Inspection on 17/01/06 for Grove Court Nursing Home

This inspection was carried out on 17th January 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Grove Court Nursing Home 17/04/07

Grove Court Nursing Home 02/09/04

Grove Court Nursing Home 25/05/04

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

CARE HOMES FOR OLDER PEOPLE Grove Court Nursing Home 13-15 Cardigan Road Headingley Leeds Yorkshire LS6 3AE Lead Inspector Michael Smithson Unannounced Inspection 17th January 2006 10:00 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 Grove Court Nursing Home DS0000001343.V271716.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. Grove Court Nursing Home DS0000001343.V271716.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Grove Court Nursing Home Address 13-15 Cardigan Road Headingley Leeds Yorkshire LS6 3AE 0113 2304966 0113 2242840 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) Grove Court Nursing Home Limited Mrs Sheila Anne Hinchcliffe Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37), Terminally ill (1) of places Grove Court Nursing Home DS0000001343.V271716.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th August 2005 Brief Description of the Service: Grove Court is a converted and extended property occupying a prominent position on a main road in a suburb of Leeds. It is close to all the main amenities in the area and adjacent to the bus service. The home provides nursing and residential care to 37 older people. Seven beds have now been designated as providing intermediate care. Accommodation is provided on 3 floors there are 31 single bedrooms and 3 shared bedrooms. The majority of bedrooms have en-suite wc facilities.The ground floor has a choice of sitting areas, and a separate dining room.There are small garden areas to the side and front of the building, which, are well used by the service users in the better weather. Grove Court Nursing Home DS0000001343.V271716.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was the second visit for this year. The first visit was announced and took place on 30 August 2005. Copies of inspection reports for this and previous inspection are available on the CSCI website. The inspection took place over the morning and early afternoon of the 17 January 2006. The focus of the inspection was the environment, however a spot check of the medications and records were undertaken. During the inspection of the environment time was spent chatting to service users and visitors. What the service does well: The environment was maintained in good order. The home was clean and maintained to a good standard of decoration. A good range of facilities are offered including hoists and adaptations. The care documentation is very well organised and informative. Good preassessment is included and the health care needs are met. The service users and relatives are encouraged to contribute to the care planning. The intermediate care beds continue to be very well used. The manager and the staff team have developed very good links with the intermediate care team. A service user guide specifically for intermediate care users has been produced which is good practice. The feedback from service users and visitors during the inspection was very positive. Service users felt the home provided a very good standard of care. They were very complimentary about the manager and the staff team. They felt the home allowed them the opportunity to maintain control of their daily lives and daily routines. The staff allowed them the opportunity to make choices in their daily lives. The visitors spoken too during the inspection were very happy with the care provided. One relative wished to place on record how much he felt his mother had benefited from her time at the home. The service user was very ill and the Grove Court Nursing Home DS0000001343.V271716.R01.S.doc Version 5.0 Page 6 family felt the home was able to meet her needs and provided excellent nursing care. 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. Grove Court Nursing Home DS0000001343.V271716.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 Grove Court Nursing Home DS0000001343.V271716.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. Service users are provided with information to enable them to make an informed choice about the home. The assessment process ensures their needs will be met. EVIDENCE: A detailed statement of purpose and service user guide is available. A separate service user guide for people admitted into the intermediate care beds is provided. The information is due to be reviewed in April this year. There have been no new long stay admissions since the last inspection. However there have been a number of intermediate care admissions. Detailed pre-admission information is provided for all new placements. The records for one service user were checked during the inspection. The reason for the admission was clearly recorded. Grove Court Nursing Home DS0000001343.V271716.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 11. The health and personal care needs of service users are very well recorded and are well met by the staff at the home. The medication administration system is maintained in good order and detailed policies and procedures are available. EVIDENCE: The records for a service user admitted for intermediate care were checked during the inspection. The records were very informative and contained details of the levels of care required. The records include entries from other agencies involved in the rehabilitation of the service user. Regular multi disciplinary review meetings are held to assess the progress made. A spot check of the medication administration system was undertaken. Detailed policies and procedures are provided for the qualified staff who administer the medications. Two trolleys are provided 1 for the ground and middle floor and 1 for the upper floor. Separate secure storage is provided for controlled drugs and medication requiring refrigeration. A number of the service users admitted into intermediate care beds prefer to self medicate. Detailed guidance is provided to facilitate this and lockable storage is provided in the intermediate care bedrooms. Grove Court Nursing Home DS0000001343.V271716.R01.S.doc Version 5.0 Page 10 The drug administration records were kept up to date. The reasons for none administration is recorded in individual service user daily records. However the controlled drug records did not always include a second witness signature. Two signatures must be provided when controlled drugs are administered. If a second qualified member of staff is not available then a member of the care staff can be used. The staff provide an excellent level of support for service users receiving terminal care. The home does have 2 palliative care beds registered as special categories. During the inspection one service user and family members were being supported through the latter stages of a terminal illness. The members of family were very happy with the current levels of care being provided. They wished to place on record how much they appreciated the care and support the staff had provided. Grove Court Nursing Home DS0000001343.V271716.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 Grove Court provides a good range of activities geared to both individuals and small groups. Relatives are encouraged to visit the home. EVIDENCE: A good range of activities is provided. The activities programme is available on a notice board in the main entrance. A number of volunteers help the staff to organise a range of craft activities. A regular newsletter is produced which keeps service users and visitors up to date with planned events, birthdays and other celebrations. The service users are free to organise their own daily routines and receive support from the staff team to enable this. Some service users spoken too preferred to spend time in their bedrooms. Many have televisions, radios and telephones in their bedrooms. Service users can have access to Sky television in their bedrooms. Grove Court Nursing Home DS0000001343.V271716.R01.S.doc Version 5.0 Page 12 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 Not covered at this inspection. EVIDENCE: No complaints have been made since the last inspection. Grove Court Nursing Home DS0000001343.V271716.R01.S.doc Version 5.0 Page 13 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, 22, 23, 24, 25 and 26. The home provides a safe, clean environment, which meets the needs of service users. A good range of specialist equipment is provided. EVIDENCE: A tour of the environment was undertaken during the inspection. The premises were maintained to a good standard of hygiene and decoration. The bedrooms are all single rooms with many having en-suite facilities. The service users and family are encouraged to personalise bedrooms with pictures, ornaments and small items of furniture. The bedrooms are located on each of the 3 floors and are linked with a shaft lift. The manager is also looking at fitting stair lifts to provide additional back up in case of lift failure. A variety of bathrooms are provided around the building. Baths with fixed hoists and wheel in showers are available. Mobile lifting hoists are also provided. Grove Court Nursing Home DS0000001343.V271716.R01.S.doc Version 5.0 Page 14 The laundry is situated in the basement area and is kept tidy and well organised. Two industrial washers with sluicing programmes and a large dryer are provided. All the personal laundry for long stay service users is undertaken on site, however many of the relatives of the intermediate care service users prefer to wash the laundry. The bedding is laundered off site. A handyman is employed to carry out general maintenance and to organise the required health and safety checks. These include the weekly fire alarm tests. Grove Court Nursing Home DS0000001343.V271716.R01.S.doc Version 5.0 Page 15 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 The staffing levels were sufficient to meet the needs of the service users. A very good level of training has been provided to ensure staff had appropriate skills to meet their needs. EVIDENCE: At the time of the inspection the home was fully staffed. The staff team has remained very stable which helps to provide consistency and continuity of care. Good levels of training are provided for both the qualified nurses and the care staff. Very good progress continues to be made with regard to NVQ training. The home exceeds the required 50 of staff achieving NVQ level 2. A number has gone on to complete NVQ level 3, NVQ level 4 and the Registered Managers Award. An annual training plan is in place and is reviewed each year. The training needs of the staff are included following the individual supervision sessions. Grove Court Nursing Home DS0000001343.V271716.R01.S.doc Version 5.0 Page 16 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, 35 and 38. The home is very well run and staff are involved in the decision making process. The financial interests of service users are protected. EVIDENCE: The home is very well managed and all staff are very clear as to their levels of responsibility. The senior managers like to give staff the opportunity to make decisions about how the home operates and allows staff to take responsibility for certain tasks within the home. This gives staff a greater sense of value and job satisfaction. The senior staff set the standards, which they expect to be followed. This gives staff a good role model and leaves them in no doubt as to the standards expected. The home does hold small amounts of money for a number of service users. . A record is kept of the income, expenditure and balance held. A spot check of the monies held was undertaken and was accurate. However it was noted that Grove Court Nursing Home DS0000001343.V271716.R01.S.doc Version 5.0 Page 17 signatures were not provided for all withdrawals. The staff must remember to sign each transaction. A record is kept of the income, expenditure and balance held. Grove Court Nursing Home DS0000001343.V271716.R01.S.doc Version 5.0 Page 18 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 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 2 X X 3 Grove Court Nursing Home DS0000001343.V271716.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP9 OP35 Regulation Reg 13(2) Reg 17(2) Timescale for action Two signatures must be recorded 01/02/06 when controlled drugs are administered to service users. A signature must be provided 01/02/06 each time monies are entered into safekeeping or are spent on service users behalf. Requirement 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 Grove Court Nursing Home DS0000001343.V271716.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Grove Court Nursing Home DS0000001343.V271716.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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