Inspection on 30/04/07 for Grosvenor Lodge Care Centre

This inspection was carried out on 30th April 2007.

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 11/05/06

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 9.30 30 April &1st May 2007 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.V335937.R02.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 Lodge Care Centre DS0000063765.V335937.R02.S.doc Version 5.2 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 www.europeancare.co.uk European Care (England) Ltd Mrs Janice Taylor (acting manager) 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.V335937.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th May 2006 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. The weekly fees payable range from £365 to £479. Grosvenor Lodge Care Centre DS0000063765.V335937.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over two days in April/May 2007 and was a key unannounced inspection. The inspection involved time talking to the acting manager, staff, service users and a visiting relative. A lunchtime meal was taken with the service users and some time was spent around the building, looking at a number of service users bedrooms, the garden and communal areas. A sample of staff records were also looked at. The inspection particularly focussed on four service users with very different needs, known as “casetracking”, and looked at what it was like, from their point of view, living at Grosvenor Lodge. This involved talking with those service users, observing staff’s care practices with them and checking that information obtained from discussion and observation was accurately recorded in the care records. What the service does well: The acting manager always gets a copy of the social work assessment so that she can make sure that the home can meet the needs of anyone moving in. The staff know the residents really well and make sure that they are treated with respect, promoting their dignity and privacy. Relatives said they can visit the home at any time and would have no hesitation in making a complaint if they were unhappy. The majority of people said that the food was good. There has been no turnover in staff, which is good for continuity of care for the service users. Service users said: “Its lovely” “the foods lovely” “I’m comfortable here” “I want to stay here” “the staff are good. Whatever you want you get”. Relatives said: “my relative is happy here” “there are never any smells”. Grosvenor Lodge Care Centre DS0000063765.V335937.R02.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home’s Statement of Purpose (or home’s brochure) needs to accurately tell prospective and current service users about the services and facilities on offer in the home. Everyone needs to be given a copy of the contract, so that they know what the terms and conditions of residency are. Care plans are poor. This needs to be sorted out, as there is not much information available to guide staff on what they need to do to meet the service users care needs. The staff need to carry out risk assessments for anyone who wants to look after their own medicines. This is to make sure they are offered the right help with this. There is little for people to do in the home and therefore opportunities to lead a fulfilled lifestyle are very limited. The building appears shabby and worn in places and although some work has been done this is not enough to improve things to make it a pleasant place for service users to live. There are some things in the home which are not good for people with dementia. For example; some of the carpets are heavily pattered. As a result Grosvenor Lodge Care Centre DS0000063765.V335937.R02.S.doc Version 5.2 Page 7 of this some people with dementia may think that the floor is uneven and therefore have problems walking on it. There is no registered manager. This needs to be sorted out as this is a legal requirement. It is also important so that service users and staff are provided with continuity and a clear sense of direction. The home’s quality assurance process needs to be put into practise to make sure that people’s views are listened to and acted upon and also to check that good standards of care are maintained. The bathwater temperatures need to be checked more regularly. If they get too hot or cold the home must do something about this so that service users can enjoy a bath at a safe comfortable temperature. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Grosvenor Lodge Care Centre DS0000063765.V335937.R02.S.doc Version 5.2 Page 8 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.V335937.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3&6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose does not accurately reflect the services and facilities available within the home and may mislead people when they are choosing where to live. Some service users have not been provided with a written contract / statement of terms and conditions, and therefore they and their representatives may not be 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 ensures that service users are offered the right type of care at the home. Intermediate care is not provided at Grosvenor Lodge. Grosvenor Lodge Care Centre DS0000063765.V335937.R02.S.doc Version 5.2 Page 10 EVIDENCE: There is a detailed Statement of Purpose and Service User Guide which have recently been reviewed and up-dated. However, the Statement of Purpose states that “the physical environment will be maintained”, “care will be provided with regard to current good practise and research” and that there is a housekeeper and maintenance manager. This information does not accurately reflect the home as it has not been well maintained, has not been designed to meet the needs of people with dementia and does not have a housekeeper or maintenance manager. Some of the service users chosen to casetrack had not been issued with a contract. Before admission to the home a needs assessment from the care manager of the placing authority is received. Staff from the home also carry out a pre admission assessment. Relatives said that the acting manager invited them to attend a meeting to discuss and review the assessment before their family member moved into the home on a permanent basis. Grosvenor Lodge Care Centre DS0000063765.V335937.R02.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9&10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users health and social care needs are not reflected in the care plans and therefore guidance is not available to ensure that the staff provide continuity of care. Medication procedures are generally satisfactory, however, some improvements are needed to fully protect the service users. Policies and procedures and staff care practices help to preserve the service users privacy and dignity. EVIDENCE: Some people who use the service do not have a care plan which accurately reflects their current care needs. For example: one service user has needs in relation to mealtimes. Entries made in the daily records often indicated that Grosvenor Lodge Care Centre DS0000063765.V335937.R02.S.doc Version 5.2 Page 12 they have had a “poor diet” yet there was no care plan in place to guide staff on the action they should take to ensure their nutritional needs are met. Care plans have not been regularly reviewed and for one person did not in any way reflect their personal care needs, which have recently significantly deteriorated. Although it had been identified in one person’s care plan that they may, as a result of their dementia, become agitated there, was no further information to advise staff of what they should do when this happens. A tick chart is used to show when people have had a bath or shower. Such records indicate that one service user had not had a bath or shower for as many as eight days. Entries made in daily records such as “ no problems” are meaningless and do not provide any information from which the care plans can be adequately evaluated. Some records had not been dated or signed and therefore it was not possible to determine whether the information was up-to-date. There are a number of assessment tools completed by staff each month. These cover a range of health care needs such as nutrition, pressure sores, and moving and handling. None of the current service users have a pressure sore. The home makes referrals to community health services on behalf of service users when necessary including GPs, district nurses and chiropodists. Relatives said that they were involved in the care of their family member and that staff always informed them if there had been any changes to their health care needs. 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 medication, confirming that the service users receive their medication. Grosvenor Lodge Care Centre DS0000063765.V335937.R02.S.doc Version 5.2 Page 13 One service user said they looked after some of their medication and where able, staff encourage people to do so. However, risk assessments and risk management strategies are not routinely undertaken to show how people are able to safely maintain independence in this area. One service user had refused their medication for a number of months. Senior staff said that a previous manager had discussed this with the GP, over a year ago, and that the family were fully aware of the situation. However, there was no written information to show what decisions had been made, by whom and why. Some of the service users have been prescribed creams, however, it was not always clear where this was to be applied, as this information had not been recorded on the medication administration record. A small number of controlled medication is held in the home in a separate controlled drugs cabinet. A controlled drugs register is maintained and a brief audit of the medication held in stock corresponded to the records. The service users and staff have formed good relationships with each other with the interaction being professional, friendly and based on mutual regard. Staff working with people with dementia were observed being kind, friendly and attentive to them. People are able to spend time in the privacy of their bedrooms and there is a telephone available if people wish to make calls in private. Grosvenor Lodge Care Centre DS0000063765.V335937.R02.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14&15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The range of activities available to service users is poor and therefore opportunities to lead a fulfilling lifestyle 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 exercise choice and control over their lives which enables them to remain independent. Service users receive a good, varied choice based menu which, helps to promote their general health and wellbeing. EVIDENCE: There is no activities co-ordinator and, despite attempts to recruit a suitable person, this position remains vacant. Other than a weekly crafts session and a singer/entertainer who visits, there is little going on in the home. Service users spend their days sitting in the lounge watching TV or sleeping or sitting Grosvenor Lodge Care Centre DS0000063765.V335937.R02.S.doc Version 5.2 Page 15 in the dining area. There was little to show how people’s religious needs are met, other than a monthly church service. There are no trips out further away, although staff do accompany people out into the local community and involve some people in table games in the afternoons. Relatives and service users commented that this was an area that they felt could be improved. Relatives said that they are able to visit their family members at any time in the home and this was observed on the day of the inspection. It was clear that service users are encouraged to make their own choices. Service users are able to choose what personal possessions to bring to the home, what to eat at mealtimes and how to spend their day within the limitations mentioned in the last paragraph. There is a choice of main meal and a cooked breakfast is available each morning. The majority of people commented favourably on the quality of the meals provided and throughout the inspection visits service users were offered drinks and snacks in between meals. The lunchtime meal was relaxed and unhurried with people able to eat at their own pace. The tables were nicely presented with tablecloths and condiments so that people could help themselves. The acting manager is currently developing a picture menu to further help those people with communication needs make an informed choice about what to eat. Grosvenor Lodge Care Centre DS0000063765.V335937.R02.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16&18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system so people know that their views will be listen to and acted upon. Policies, procedures and staff training ensure that the service users are protected from abuse and potential harm. EVIDENCE: There is an up-dated complaints procedure which has been placed in everyone’s bedroom. It is written in plain English and is easy for people to understand. Everyone said that they knew how to make a complaint and would have no hesitation in approaching the acting manager or any of the staff if they had any concerns. There have been no complaints since the last key inspection. Arrangements are in place for all staff, including the acting manager, to undertake the local authority “alerter” training. A policy on prevention of abuse is available in the home to guide staff on what to do should they witness or suspect that this has taken place. There has been one adult protection meeting since the last inspection and discussion with those involved confirmed that it had been managed well. Grosvenor Lodge Care Centre DS0000063765.V335937.R02.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21&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, not all bathing facilities are fully accessible and a potential hazard to service users. EVIDENCE: It is disappointing to note that there continues to be no maintenance or refurbishment programme for the building despite requests being made for this during previous inspections. Essential maintenance appears only to be Grosvenor Lodge Care Centre DS0000063765.V335937.R02.S.doc Version 5.2 Page 18 addressed when a problem has arisen and even then it is not addressed within a reasonable timescale. For example: during a random inspection in January 2007 records showed that in August 2006 essential electrical work needed to be undertaken. This work commenced on the day of this key inspection, some nine months later. A number of the fixtures and fittings need replacing and the décor needs upgrading. For example: • Although attempts have been made by staff to re-decorate one bathroom, the design is not age appropriate and may “frighten” some people with dementia who have difficulties with perception and prevent them from using this area. One bathroom continues to be used for the inappropriate storage of furniture, a potential health and safety hazard. The flooring in the en-suite WC’s is very dirty in appearance, despite them regularly being cleaned. The handrails by the staircase are chipped and worn. Some of the carpets in communal areas are heavily pattered and may cause difficulties for some people who have dementia to walk on as they may perceive the floor to be uneven. There is no sluice facility. The laundry floor and walls are old and worn. The hot water tap was also not working in this area. The carpet outside the laundry is also old and worn and the wallpaper in this area is peeling off the walls. There is still no staff room. • • • • • • • • Relatives commented, however, that there were never any unpleasant odours in the home when they visited. Staff demonstrated an awareness of the prevention of cross infection by using protective gloves and aprons where appropriate and policies and procedures are available to guide staff on the safe disposal of clinical waste. Grosvenor Lodge Care Centre DS0000063765.V335937.R02.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29&30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are adequate and staff are generally suitably trained to meet the health and welfare needs of the service users. Staff recruitment procedures protect the service users. EVIDENCE: Relatives said that they were satisfied with the care their family member receives and that most of the staff were friendly. There are always three members of staff on duty, including a senior, from 8.00am until 10.00pm. There are 30 domestic hours allocated to the home per week and 45 catering hours. There has been no turnover in staff, which is good for continuity of care. The majority of staff have completed the NVQ level 2 qualification in care and some have gone on to complete the NVQ level 3. One member of staff has completed “Yesterday Today Tomorrow” facilitator training, (training developed by the Alzheimer’s Disease Society for staff who work with people who have dementia), which means she is able to deliver this training to the rest of the Grosvenor Lodge Care Centre DS0000063765.V335937.R02.S.doc Version 5.2 Page 20 staff in the home. She is soon to undertake refresher training to enable her to implement this. The acting manager recognises the importance of training and is in the process of delivering a programme that meets statutory requirements, including moving and handling, food hygiene, fire safety and first aid. There have been no new staff recruited since the last inspection. Grosvenor Lodge Care Centre DS0000063765.V335937.R02.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36&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 and staff have not benefited from continuity of management and the procedures in place for safeguarding service users finances are not sufficiently robust to fully protect people. There are also some areas of potential risk to service users safety which need to be addressed. Staff have begun to be appropriately supervised and this will help to promote and safeguard the best interests of the service users. The quality assurance system has not been fully implemented to ensure that and home is run in the best interests of the service users. Grosvenor Lodge Care Centre DS0000063765.V335937.R02.S.doc Version 5.2 Page 22 EVIDENCE: The current acting manager has been in post since February 2007. She has several years experience of managing a care home and is a qualified nurse. However, this is only a temporary arrangement and the home has been without a registered manager for a significant period of time. The acting manager confirmed that interviews were due to take place. Staff said that they had recently had a supervision with the acting manager. The acting manager has recently sent questionnaires to relatives requesting feedback on the service provided. However, there has not been a relative/service user meeting for some time. The acting manager has begun to carry out her own internal audit’s to identify gaps in service provision. This has recently included an audit of the care plans. This must continue to include all aspects of service provision. The personal allowance records of those people chosen to “casetrack” demonstrated that receipts and double signatures are maintained for most transactions. However, one receipt could not be found for one purchase made. Discussion with senior staff indicated that recently a service user, who has dementia, had given another service user some money, money which staff were not aware was in the building. Although the staff had put this money in the safe for safekeeping there was no record of this. The incident had also not been reported to the acting manager. Staff were observed following health and safety policies and procedures throughout the day and demonstrated awareness of these issues so that service users were supported safely and protected from potential harm. An appropriate record of accidents is maintained and the acting manager has recently carried out a thorough fire risk assessment for the building. Staff carry out a monthly check of bathwater temperatures. However, records showed that the bathwater had been as cool as 33 degrees centigrade and in one sink had been as hot as 50 degrees centigrade. There was no evidence available to show that these issues had been reported and subsequently addressed. There are detailed health and safety risk assessments which cover a wide range of activities in the home and the potential hazards associated with these. The manager agreed, however, that as these were completed in June last year they would soon need to be reviewed. Grosvenor Lodge Care Centre DS0000063765.V335937.R02.S.doc Version 5.2 Page 23 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 2 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 1 2 1 X X X X 1 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 x 2 3 x 2 Grosvenor Lodge Care Centre DS0000063765.V335937.R02.S.doc Version 5.2 Page 24 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 OP1 Regulation 4 Requirement Timescale for action 31/07/07 2. OP2 5(1)(b) 3. OP7 15 The Statement of Purpose must provide accurate information so that people can make an informed choice about where they want to live. All Service users must be 31/07/07 provided with a copy of the contract so that they know the terms and conditions of residency. Care plans must record all of the 31/07/07 support and intervention carried out by staff to ensure that the service users care needs are fully met. (Previous timescale not met 30/08/06). Risk assessments and risk management strategies must be completed for those service users who look after their own medication. Records must be maintained to show what decisions have made and by whom in relation to those service users who regularly refuse to take their prescribed medication. This is to ensure DS0000063765.V335937.R02.S.doc 4. OP9 13 (2) 31/07/07 Grosvenor Lodge Care Centre Version 5.2 Page 25 that service users are fully protected. 5. OP12 16(m) A range of activities must be offered to service users to ensure that opportunities to lead fulfilling lifestyles are provided. (Timescale not met 30/06/06&31/05/07). All parts of the home must be maintained in a good state of repair. In order to address this issue 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 & 30/06/06). Damaged or worn out furniture and fittings must be replaced in order to provide a pleasant environment for service users. (Timescale not met 10/02/06&31/07/06). Bathing facilities must not be used as a store area to ensure that service users can safely use these areas. The manager must ensure that sufficient sluicing facilities are available at the home so that items can be hygienically cleaned. (Timescale not met 01/03/06 & 30.8.07). The provider must recruit a suitably qualified manager and submit a registration application to the Commission without further delay. This is to ensure continuity for the staff and service users. The quality assurance process must be fully implemented so DS0000063765.V335937.R02.S.doc 31/07/07 6. OP19 23 31/05/07 7. OP20 23(2)(b) 31/07/07 8. OP21 13(4) (c ) 31/05/07 9. OP26 23(2)(k) 31/07/07 10. OP31 9 30/06/07 11. OP33 24 31/07/07 Page 26 Grosvenor Lodge Care Centre Version 5.2 12 OP35 13 OP38 that service users know that their views will be listened to. 13(6) The procedures in place in relation to service users money must be improved to fully safeguard people from financial abuse. 13 (4)( c ) The frequency of checks of the bathwater temperatures must be increased and appropriate action taken as necessary to ensure service users can enjoy a bath at a safe comfortable temperature. 31/05/07 31/05/07 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 OP7 OP19 Good Practice Recommendations All written information should be dated and signed. The environment should be developed, based on current good practice guidelines, for people with dementia. Grosvenor Lodge Care Centre DS0000063765.V335937.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South Shields Area Office 4th Floor St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Grosvenor Lodge Care Centre DS0000063765.V335937.R02.S.doc Version 5.2 Page 28 - 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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