Inspection on 07/11/05 for Grosvenor Lodge Care Centre

This inspection was carried out on 7th November 2005.

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 11/05/06

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 Mr Steve Tuck Unannounced Inspection 1:00 7/18 November and 2 December 2005 th nd 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.V253365.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Grosvenor Lodge Care Centre DS0000063765.V253365.R01.S.doc Version 5.0 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.V253365.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12/7/05 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.V253365.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over three days and was a scheduled unannounced inspection. The inspection process involved spending time talking to a number of the people who live in the home as well as the manager and staff. A sample of records were examined including care plans. Questionnaires were available for service users and their families to give their views about the home and some relatives gave their views by letter. A tour of the building took place which included all communal areas and a selection of service users bedrooms. Service users were joined for lunch and observations were made of the support the staff offered to service users at lunchtime and throughout the day. The judgements made are based on the evidence available on the day of the inspection. What the service does well: Service users needs are assessed prior to moving to the home to ensure that the home is the right place for them to live and that their needs can be met there. Staff and the manager treat service users with dignity and respect and they encourage family and friends to visit. The atmosphere at the home is warm and welcoming. Staff turnover is low so they get to know service users well and clearly enjoy each others company. Relatives are complimentary about the home. One said ‘I like a say in what goes on in (my mothers) day-to-day life. The staff let me do this without making me feel as if I am interfering. I feel both welcome and involved every time I visit.’ Service users like the meals, which offer them a balanced diet. The temporary manager has began to address the issues identified in the previous report and has worked hard to provide leadership and direction for the staff team. Grosvenor Lodge Care Centre DS0000063765.V253365.R01.S.doc Version 5.0 Page 6 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 Lodge Care Centre DS0000063765.V253365.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Grosvenor Lodge Care Centre DS0000063765.V253365.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 A range of information is available and trial visits can be made which enable service users to make a fully informed choice about where they would like to live. Each service user’s needs are assessed prior to their move to the home and periodically thereafter. This will help ensure that each service user’s needs are met at the home and inappropriate admissions avoided. The home does not provide intermediate care. EVIDENCE: The Service User Guide is used by the manager to provide potential customers and their relatives with easily understandable information on the facilities available to them at the home. This includes information about how to make a complaint. Each service user has an assessment of their needs carried out prior to their admission to the home. These are completed by the social worker, the homes manager and senior staff or by both and are carried out to make sure that the home is suitable for meeting the needs of service users who are living there. Records indicate that the manager has also involved other health and social care personnel where specialist assessment has been required. Grosvenor Lodge Care Centre DS0000063765.V253365.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 and 10 The measures staff take to support the health and personal care needs of service users is not fully recorded in the individual plan of care therefore making it difficult for staff to consistently meet their needs. Staff have a friendly and respectful approach towards service users. This helps to empower service users and to give them control over their lives. Systems for storing and administering service users medication are in place, which usually ensure that service users get the treatment which they have been prescribed. EVIDENCE: A random sample of service users records were examined which indicated that staff and the manager have worked together to introduce a new format for care planning at the home. However this work is yet to be completed so that all service user plans adequately describe the actual support and intervention which staff are currently carrying out. Grosvenor Lodge Care Centre DS0000063765.V253365.R01.S.doc Version 5.0 Page 10 The manager has developed a risk assessment process which describes the risks undertaken by service users for example to promote or maintain their independence. And intends to put this process into practice so that the assessments and risk reduction measures currently taking place are shared agreed and recorded in service user records. All service users spoken to commented positively about the service they receive from care staff and how they felt supported by them. They confirmed that they were treated with dignity and respect by staff and the manager. The manager and senior staff described how they monitor the healthcare needs of service users and ensures that involvement of healthcare professionals e.g. district nursing staff and general practitioners takes place, should these services be required. Due to their levels of need, service users are not able to administer their own medicines, and designated staff therefore assist in this area. Staff at the home have undergone training in relation to medication administration. Medication is securely stored. However a mathematical error was noted which was subsequently traced and resolved. Grosvenor Lodge Care Centre DS0000063765.V253365.R01.S.doc Version 5.0 Page 11 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, 14 and 15 A selection of social activities are provided enabling service users to make positive choices about how they spend their day and friends and families are encouraged and involved too so that they are able to maintain control over their lives. Service users are offered a varied menu with wholesome food, which promotes their health and well being. EVIDENCE: The manager has appointed an activity co-ordinator who has successfully engaged service users in a programme of activities throughout the week. As an accomplished performer he has also provided entertainment at the home which have proved to be popular with service users and families. The relatives and friends of service users are welcomed to the home and encouraged to visit. The manager makes himself available for one to one meetings on a regular basis to discuss individual issues or points of view. All service users spoken to commented that they liked the food provided. They said that they were given a choice of main meal, and that there was always sufficient. The cook also successfully prepares specialist meals for example for those people of a minority ethnic culture. Menus and stock indicate that fresh Grosvenor Lodge Care Centre DS0000063765.V253365.R01.S.doc Version 5.0 Page 12 ingredients are used which includes good quality seasonal vegetables. Staff were observed asking service users about their choice of meal, size of portion etc to ensure that the element of choice for service users is always followed. And the cook demonstrated that she is knowledgeable of service users dietary preferences. Staff were around during the meal to offer support and assistance where needed and this made the meal time a relaxed and unhurried experience for service users. Grosvenor Lodge Care Centre DS0000063765.V253365.R01.S.doc Version 5.0 Page 13 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 and 18 Service users are able to make complaints if they wish and are confident that these will be properly responded to fairly and quickly by the manager. The home has arrangements in place which should protect service users from abuse but staff need to know how and when to use them. EVIDENCE: Although there have been no complaints since the previous inspection, the manager demonstrated that a procedure is in place, which ensures that service users and their families are able to make complaints and that these are taken seriously. All service users have a copy of the home’s complaints procedure, which is available in each room. Service users commented that they are confident that any complaints made would be acted upon. Although there have been no instances or allegations of abuse at the home, specific procedures, which link to the statutory responsibility of the local authority, are in place. Staff have signed to indicate that they have read the homes protection of vulnerable adults procedures however training for some has not yet taken place. Grosvenor Lodge Care Centre DS0000063765.V253365.R01.S.doc Version 5.0 Page 14 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 Grosvenor Lodge offers service users a homely environment in which to live. However there were a number of maintenance issues, which need to be addressed to ensure that service users can live in a safe, comfortable and hygienic environment which protects them from unnecessary illness or an accident. EVIDENCE: All communal areas and some service users bedrooms were viewed during the inspection. Service users said that they liked their rooms and almost all had personalised them with photographs and other furniture or possessions. However some of the homes furnishings in some of the bedrooms is damaged or worn. Some service users prefer to live in their rooms and have taken steps to adapt their rooms for this purpose with additional furniture, TV’s etc. Grosvenor Lodge Care Centre DS0000063765.V253365.R01.S.doc Version 5.0 Page 15 A number of service users like to have their bedroom doors open so the manager has arranged for devices which are linked to the fire alarm system to be fitted so that this is achieved safely. Some rooms have received redecoration since the last inspection which has helped to create a more comfortable atmosphere at the home. However a more thorough refurbishment is required which would ensure that all individual and communal areas in which service users live are suitable for them. The manager reports that a thorough refurbishment of the home is planned. Strategies in place to manage unpleasant odours in the home have been limited because the home does not currently have cleaning equipment available on site making it difficult to maintain areas which require frequent cleaning. The kitchen dishwasher was broken so effective infection control is difficult to achieve. The home’s central heating boiler has developed a fault and does not work reliably although the manager has successfully arranged for repairs to take place on several occasions in recent months. Grosvenor Lodge Care Centre DS0000063765.V253365.R01.S.doc Version 5.0 Page 16 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 and 30 The deployment and number of staff on all shifts ensures that at all times service users are supported by an experienced group of staff. However recruitment arrangements do not yet ensure that staff are safe to work with vulnerable people and staff training does not ensure that staff have the necessary skills to meet the needs of service users. EVIDENCE: There are sufficient staff available to meet the needs of service users at the home. Staff were noted to spend some time with service users, listening to their opinions and experiences and taking part in discussions. There is a low turnover of staff at the home so they can demonstrate longstanding relationships and they are knowledgeable of service users personal histories and needs. Service users said that they liked the opportunity to talk with staff. A number of staff are currently undertaking NVQ at levels 2 and 3. The manager is currently taking steps to ensure that sufficient numbers of staff that is, at least 50 , have completed their level 2 training. European Care have recently introduced a training strategy at the home so that staff can obtain the specialist and statutory training they need to carry out their work. The manager has recently recruited one member of staff without having a full CRB carried out prior so that their suitability to work with vulnerable people could not be assessed. Grosvenor Lodge Care Centre DS0000063765.V253365.R01.S.doc Version 5.0 Page 17 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, 32, 33, 35 and 38 Service users do not benefit from a staff team who have effective leadership, supervision and direction in meeting their care needs. Service users are successfully assisted by the home to manage their day-today expenditure so that they retain control of their finances and retain their independence. There are not yet arrangements in place which make sure that the quality of life experienced by service users at the home is improved. Grosvenor Lodge Care Centre DS0000063765.V253365.R01.S.doc Version 5.0 Page 18 EVIDENCE: Following this inspection the temporary manager left the home to take up another position within the company. Further temporary arrangements have been put in place however this home has been without a permanent manager who has been assessed by the Commission as being fit to carry out this role, for over 16 months. Service users manage their day-to-day finances and are encouraged and supported by staff. Detailed and accurate records are kept which matched the amounts securely held at the home. The manager has started to have regular supervision meetings with staff so that their work performance can be developed. Service users and their families are complimentary about the home, the manager and staff however formal arrangements to ensure that the quality of the service is improved and that service users views are sought, have not yet been introduced. New policies and procedures are available which, once put in practice, should enable the home to improve and enhance the quality of service experienced by people living there. Grosvenor Lodge Care Centre DS0000063765.V253365.R01.S.doc Version 5.0 Page 19 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 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 2 X X 2 2 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 2 1 X 3 2 X 2 Grosvenor Lodge Care Centre DS0000063765.V253365.R01.S.doc Version 5.0 Page 20 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 OP7 Regulation 15 Requirement The responsible individual must ensure that care plans record all of the support and intervention carried out by staff to meet service users needs. (Previous timescale 1.6.05) The responsible individual must ensure that where service users are taking risks their care plan details the measures taken to minimise the likelihood of harm. The responsible individual must ensure that all staff have undertaken Protection of Vulnerable adults training. The responsible individual must ensure that a programme of the maintenance, renewal and refurbishment is put in place and carried out. (Previous timescale 1.6.05). The responsible individual must ensure that sufficient sluicing facilities are available at the home. Damaged or worn out furniture or fittings must be replaced The responsible individual must ensure that the home has DS0000063765.V253365.R01.S.doc Timescale for action 20/02/06 2 OP7 13 11/01/06 3 OP18 13 01/02/06 4 OP20OP19 OP24 23 01/02/06 5 OP21 23 01/03/06 6 7 OP24 OP25 16 23 10/02/06 01/01/06 Grosvenor Lodge Care Centre Version 5.0 Page 21 8 OP38OP26 16 13 9 OP26OP38 13 10 11 OP28 OP29 18 17 12 OP30 19 13 OP31OP32 9 14 OP33 24 15 OP36 18 reliable heating. The responsible individual must ensure that suitable equipment and materials are available so that the building can be effectively cleaned. The responsible individual must ensure that catering utensils and crockery can be hygienically cleaned. At leas 50 of care staff must have achieved NVQ in Care at level 2 or higher. The responsible individual must ensure that Department of Health guidance regarding the employment of staff in exceptional circumstances, without a full Criminal Records Bureau check, is followed. 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. The responsible individual must ensure that a suitable manager is appointed at the home and an application for registration with the Commission is made. The responsible individual provider must ensure that arrangements are in place for the review and improvement of the quality of care provided which include feedback from service users and their relatives / visitors. All staff must receive appropriate supervision at least six times per year. (Previous timescale 1/7/05) 10/01/06 10/01/06 31/12/05 31/12/05 20/03/06 20/02/06 20/03/06 20/02/06 Grosvenor Lodge Care Centre DS0000063765.V253365.R01.S.doc Version 5.0 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Grosvenor Lodge Care Centre DS0000063765.V253365.R01.S.doc Version 5.0 Page 23 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.V253365.R01.S.doc Version 5.0 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!