Inspection on 10/10/05 for Grove Court (Woodbridge)

This inspection was carried out on 10th October 2005.

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 (Woodbridge) 23/05/07

Grove Court (Woodbridge) 23/05/06

Grove Court (Woodbridge) 13/07/05

Grove Court (Woodbridge) 22/11/04

Grove Court (Woodbridge) 12/05/04

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

CARE HOMES FOR OLDER PEOPLE Grove Court (Woodbridge) Beech Way Woodbridge Suffolk IP12 4BW Lead Inspector Tina Burns Announced Inspection 10th October 2005 9.30 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 (Woodbridge) DS0000024401.V257969.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 (Woodbridge) DS0000024401.V257969.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Grove Court (Woodbridge) Address Beech Way Woodbridge Suffolk IP12 4BW 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) 01394 446500 01394 446501 ralphael.perez@elizabethfirm.org.uk Elizabeth Finn Homes Limited Mr Raphael Perez Care Home 61 Category(ies) of Old age, not falling within any other category registration, with number (61) of places Grove Court (Woodbridge) DS0000024401.V257969.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home has approval to care for one named service user (as per application for variation dated 19/8/05) under the age of 65 with palliative care needs. 13th July 2005 Date of last inspection Brief Description of the Service: Grove Court is owned by Elizabeth Finn Homes and is registered as a care home with nursing, accommodating a maximum of 61 older people. The home is located on the outskirts of Woodbridge town centre. To fit the slope of the land, the home is built on three floors, lower, middle and upper. The main entrance is located on the middle floor at the front of the building, with appropriate signage and parking nearby. Internally the building is modern and attractive in design, with communal and private accommodation at all levels. All bedrooms are single accommodation with en suite toilets, with some having en suite shower facilities. There are two dining rooms, a number of lounges including an activities lounge, library, physiotherapy and sensory rooms, hairdressing salon and shop. Grove Court (Woodbridge) DS0000024401.V257969.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a routine announced inspection that took place on a weekday between the hours of 9.30am and 4.30pm. The manager was present throughout the day and fully contributed to the inspection process. The process included collecting information from the homes pre inspection questionnaire, residents and relative’s surveys, and speaking with the manager, residents and staff. A tour of the premises was made and the inspector examined a variety of policies, procedures and documents including three staff files and three residents’ records. What the service does well: What has improved since the last inspection? What they could do better: Generally the home has good systems in place to protect residents including thorough recruitment practices. However, the manager needs to ensure that Grove Court (Woodbridge) DS0000024401.V257969.R01.S.doc Version 5.0 Page 6 long serving members of staff have the documentation in place that is required, by legislation, to safeguard residents. It was also apparent that the high dependency of some residents has altered the effectiveness of the staff: resident ratio. The home should undertake a review to ensure that there are appropriate numbers of staff on duty to meet residents needs at all times. 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 (Woodbridge) DS0000024401.V257969.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 (Woodbridge) DS0000024401.V257969.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, 2, 3 and 4. Prospective residents can expect to have detailed information about the home and a thorough assessment of their needs prior to admission. EVIDENCE: The home had a Statement of Purpose and Service User Guide available for prospective residents and their families. The Statement of Purpose contained up to date and comprehensive information about the homes aims and objectives, philosophy of care, services and facilities and terms and conditions. Resident’s records contained signed Residents Agreements and included detailed and thorough assessments of need undertaken prior to admission. Assessments also included criteria for determining the level of care required according to the individual’s complexity of needs. Staff records demonstrated that the home employs a mix of qualified and trained staff that have the experience and skills to deliver the services and care which the home offers to provide. Grove Court (Woodbridge) DS0000024401.V257969.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, 8 and 10. Residents can expect to have their personal, health and social needs met and their privacy respected. EVIDENCE: Three residents care plans were seen and reflected the needs identified in the pre admission assessments. The elements covered in each care plan included; maintaining a safe environment, communication, breathing, eating and drinking, elimination, personal cleansing and dressing, controlling body temperature, mobility, work and play, privacy and dignity, sleeping and dying. Each element highlighted the individual’s needs in that area and the tasks that needed to be undertaken to meet those needs. Care plans seen had been regularly reviewed and updated where necessary. There was good evidence that the home promotes and maintains residents health. As well as detailed care plans that identified specific health care needs (for example, controlled diets, allergies, palliative care) resident’s records included clinical assessments, nutritional screening records, waterlow pressure sore prevention records, and physiotherapy assessments. There was also Grove Court (Woodbridge) DS0000024401.V257969.R01.S.doc Version 5.0 Page 10 evidence that the home worked closely with GP’s and enabled residents to access appropriate medical facilities and appointments. All residents have the privacy of their own rooms with en suite facilities. On the day of inspection staff were observed interacting with residents politely and respectfully. Twenty-five residents survey forms were completed and returned and all indicated that residents felt well cared for and that their privacy was respected. Grove Court (Woodbridge) DS0000024401.V257969.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, 13, 14 and 15 Residents can expect to be offered a variety of social and leisure opportunities and be helped to exercise choice and control over their lives. EVIDENCE: The home employs two coordinators that organise a range of activities for residents to choose from. A list of the activities arranged for the month of October was displayed on the notice board in the foyer. The types of activities arranged included musical movement and appreciation, games and creative activities, videos and topical talks, tea parties and pub lunches, shopping trips and home shopping, mobile and home library, hairdressing and manicures and religious services and holy communion. On the day of inspection the home had an ‘apples and pears’ morning and residents were seen enjoying the wares of a local supplier. Residents choosing not to participate in the activity were in their own rooms or using other communal areas throughout the home. During the inspection three residents were spoken to in the privacy of their own rooms. The rooms seen were personalised with the occupant’s own possessions including small items of furniture, ornaments and personal effects. Residents spoken with confirmed that their visitors were always made welcome and some were anticipating the arrival of visitors on the day of inspection. Grove Court (Woodbridge) DS0000024401.V257969.R01.S.doc Version 5.0 Page 12 The manager confirmed that the home does not manage resident’s financial affairs. Where residents were unable to look after their own money the home held small amounts of cash for safe keeping on their behalf. An outside company was contracted to provide the catering for the home. Resident’s surveys indicated mixed feelings amongst the residents concerning the standard of meals. Comments made to the inspector on the day of inspection were also varied. The manager confirmed that there had been several complaints in recent weeks about the food, the complaints had been recorded and responded to appropriately by the manager in consultation with the catering company. The autumn menu was examined and included a good variety of healthy meals. There was evidence that residents had been consulted about the menus at residents meetings and through the homes quality assurance process. The manager and staff spoken with confirmed that there were always options to the main menu and the kitchen supplied meals for residents on special diets. On the day of inspection residents were observed in the dining area at lunchtime, others were taking their meals in their own rooms. The dining room was light and airy, pleasantly furnished and decorated. The lunchtime menu was fisherman’s pie with flaky pastry or cheese and spinach cannelloni with buttered peas, carrots and creamed potatoes, followed by spiced apples and plums with custard. The food looked nicely presented and smelled appetising. Grove Court (Woodbridge) DS0000024401.V257969.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 Residents can expect to have their complaints listened to, taken seriously and acted upon and be assured that systems are in place to protect them from abuse. EVIDENCE: The complaints procedure is included in the homes Statement of Purpose and Service User Guide. It details the stages and timescales of the complaints process and includes the address and telephone number of the Commission For Social Care Inspection. The records of complaints made since April 2005 were examined during the inspection. There were seven complaints in all, with evidence that the issues raised had been appropriately investigated and responded to. The home had the Suffolk Inter Agency Policy and Procedures For The Protection Of Vulnerable Adults in place. The manager confirmed that they had undertaken the training for trainers course so that they could deliver training to the staff group in house. Staff files and training and development plans confirmed that staff receive the associated training and residents comment cards indicated that they feel safe living at The Grove. Grove Court (Woodbridge) DS0000024401.V257969.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, 22 and 26. Residents can expect to live in safe and comfortable surroundings with their own possessions around them. EVIDENCE: On the day of the inspection the home was clean, hygienic and well maintained. The environment was attractive, communal areas pleasantly decorated and fitted with comfortable, domestic in style furniture and fittings with all areas carpeted. All residents had their own single bedrooms with en-suite facilities. Three residents were spoken with in the privacy of their own room’s; the rooms were comfortable and personalised with resident’s own furnishings and personal belongings. Each room had call systems in place for the residents use. Grove Court (Woodbridge) DS0000024401.V257969.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, 28, 29 and 30 Residents can expect their needs to be met by trained and competent staff, however they cannot be assured that their needs will be attended to promptly. The homes current recruitment practices are thorough but the lack of some documentation for long serving staff does not ensure residents are entirely protected. EVIDENCE: The pre inspection questionnaire and staff rotas confirmed that the home employs a total of twenty registered nurses, forty-nine care staff and five ancillary staff. Each shift, including nights, had a minimum of two registered nurses on duty. There were also eleven carers on early shifts, nine on late shifts and four at night. The manager and deputy manager were supernumerary. Twenty-six care staff had completed NVQ level 2 or above and six were currently undertaking it. Residents and staff spoken with on the day of inspection said that staff were always very busy and that at peak times residents would often have to wait some time for attention. The manager confirmed that there had been an increase in the dependency levels of residents and that was having an effect on the staff: resident ratio. Records seen and staff spoken with confirmed that staff training is ongoing and included First Aid, Health and Safety, Protection of Adults, Managing incontinence, Food Hygiene, Dementia and Confusion, Fire and Safety, Grove Court (Woodbridge) DS0000024401.V257969.R01.S.doc Version 5.0 Page 16 Customer care and Complaints, Moving and Handling, Palliative Care, Dining with Dignity, Care of the Dying, Diabetic Care, Tissue Viability and Physiotherapy. There was evidence that appropriate recruitment and induction programmes were in place. The staff induction handbook used during the initial three months of employment was very comprehensive and included five units: maintaining health and safety, understanding the organisation and the role of the worker, understanding the experiences and needs of the service user, understanding the principles of care and understanding the effects of the service setting. Staff records examined included signed statements that they had read and agreed to comply with the homes confidentiality and protection policies, Criminal Record Bureau checks had been undertaken and all document’s were in place with the exception of one long service member of staff, for whom the home did not hold a photograph or verification of identity. Grove Court (Woodbridge) DS0000024401.V257969.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, 36 and 38. Residents can expect the home to be well managed and the health, safety and welfare of residents and staff to be promoted and protected. EVIDENCE: The registered manager and the clinical care manager are registered general nurses. The manager has a diploma in management studies and registered managers award. The clinical care manager also has the registered managers award and is an NVQ assessor and verifier. Records seen and staff spoken with during the inspection confirmed that there are regular team meetings, staff supervisions and individual annual appraisals. One member of staff said “I think the supervisions are really good, its nice to have someone to talk to, someone you feel comfortable with”, they also confirmed that the management team was approachable and that their “door’s always open”. Grove Court (Woodbridge) DS0000024401.V257969.R01.S.doc Version 5.0 Page 18 The manager confirmed that the home has a Residents Forum Committee that meets every eight weeks and the minutes of the last meeting were seen. The meeting had given residents the opportunity to raise issues and exchange information with the manager. There was also good evidence of quality assurance systems in place. Elizabeth Finn Homes and the manager undertake annual quality audits, furthermore the annual residents “satisfaction survey” had recently been completed and the manager was able to evidence that they were in the process of collating the data for discussion at a future residents meeting. Policies and procedures were in place concerning the handling of resident’s finances. The home does not act as appointees or manage bank accounts for any of the residents but held small amounts of cash for safe keeping for 28 residents by request. On the day of inspection the records relating to residents monies held were examined. All transactions were clearly recorded, signed by two people, with relevant receipts attached. Signed agreements between the home and the resident’s representative were in place. Records seen on the day of inspection indicated that the home promotes safe working practices. Risk assessments were in place and training related to health and safety, food hygiene, infection control and moving and handling had taken place. Staff were seen equipped with appropriate protective clothing and made positive comments about the homes commitment to provide a safe place to work. Grove Court (Woodbridge) DS0000024401.V257969.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 3 4 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 Grove Court (Woodbridge) DS0000024401.V257969.R01.S.doc Version 5.0 Page 20 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 Standard 29 Regulation 19 Sch.2 Requirement The Registered Manager must have full and satisfactory information in respect of all persons working at the care home. Timescale for action 31/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard 27 Good Practice Recommendations The Registered Manager should undertake a review of staff hours to ensure that the homes ratio of staff: residents effectively meet resident’s needs at all times. Grove Court (Woodbridge) DS0000024401.V257969.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 (Woodbridge) DS0000024401.V257969.R01.S.doc Version 5.0 Page 22 - 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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