out in relation to medication arrangements. There was no evidence of any Residents being over sedated with Residents found to be lively and sociable. One of the new Residents indicated how they are able to continue to self medicate with all safeguards and risk assessments in place. The home also benefits from a new purpose built medication room. The home was found to be considering whether to record in each care-plan the individual reasons for and effects of each medication listed so that staff are aware of why they are giving medication to that individual. The home provides a range of medication sheets and other information to give staff general advice on each drug, whilst recognising that Residents could be on the same medication for different reasons. All staff who administer medication only do so after accredited external training and in house induction. Grosvenor House DS0000021123.V311713.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15. Quality in this outcome area is EXCELLENT. This judgement has been made using available evidence including a visit to this service. Residents are offered a good range of activities and are able to make a range of choices about their lives with significant consideration given to their views and feelings. The level of resident involvement in the home is again assessed as exceptional. Food served by the home was found to be exceptional in terms of taste variety, and choice. . EVIDENCE: The home operates a weekly-advertised timetable of activities, which includes music, dance, and bingo, along with visiting libraries, church services, and socially focused activities such as regular monthly coach trips and a visiting magician and other actors. During the inspection some Residents demonstrated some stretching exercises they had learnt. It was evident how Residents were benefiting from the new level access to the rear gardens and new conservatory. Some residents enjoy a strong community presence. Residents continue to be consulted on their activity and other needs such as at resident meetings or through questionnaires. Some residents were found to have made a clear choice to remain in their rooms although were seen to be encouraged to come down for meals where necessary. Some of the new Grosvenor House DS0000021123.V311713.R01.S.doc Version 5.2 Page 13 residents indicated how they had recently enjoyed several mini-bus outings, had visited the local theatre, were taking part in some Halloween activities and had already had the full list of the Christmas activity programme, which they found impressive. Visitors praised the access they have to the home and commented on the calm open and supportive atmosphere they are afforded whenever they pop in, often unannounced. Records, observations, and discussions indicated the range of choices open to residents such as the choice of a room key, going out independently and selfmedication subject to risk assessment. Some relatives indicated how the home expertly balances good care and supervision whilst allowing Residents to have freedoms and maintain existing skills. Residents especially praised meal arrangements. The inspector sampled a meal and found it to be tasty, wholesome and imaginative. Residents as confirmed by the Residents representative [spokesperson], benefit from the provision of monthly residents meetings which most attend along with the manager. Residents were found to be well informed about the running of the home and forthcoming events. Grosvenor House DS0000021123.V311713.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, & 18. Quality in this outcome area is EXCELLENT. This judgement has been made using available evidence including a visit to this service. The home operates in an open and pro-active manner. All residents and visitors are made fully aware of how to complain or raise concerns. The home continues to treat even minor concerns as complaints and purposely encourages residents to air their views. The overall handling of complaints/concerns is exceptional. EVIDENCE: All residents spoken too confirmed the sensitive care they receive from an established staff team who were observed by the inspector to operate in an appropriately caring and patient manner. The home has a comprehensive complaint policy and form for reporting concerns. The inspector saw written examples of one complaint since the last inspection, which was not about the care of Resident’s but concerned how information about fees is communicated to the public. The concern was found to be thoroughly investigated by the organisation and was unsubstantiated. The person who brought the concern is sufficiently reassured to still be looking to place a relative in the home. Records showed how historic concerns dating back before this year mainly from one Resident received a prompt and thorough response, which fully respects the right to raise any concerns. The Resident concerned has confirmed to the inspector their overall satisfaction with the home. It is also noticeable how the home continues to improve practice in light of any concerns. Grosvenor House DS0000021123.V311713.R01.S.doc Version 5.2 Page 15 All steps taken to resolve concerns are fully included in the complaints records including writing to the complainant. The home maintains a suggestion scheme in the visitors reception area based on improving the service. Staff continue to receive regular and updated training on the prevention and reporting of abuse procedures based on protecting vulnerable people. Staff interviewed, again indicated a good knowledge of how to both identify and report allegations of abuse. The home was again found to have an appropriate adult protection policy which all staff sign and cover during their comprehensive induction. Residents and relatives were fulsome in their praise of staff. Grosvenor House DS0000021123.V311713.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24, 25, & 26. Quality in this outcome area is EXCELLENT. This judgement has been made using available evidence including a visit to this service. The home is impressive in scale, layout, and location. It is a well-maintained Victorian building, which has undergoing substantial modernisation to meet all requirements and now exceeds basic standards. Resident’s benefit from excellent rooms, views, and exceptional facilities. Communal space and accessibility is exceptional. EVIDENCE: The inspector toured the home including all communal areas some bathrooms and bedrooms. The building work which started in June 2005 was found to be complete with only some minor details to satisfy building control in order to open the 5 new bedrooms followed by a successful application to increase registration numbers to 33. All hot pipes and radiators are now guarded, all rooms have en-suite walk-in shower rooms, full disabled accessibility to the large decorative gardens, and hot water outlets accessible to residents Grosvenor House DS0000021123.V311713.R01.S.doc Version 5.2 Page 17 delivering water at safe temperatures. The new modern lift was found to be reliable [confirmed by residents] and stopped at all floors. The large sliding automatic door entrance area to the home was found to be user-friendly with the inner door now secure along with the installation of CCTV to improve overall security of the home in a popular seaside location. This new front entrance is now level and fully wheelchair accessible. The finished building was found to extremely popular with Residents and their relatives with exceptional amounts of communal space. The relocation of the dining room to the lower ground floor was found to be popular with this affording a good amount of light due to the construction of large windows and adjoining conservatory. The accessibility of the rear garden was found to have encouraged greater use by Residents. The conservatory is also useful for Residents to welcome visitors. Apart from walk in showers in each bedroom there are 4 supported parker baths along with a high number of toilets within easy reach of any part of the home. The home was found to be clean and free from any odours. All relatives and residents who spoke with the inspector all stated how clean the home was on any visit. Grosvenor House DS0000021123.V311713.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, & 30. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of experienced staff on duty who are well supervised and who continue to benefit from increased training. Staffing levels are regularly reviewed and have increased in line with the number of Residents. Tight recruitment and disciplinary procedures are followed to protect the interests of Residents although evidence is needed in the home to confirm the checks carried out on agency staff. All Residents and visitors praised the quality of the staff. Staff training was found to be excellent with sufficient staff now having the basic National Vocational Qualification in Care. EVIDENCE: Staffing levels are matched to the needs of the 27 Residents as evidenced during the inspection. The Manager again demonstrated how staffing levels are adjusted to meet need as evidenced on the rota, which indicates that staffing on the morning shift has increased to 4 care staff along with domestic and catering staff, and a manager on duty. Night time staffing is planned to increase to 3 with one of these being a senior carer. Residents, relatives and Grosvenor House DS0000021123.V311713.R01.S.doc Version 5.2 Page 19 staff spoken confirmed that this was sufficient staffing levels. The inspector observed how quickly Residents had their needs met. Staffing levels will be reviewed as needs increase and when numbers increase to 33. The number of staff with National Vocational Qualification in Care at least level 2 has increased to over 50 with this figure on course to be near 75 once all other staff on these courses complete them All staff were found to have compulsory training such as Moving and Handling, First Aid, food hygiene and Fire. It was noted that a range of training such as dementia has taken place since the last inspection. The manager closely monitors staff training and development as seen on matrix style yearly planner’s and records. The recruitment records of the two of the most recently employed staff where found to contain all necessary information including ID checks and Police CRB’s. All staff work under full supervision after passing their Protection of Vulnerable Persons Register check and before the Police CRB comes back clear. These staff were also found to have started or finished their TOPSS induction under the supervision of the manager. Supervision records showed the progress being made, along with close monitoring of performance and development needs. New staff interviewed indicated how they are closely supervised and receive continuous induction training into all aspects of the job and the standards expected in the home whatever their previous experience is. Relatives commented on the positive attitude of staff Its was noted that during the summer there was a higher then usual use of agency staff which was due to permanent staff taking annual leave although this was not found to be affecting outcomes. The organisation were found to be looking at shift arrangements for staff to ensure less use of agency staff in the future by the time of the inspection agency staff was found to be minimal with only one staff vacancy. No staffing records of those agency staff who work in the home was on site with all checks carried out by the employing agency. The manager was advised to ensure that have copies of these checks before such staff work in the home. There was no indication that these checks had not been carried out by the registered agency with the manager informed verbally that this is the case. Grosvenor House DS0000021123.V311713.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35, 36, & 38. Quality in this outcome area is EXCELLENT. This judgement has been made using available evidence including a visit to this service. A motivated and highly competent management team ensures an exceptionally well run home. The open management of the home ensure that they are well informed about resident’s, staff’s , and relative’s, viewpoints. Quality for residents is regularly reviewed and improved upon. The safety and welfare on Residents is given top priority EVIDENCE: The registered manager has managed the home for a number of years and is well qualified. She has a National Vocational Qualification in Management and Care at level 4 and has worked in the home in senior capacity for 12 years with the deputy having worked for 14 years. Minutes indicated regular monthly meetings of staff and residents. Residents along with their representatives Grosvenor House DS0000021123.V311713.R01.S.doc Version 5.2 Page 21 complete satisfaction questionnaires every 12 months with a full report and action plan developed in response to views collected. The last published survey took place between October and November 2005 with a high number collected by residents, relatives and other professionals such as district nurses [stakeholders] comments were found to be highly positive with one relative stating “first class home” a report on these views was found to be in the homes service user guide as well as being circulated throughout the home. The Inspector found during the inspection that a new survey had started of Residents and relatives with some highly positive questionnaire already completed dated 9/10th October 2006. All residents spoken with during the inspection praised both the management and the staff who work in the home. The managing organisation Greensleeves has since the last inspection improved the quality of the monthly section 26 report to include named interviews with Residents. Although the quality is not as detailed as some historical reports the inspector was informed of plans to improve the current reports further. Then home are no longer required to send these reports to the Commission given that the homes is well managed and has at least a good rating. Although the manager is considering this in ordure to keep the Commission informed. All other aspects of the homes quality assurance systems such as monthly reviews of care-plans and six monthly review meetings were found to be exceptional. Records relating to those Residents monies maintained in the home’s safe along with record keeping was inspected on a previous inspection and found to be in order. Residents also have lockable units in their room for safe- keeping. All safeguards are in place and some occasional residents or missing items have been thoroughly investigated with no reoccurrence since April 2006. Written record showed that staff receive exceptional supervision with some staff receiving this on a monthly basis assisting them to improve their performance and access more training A regular round of varied health and safety training is delivered to staff. The home’s questionnaire completed prior to the inspection confirmed that all equipment in the home is regularly and properly maintained. Regular fire drills take place with residents having the option of evacuating with staff although they are encouraged to remain in the home. Full written evaluations are carried out after each drill. A tour of the home showed it to be free from hazards. Accident reporting was found to be thorough with all necessary action promptly taken to support Residents. Grosvenor House DS0000021123.V311713.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 4 3 3 X 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 4 4 4 X X 4 4 4 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 4 X 3 Grosvenor House DS0000021123.V311713.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. 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 OP29 Good Practice Recommendations That copies of staffing records including recruitment checks carried out by the care worker agency who periodically supply staff, are kept in the home. Grosvenor House DS0000021123.V311713.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 House DS0000021123.V311713.R01.S.doc Version 5.2 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. 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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