Inspection on 11/05/06 for Grosvenor Lodge Care Centre

This inspection was carried out on 11th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Lodge Care Centre 30/04/07

Grosvenor Lodge Care Centre 07/11/05

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

CARE HOMES FOR OLDER PEOPLE Grosvenor Lodge Care Centre 26 Grosvenor Road South Shields Tyne And Wear NE33 3QQ Lead Inspector Miss Nic Shaw Key Unannounced Inspection 10:00 11 , 12 and 15th May 2006 th th 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 Lodge Care Centre DS0000063765.V291497.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Grosvenor Lodge Care Centre DS0000063765.V291497.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Grosvenor Lodge Care Centre Address 26 Grosvenor Road South Shields Tyne And Wear NE33 3QQ 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) 0191 4569399 0191 4562576 European Care (England) Ltd Care Home 22 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (22), of places Physical disability over 65 years of age (1), Sensory Impairment over 65 years of age (3) Grosvenor Lodge Care Centre DS0000063765.V291497.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2005 Brief Description of the Service: Grosvenor Lodge is a large Victorian residence, which has been extended and adapted for its present use as a care home. The home is set in its own grounds in a quiet area of South Shields and is within walking distance of the local shops, post office and churches. The beach is a short car or bus ride away. There is easy access to the town centre and public transport routes. The home provides personal care for twenty-two service users, it does not provide nursing care. All but one of the bedrooms are single, the double room is only available to couples or relatives who request to share. Eleven of the rooms have en-suite facilities. There is a separate dining room, lounge and conservatory, which leads into a garden area. Grosvenor Lodge Care Centre DS0000063765.V291497.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over three days in May 2006 and was an unannounced inspection. The inspection included information which had been provided by the manager in a pre-inspection questionnaire and a sample of staffing and service user records. Time was spent talking to the manager, approximately twelve service users, five staff, two visitors and six relatives during a relatives meeting. A meal was also taken with the service users on the first day of the inspection. The inspection particularly focussed on five service users with very different needs. This involved talking with those service users and their relatives, observing staff’s care practices with them and checking that information obtained from discussion and observation is accurately recorded in the care records. The judgements made are based on the evidence available to the inspector during the inspection, the pre-inspection questionnaire supplied by the manager and comments received by service users and their relatives. What the service does well: The manager makes sure that the home is suitable for any service user who wishes to live there by visiting them in their own home and carrying out his own assessment of their needs. He also makes sure that he obtains an assessment which has been completed by the service user’s social worker. The manager is in the process of issuing all service users with a contract so that they know the terms and conditions of their stay. There are good clear systems for recording and giving medication which ensures that all service users receive the medicine which they have been prescribed. Service users spoken to said that they felt their healthcare needs are met in the home and that the staff always treat the service users with dignity and respect. Mealtimes are a relaxed social occasion and service users and relatives said that the food was good with plenty of choices. There is also lots of fresh fruit available so that service users could help themselves. There is good contact maintained with family and friends and relatives said they could visit anytime. They also said that they would have no hesitation in making a complaint. Grosvenor Lodge Care Centre DS0000063765.V291497.R01.S.doc Version 5.1 Page 6 The service provides a “homely” environment, a feature the relatives said that they particularly liked. There is little turn over in staff. This means that staff have time to get to know the needs of the service users and therefore are able to provide good care. Service users and relatives spoken to said “the foods good” “the supervisors (staff) are lovely” “I’ve no complaints” “you can spent time in your room if you want” What has improved since the last inspection? What they could do better: Care plans are poor. This needs to be sorted out as there is limited information available to guide staff on what they need to do to meet the service users health, cultural and social needs. There is no activities co-ordinator and currently no programme of activities which means there is little for the service users to do during the day. Grosvenor Lodge Care Centre DS0000063765.V291497.R01.S.doc Version 5.1 Page 7 Service users also commented on the lack of activities and said that all you do is sit around all day. The manager has made a number requests to the company to buy a carpet cleaning machine so that the home can be properly cleaned, a fridge so that certain medicines can be stored safely, and a set of scales, so that staff can make sure that the service users weight can be regularly measured, however, these items have not yet been provided, which means that the health and welfare of the service users may be at risk. The building appears shabby and worn in places. Work needs to be done to improve things to make it a pleasant place for service users to live and there needs to be a programme of maintenance and renewal in place so that everyone can be assured that plans are in place to improve. Bathrooms and WCs should not be used as storage areas. Certain items are inappropriately stored in bathrooms and WC’s which means that service users may not be able to use these rooms safely as they may trip and fall over some of these things. There is a garden, which service users can freely use, however, this has not been looked after and is now overgrown. There is also no sluice facility and this issue has been raised during previous inspections. Staff should be provided with training on the cultural and religious needs of those people from ethnic minority groups so that their needs can be fully met in the home. The complaints procedure also needs to be in languages that those people from ethnic minority groups can understand and in a format so those people with a visual impairment can see it. Staff need to receive regular supervision to ensure the health, safety and welfare of the service users. There are some health and safety issues which need to be sorted, such as bathwater temperatures being too low and potentially uncomfortable for anyone having a bath. The door guards fitted to bedroom doors, so that these can be held open yet close in the event of a fire, need to be checked regularly to ensure that they are working properly and staff must ensure that they carry out safe moving and handling techniques and use the hoist where this has been assessed as being necessary. Grosvenor Lodge Care Centre DS0000063765.V291497.R01.S.doc Version 5.1 Page 8 The environment could be improved for those people with dementia by using signs, so that people can find their way around independently, use of contrasting colours, so that they can see features such as grab rails, and be less confusing with light switches that actually operate the nearest light and the hot and cold signs for taps being the right way around. 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 Lodge Care Centre DS0000063765.V291497.R01.S.doc Version 5.1 Page 9 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 Lodge Care Centre DS0000063765.V291497.R01.S.doc Version 5.1 Page 10 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): 2,3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each service user is being provided with an adequate written contract / statement of terms and conditions with the home, which provides information on the rights and obligations of both parties. This helps to ensure that service users and their representatives are clear about what they can expect from the home. The admissions process ensures that service users’ needs are adequately assessed prior to care being offered. This helps to ensure that service users are offered the right type of care at the home. Intermediate care is not provided at Grosvenor Lodge. EVIDENCE: The manager confirmed that he is currently in the process of issuing each service user with a new contract so that the service users know the terms and conditions of residency. Grosvenor Lodge Care Centre DS0000063765.V291497.R01.S.doc Version 5.1 Page 11 Five service users case files were examined, including those service users who had recently been admitted to the home, and in all but one a full comprehensive assessment had been provided by the placing social worker. In addition to this information the staff had completed the home’s own assessment documentation. Discussion with the manager confirmed that he is in the process of re-assessing each service users care needs to ensure that the home continues to have the correct categories of registration as some of the service users, who have lived at Grosvenor Lodge for a number of years, may have developed a dementia type illness. There is a separate registration category for dementia and the manager said that he would apply to the Commission for a variation to increase the numbers within this category if this was found to be necessary. During the inspection the manager was observed to take a telephone call from a social worker enquiring about respite care. The manager asked for a copy of the social work assessment and explained to the social worker that he would need to carry out his own pre-admission assessment to ensure that the home could meet the prospective service users care needs. As the home offers a short break service advice was offered to include details of this within the home’s brochure. Service users spoken to said that they felt that their needs were met in the home. Grosvenor Lodge Care Centre DS0000063765.V291497.R01.S.doc Version 5.1 Page 12 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 adequate. This judgement has been made using available evidence including a visit to this service. The service users health and social care needs are currently not reflected in the care plans and therefore guidance is not available to ensure that the staff provide continuity of care. Medication is generally administered following recognised good practice, and recording and auditing arrangements are in place, however, there is no secure storage for those medicines which need to be refrigerated, a potential risk to the service users health and well-being. Staff undertake appropriate care practices that help to preserve service users’ privacy and dignity. EVIDENCE: There are a number of assessments carried out on nutrition, pressure sores, moving and handling and infection. In some instances these indicated that the service user was “at medium risk”. However there was no further information in the form of a care plan to advice staff of action needed of them to meet the service users health and social care needs. There were also no monitoring Grosvenor Lodge Care Centre DS0000063765.V291497.R01.S.doc Version 5.1 Page 13 sheets in place for those people for whom adequate food and fluid intake had been identified as a risk and as the home does not possess a set of scales, there is no monthly record of the service users weights. For service users from an ethnic minority group, there was some information in relation to their specific cultural needs. The manager collates information in relation to their special needs. However there was no detailed care plan or information in relation to the activities of daily living within the case file. Service users spoken to said that if they felt unwell the staff would contact the GP straight away and said that they had their “eyes, ears and feet” regularly checked. Relatives spoken to said that the staff always kept them informed of any changes in their relatives health care, including any changes to their medication, however, health care needs were not clearly recorded in the care plan. Although records were maintained of GP and nurse visits there was no follow up information available to inform staff of the outcome of these. Discussion with the manager confirmed that work was currently underway to up-date all of the service users case files using the new company’s standardised care plan format. Medication is handled and administered by senior care staff. Medication rounds take place during the morning, at lunch time, teatime and in the evening. A monitored dosage system is used, whereby the dispensing pharmacist supplies a month of each service users’ medication within a “blister pack”. Printed ‘medication administration records’ are also supplied by the pharmacist. Medication is administered in a discreet manner by senior staff. Discussion with the senior staff confirmed that they were knowledgeable of the different types of medication and what they had been prescribed for. Good clear recording systems are in place with records maintained of all prescribed oral medication, confirming that the service users receive their medication. However, a number of service users use prescribed creams, and although staff confirmed that this is administered to them as per instruction from the GP, a record of this is not maintained. There is no secure storage available for those medicines, such as antibiotics and eye drops, which need to be refrigerated. Discussion with the senior staff confirmed that currently they store such medications in the service users drawer in their bedroom in order to try and keep them cool. They agreed that this was far from satisfactory and despite the manager, on a number of occasions, requesting the provision of a medication fridge from the organisation, this issue has not been addressed. An immediate requirement notification was issued to the manager in relation to this issue. Grosvenor Lodge Care Centre DS0000063765.V291497.R01.S.doc Version 5.1 Page 14 Controlled medication is stored in a separate lockable facility and appropriate records maintained, with two staff signatures, for the administration of this. However, discussion with the senior staff confirmed that although two staff sign the controlled drugs register, it is not always the case that two staff witness this medication being administered. Discussion was held in relation to the use of the code “R” which is used to show that a medication had been refused by a service user. Advice was offered that it is not necessray to use a code for those medications which are “as and when required” as in such a situation a service user is not actually refusing to take their medication, rather it is not required. Observations concluded that the service users right to privacy is respected. This includes the service users being able to spend time in the privacy of their bedrooms. Staff were also observed to carry out personal care tasks in the privacy of bedrooms and bathrooms. Grosvenor Lodge Care Centre DS0000063765.V291497.R01.S.doc Version 5.1 Page 15 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 adequate. This judgement has been made using available evidence including a visit to this service. Arrangements to provide activities and occupation have declined since the last inspection which means that service users opportunities to lead fulfilling lifestyles are limited. Service users are able to maintain family and other contacts to a good degree should they wish. This ensures they do not become socially isolated. Service users are actively encouraged by staff to a good degree in exercising choice and control over their lives which enables the service users to remain independent. Service users receive a good, varied and well presented, choice based, menu. This helps promote their general health and wellbeing, however, the menu needs to developed to meet the diverse cultural needs of all of the people living in the home. EVIDENCE: During this inspection some people spent time sitting in the lounge and conservatory area of the home whilst others, during the warmer weather, Grosvenor Lodge Care Centre DS0000063765.V291497.R01.S.doc Version 5.1 Page 16 spent time sitting in the garden. Staff had time to sit and chat with service users in the afternoon and also joined in with a small group of people in a game of dominoes. Service users spoken to said that they loved to go out shopping for make-up and that staff supported them with this activity. Another service users attends church each week, with her friends, and in these ways links with the local community are maintained. Relatives and service users commented positively on an entertainer that visits the home once a week and also the recent purchase of garden seats. Some of the service users spoken to said that they used to love to garden, however, they did not get sufficient opportunity to enjoy it. Some service users are supported by staff to continue to follow their preferred religious beliefs. However, there was no evidence available of how the home meets the cultural and religious needs of those people from ethnic minority groups. Service users and relatives spoken to also said that there was little for them to do in the home. One service user said they liked to read but as their eyesight had failed was no longer able to do this. There were no talking books available as an alternative. Relatives spoken to said that the service users used to enjoy trips out to the theatre but that there had been no such outings lately. A record is maintained of the few activities that take place in the home, however, entries made indicated that some service users did little other than spend time in the lounge or in their bedroom. The manager confirmed that there is no activities programme at this time, and the post of activities co-ordinator has been vacant for some time, although they are recruiting for this position. Service users were very complimentary about the quality and quantity of the meals. Meals are served in the dining room by the staff to individual’s tastes and preferences. Condiments, such as salt and pepper were on the tables to encourage independence and service users helped themselves to these. The food that was sampled was of good quality, hot and tasty and the lunchtime meal was found to be a relaxed, enjoyable experience. Relatives spoken to said that they could have a meal in the home and at the time of the inspection one service user’s relative spent time with their family member helping them with their meal. There were lots of hot and cold drinks, ice-lollies and chocolates offered to service users during each day of the inspection visit. Fresh fruit was on display and relatives confirmed that this was usual the norm. Although relatives said that facilities were not available so that they could make themselves a cup of tea, they said the staff always offered them refreshments during their visit. Grosvenor Lodge Care Centre DS0000063765.V291497.R01.S.doc Version 5.1 Page 17 The manager is currently reviewing the menus and discussion was held about the need to cater for the needs of those people from an ethnic minority group. Visitors regularly call to the home, and the majority of the relatives spoken to said that they were made to feel welcome and that they could visit their relative in private. It was clear that service users are able to continue their own preferred daily routines and to make their own choices about how they spend their day. One service user spoken to said that she liked to spend her time in the lounge “people” watching and the manager confirmed that the staff open the vertical blinds in this area to enable her to do so. In the home some people enjoy spending time in the privacy of their own rooms as well as some time socialising in lounges. One service user spoken to said that they liked to spend time watching TV in their bedroom after their evening meal and their choice to do so was respected by the staff. Grosvenor Lodge Care Centre DS0000063765.V291497.R01.S.doc Version 5.1 Page 18 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 adequate. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system. Complaints are handled appropriately and the outcomes used to improve the service. However, the complaints procedure is not available in a format suitable for those people who have a visual impairment or for those people from an ethnic minority group. This may prevent some of the service users from expressing their views. Policies and procedures are in place in relation to adult protection, however staff need to receive training in relation to this issue to fully protect service users from abuse and potential harm. EVIDENCE: The home has a complaints procedure which is on display in the service user’s bedrooms. Relatives and service users spoken to, without exception, said that they would have no hesitation in approaching the manager or staff if they had any concerns or complaints. The complaints procedure needs to be made available in a suitable format for those service users who have a visual impairment and those service users from an ethnic minority group. There have been no recorded complaints made to the manager since the last inspection. Discussion with staff confirmed that they were knowledgeable of the different types of abuse and said that they would have no hesitation in reporting a Grosvenor Lodge Care Centre DS0000063765.V291497.R01.S.doc Version 5.1 Page 19 colleague if they witnessed or suspected that abuse had occurred. The staff spoken to said that they treated the service users in the same manner in which they would expect their own elderly relative to be treated. However, in order to further raise staff awareness they need to receive training in this issue. Discussion with the manager and the training plan confirmed that this issue is soon to be addressed. Grosvenor Lodge Care Centre DS0000063765.V291497.R01.S.doc Version 5.1 Page 20 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): 19,20,21,23,24,25&26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Grosvenor Lodge offers service users a homely environment. Although there have been some improvements made to the environment there remain a number of outstanding maintenance issues which must be addressed to ensure that service users are safe and the needs of people with dementia are met. Service users’ bedrooms are accessible so that people can spend time in private, however, bathing and WC facilities are not fully accessible which may prevent people from using these facilities independently. EVIDENCE: In the short period of time the new manager has been in post relatives said that housekeeping arrangements have greatly improved. They said that the home seemed brighter, less cluttered, there were no longer noticeable odours, new bedside tables, “that worked”, had been provided and the poor TV Grosvenor Lodge Care Centre DS0000063765.V291497.R01.S.doc Version 5.1 Page 21 reception, which they had mentioned to staff for some time, had been fixed within days. Discussion with the manager confirmed that certain aspects of the environment have been improved for the service users such as new vertical blinds being fitted to communal areas. A new dishwasher, cooker, microwave and toaster have been provided for the kitchen to ensure that crockery can be cleaned effectively and to assist the cook with catering arrangements. However, despite these improvements, there are a number of outstanding maintenance issues which must be addressed to improve the environment for the people who live there. For example: • There is currently no carpet cleaning machine and there was an odour evident in one service user’s bedroom which cannot be effectively dealt with. • • One bathroom is currently used for the inappropriate storage of furniture, a potential health and safety hazard. Yellow bins, for the hygienic disposal of incontinence pads, situated in WC’s, prevent full access to hand washing facilities and may make these areas difficult to access for those people with mobility needs. There is currently no staff room and as such staff have their breaks in the dining room. This area is used as a smoking area, an issue a number of relatives raised concern about ,which is to be addressed by the manager during the relatives meeting. Bathwater temperatures are tested by staff and records indicated that they measured at 38 degrees centigrade, which is tepid. The garden is overgrown. Wooden chairs in bathrooms are badly worn. • • • • Although maintenance checks are carried out regularly, the records maintained in relation to these did not indicate whether or not the outcome of the check was satisfactory. Plans are in place to create a staff facility, sluice room, replace some carpets, and flooring in en-suites to be cleaned. Information contained within the home’s line manager’s monthly report highlights a number of environmental issues that must be addressed. There is however no maintenance plan in place to indicate when this will occur. Grosvenor Lodge Care Centre DS0000063765.V291497.R01.S.doc Version 5.1 Page 22 Service users and relatives spoken to said that they liked the bedrooms. These areas had been personalised with the service users possessions and during the inspection visits service users were observed to freely access their rooms. Relatives commented on the “homeliness” of Grosvenor Lodge, however, some aspects of the environment may be confusing and disabling for those people with dementia. For example: there is little in the way of signage to help people with dementia find their way around, the hot and cold taps in the bathroom are wrongly labelled, the light switch on the first floor does not activate the overhead light and some of the carpets are heavily patterned, which may be confusing for people who have dementia. Grosvenor Lodge Care Centre DS0000063765.V291497.R01.S.doc Version 5.1 Page 23 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 adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are adequate and enable service users’ needs to be effectively met. Service users are protected by the home’s recruitment procedures, which are implemented to a good standard. This helps to ensure that unsuitable candidates do not gain employment in the home. The way training is planned has improved and this highlights where staff require broader and more frequent training opportunities. This will ensure that the service users personal and health care needs are fully met. There is no training provided for staff on the needs of those people from ethnic minority groups which means that their social, cultural and religious needs cannot be fully met. EVIDENCE: Staff spoken to confirmed that they had achieved either the NVQ level 2 or 3 qualification in care. However they also said that they needed to attend refresher training in relation to health and safety matters such as moving and handling and basic food hygiene. Discussion with the manager and records Grosvenor Lodge Care Centre DS0000063765.V291497.R01.S.doc Version 5.1 Page 24 confirmed that he has carried out an audit of the staff files and arranged for these gaps in staff training to be addressed. Training has been arranged to commence in June 2006 and this is to include training in the area of dementia. There are currently 15 service users living at Grosvenor Lodge and rotas examined confirmed that there are always three staff on duty one of whom is the designated person in charge. There has been very little turnover in staff and relatives said that when the home was without a manager “the girls” kept the home going. Service users spoken to said that they liked the staff and the majority of relatives spoken to said that the staff were friendly and made them feel welcome in the home. Observations confirmed that the staff were knowledgeable of the service users needs and one member of staff has learned key words so that she can communicate to a degree with those service users from ethnic minority groups who are not familiar with the English language. However, discussion was held with the manager of the need to provide staff with training on the needs of ethnic minority groups so that service users cultural and religious needs can be fully met. The manager has obtained copies of the GSCC code of practise and confirmed it is his intention to discuss the contents of this with staff during future team meetings to ensure that they are fully aware of their responsibilities. Staff records indicate that the manager receives an ‘enhanced’ Criminal Records Bureau disclosure prior to staff commencing duties. POVA first checks are also being received. Two references are always obtained prior to employment being offered and an interview is carried out to ensure the prospective employees possess the necessary skills and experience. Grosvenor Lodge Care Centre DS0000063765.V291497.R01.S.doc Version 5.1 Page 25 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 adequate. This judgement has been made using available evidence including a visit to this service. The service users welfare is promoted by a well managed home and robust procedures are in place to safeguard the service users finances. However, there are some areas of potential risk to service users safety, which need to be addressed. Staff are not as yet appropriately supervised. This needs to be addressed to promote and safeguard the best interests of the service users. Internal quality assurance systems have been developed to an adequate level, but with scope for further improvement, to allow the views of service users, relatives and others to be sought and the internal quality management of the service to be progressed. Grosvenor Lodge Care Centre DS0000063765.V291497.R01.S.doc Version 5.1 Page 26 EVIDENCE: All of the relatives and staff spoken to commented favourably on the new manager. As has been discussed earlier they said that since he has been in post they have noticed positive changes in the home. They said that he has an “air of authority” about him and that he is “very hands on”. Observations made during the inspection confirmed that the manager offers a clear sense of direction and the relatives spoken to said that they felt that the morale of the staff has improved. Discussion with the manager confirmed that he has obtained the NVQ level 3 qualification in care and is willing to undertake the Registered Managers Award and NVQ level 4 qualification in care. The manager has held a staff team meeting and agreed it would be beneficial to hold these on a more regular basis so that staff can be kept up-to-date of planned improvements and changes. There is a need for all staff to receive regular supervision, an issue which the manager has begun to address. The manager has recently sent questionnaires to relatives requesting feedback on the service provided and has arranged for a relative/service user meeting to take place. These are positive developments in the area of quality assurance and should continue. The personal allowance records of those people chosen to “casetrack” demonstrated that receipts and double signatures are maintained for all transactions. A recent audit carried out by the manager has shown the system to be working effectively. Advice was offered that it is good practise for auditing purposes to issue a receipt to relatives who have brought money in for their family member. Appropriate records are maintained of accidents and the manager has arranged for a fire officer to visit the home to discuss the current fire procedure. Door guards have been fitted to a number of areas throughout the home which means that fire doors can be safely held open, yet close in the event of a fire. During the inspection visit some door guards appeared to be sticking on the carpets and therefore may be ineffective. There is a need to carry out a regular check of the door guards to ensure that they are working effectively. Discussion with the manager confirmed that at present staff are not using the hoist despite this having been identified as a need in some of the service users assessments. Grosvenor Lodge Care Centre DS0000063765.V291497.R01.S.doc Version 5.1 Page 27 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 1 1 1 X 3 3 X 1 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 2 X 1 Grosvenor Lodge Care Centre DS0000063765.V291497.R01.S.doc Version 5.1 Page 28 Are there any outstanding requirements from the last inspection? Yes 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 OP8 Regulation 15 Requirement The manager must ensure that care plans record all of the support and intervention carried out by staff to meet service users health, social and cultural needs. (Previous timescale not met 20/02/06). The manager must ensure that care plans record all of the support and intervention carried out by staff to meet service users health, social and cultural needs. (Previous timescale not met 20/02/06). A record of service user’s weights must be maintained. Appropriate facilities must be provided for the safe storage of all medication. Two staff must witness the administration of controlled medication. The administration of all prescribed items, including creams and ointments must be recorded on the medication administration record. A range of activities must be DS0000063765.V291497.R01.S.doc Timescale for action 30/08/06 2. OP7 15 30/08/06 3. 4. OP8 OP9 12(1)(a) 13(2) 15/05/06 15/05/06 5. OP12 16(m) 30/06/06 Page 29 Grosvenor Lodge Care Centre Version 5.1 6. OP15 12(4)(b) 7. OP16 22(2) 8. OP18 13 offered to service users and these should be advertised for service users information. The review of the menu must 31/07/06 take into consideration the needs of people from ethnic minority groups. The complaints procedure must 30/07/06 be made available in a format suitable to those people who have a visual disability and those people from ethnic minority groups. The manager must ensure that 31/07/06 all staff have undertaken Protection of Vulnerable adults training. (Timescale not met 01/02/06). Grounds must be kept tidy. The manager must ensure that a programme of the maintenance, renewal and refurbishment of the building is put in place and carried out. (Timescale not met 01/02/06). Damaged or worn out furniture or fittings must be replaced. (Timescale not met 10/02/06). The manager must ensure that sufficient sluicing facilities are available at the home. (Timescale not met 01/03/06). WC and bathing facilities must be accessible to service users. Bathwater temperatures must be maintained at 43 degrees centigrade. Suitable equipment and materials must be available so that the building can be effectively cleaned. (Timescale not met 10/01/06). Suitable equipment and DS0000063765.V291497.R01.S.doc 9. 10. OP19 OP19 23(2)(o) 23 30/06/06 30/06/06 11. 12. OP20 OP21 23(2)(b) 23 31/07/06 30/08/06 13. 14. 15. OP21 OP25 OP26 13(4)( c )&23(3) 13(4)( c) 16 30/06/06 15/05/06 15/05/06 16. OP38 16 15/05/06 Page 30 Grosvenor Lodge Care Centre Version 5.1 materials must be available so that the building can be effectively cleaned. (Timescale not met 10/01/06). 17. OP30 19 The responsible individual must ensure that all staff have undertaken specific training to meet the specialist needs of service users and that records are kept. (Timescale not met 20/03/06). The manager must submit an application to be registered with the Commission for Social Care Inspection. 11/05/06 18. OP31 9 30/05/06 19. OP36 18 All staff must receive appropriate 30/06/06 supervision at least six times per year. (Previous timescales not met 1/7/05&20/02/06) Door guards must be regularly checked and a record maintained of this. Staff must practise safe moving and handling techniques. 30/06/06 15/05/06 20. 21. OP38 OP38 13(4)(b) 13(5) 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. Refer to Standard OP33 OP19 Good Practice Recommendations Quality assurance systems should continue to develop. The environment should be developed, based on current good practice guidelines, for people with dementia. Grosvenor Lodge Care Centre DS0000063765.V291497.R01.S.doc Version 5.1 Page 31 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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 Lodge Care Centre DS0000063765.V291497.R01.S.doc Version 5.1 Page 32 - 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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