Inspection on 13/07/05 for Grove Court (Woodbridge)

This inspection was carried out on 13th July 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) 10/10/05

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 Beech Way Woodbridge Suffolk IP12 4BW Lead Inspector Iain Smith Unannounced 13th July 2005 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 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 I54-I04 S24401 Grove Court V239002 050713 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Grove Court Address Beech Way, Woodbridge, Suffolk, IP12 4BW Telephone number Fax number Email 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 grovecourt@efhl.co.uk Elizabeth Finn Trust Mr R Perez CRH 61 Category(ies) of OP - 61 registration, with number of places Grove Court I54-I04 S24401 Grove Court V239002 050713 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 22.11.04 Brief Description of the Service: Grove Court is owned by the Elizabeth Finn Trust 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 at the upper 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 I54-I04 S24401 Grove Court V239002 050713 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was arranged as an unannounced inspection, the first inspection for the year 2005/2006. The visit commenced at 10.00 and lasted 5.5 hours and was conducted by Iain Smith Lead Inspector and Tina Burns Inspector. During the inspection residents were spoken to, in addition to catering, housekeeping and care staff that were on duty during the day. The manager and deputy were present throughout the day and fully contributed to the inspection process. A tour of the premises was made with rooms and communal areas visited. Care plans were read as part of the tracking process and two staff files were examined. What the service does well: What has improved since the last inspection? The home has developed the statement of purpose and has produced a large print copy. This is available in the foyer of the home. The medication policies and procedures have been reviewed. The arrangements for the administration, recording and storage of medication have also been reviewed and the newly introduced medication audit tool ensures better quality control. Grove Court I54-I04 S24401 Grove Court V239002 050713 Stage 4.doc Version 1.40 Page 6 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 I54-I04 S24401 Grove Court V239002 050713 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Grove Court I54-I04 S24401 Grove Court V239002 050713 Stage 4.doc Version 1.40 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 standard(s) 1,3,4 and 5. People who use the service receive clear information to enable them to make a choice about whether or not they might wish to live in the home. Each residents needs are assessed prior to moving into the home. EVIDENCE: The statement of purpose and service users guides were available for prospective residents and their families. These documents were displayed in the foyer of the home. The manager has developed an additional statement of purpose and produced it in large print. Prior to each resident moving into the home a pre admission assessment is required. The home has a comprehensive pre admission assessment form that the manager or another trained member of staff completes. The form includes preferred lifestyle choices, personal care needs and diet and weight. Attached to the assessment are the criteria for determining the level of care within the framework of stability, predictability, risk and complexity. The home demonstrates that the assessment is considered as a holistic approach. This ensures that all resident needs are assessed and considered at the point of admission. This pre admission assessment is assessed as an excellent Grove Court I54-I04 S24401 Grove Court V239002 050713 Stage 4.doc Version 1.40 Page 9 assessment tool, in addition to the form that is used for the agreed reasons for admission. Evidence was found in the one care plan that was examined, of the pre admission assessment. The assessed care needs included those of nutrition and on examination of the care plan this element of the care was identified. Therefore, the assessed care need was transferred to the care plan. Staff training records evidenced that they have the skills and experience to deliver the services and care which the home offers to provide. Grove Court I54-I04 S24401 Grove Court V239002 050713 Stage 4.doc Version 1.40 Page 10 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 standard(s) 7,8,9 and 10. Resident’s needs were assessed and care planning was completed therefore ensuring that staff delivered the appropriate care to each resident. Medication policies and practices were in place to ensure safe working practices. EVIDENCE: One care plan was examined and found to include relevant information. The care plan was based on the Roper, Logan and Tierney model of care that states the aids to daily living elements of care. Each element was broken into four sections, the activity, condition, caring goal and the actions. The pre admission assessment information was transferred on to the initial care plan, for example diet and weight. This element of care was identified as requiring assistance with eating by cutting food up and encouragement with eating. There was a weight assessment form and a fluid balance chart, these forms were maintained to enable the staff to monitor the resident’s progress. Care planning is managed on computer on each of the three care bases. The trained nurse in charge of the shift will enter details of the shift relating to the residents and the care plan is updated from those notes. There is a date on each of the care plans therefore the manager is able to monitor the review dates. The home has recently introduced a care plan audit review form. This is Grove Court I54-I04 S24401 Grove Court V239002 050713 Stage 4.doc Version 1.40 Page 11 completed by the deputy manager and is assessed as a positive audit tool. The care-planning standard was assessed as exceeding the standard and awarded a four. The home uses the Malnutrition Universal Screening Tool (MUST) for a number of residents. This tool is used to assess the nutritional status of the residents and the staff then plan the appropriate care. The medication procedures and records were examined on care base one, in addition to one resident who self medicates. The care base Medication Administration Records (MAR) were found to have a photograph of each resident at the front of the record. A trained nurse signed the MAR sheets and the storage of the medication was appropriate. One Controlled Drug was checked against the record in the Controlled Drugs (CD) book. This was assessed as correct in addition to the record matching the MAR sheet for the resident. One resident who self medicates was visited. The medication was seen to be stored correctly in a lockable cabinet and a record was seen to evidence that the medication had been taken. Grove Court I54-I04 S24401 Grove Court V239002 050713 Stage 4.doc Version 1.40 Page 12 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 standard(s) 12,13, 14 and 15. The home offers daily activities and encourages residents to fulfil their cultural and recreational interests. Meals are planned and prepared specifically to meet the needs of all residents. EVIDENCE: A list of the activities that were organised in the home was displayed in the foyer of the home. In addition, there was an information sheet produced for each resident and taken to each person’s bedroom. One resident stated that they could select an activity to attend or spend time in their room. The balcony on the first floor of the home, overlooking the day room, was used as an activities area. On display were a video library, pool table and magazines. Visits were arranged in the community, for example shopping trips. An outside company is contracted to provide the catering for the home. The catering manager stated that they were involved in meetings with the manager and care staff to discuss menus and choices of food. One resident stated ‘we are very well fed here.’ The menu for the day of inspection was honey roast gammon with mustard. This was served with stuffed pepper, roast potatoes, buttered cabbage and glazed carrots. Fresh strawberries were one of the choices for sweet. Grove Court I54-I04 S24401 Grove Court V239002 050713 Stage 4.doc Version 1.40 Page 13 The catering manager stated that they were aware of the Malnutrition Universal Screening Tool (MUST) and stated that food would be ordered to accommodate for special diets and liquidised meals. The care plans evidenced member of the care staff, coordinate the assessments nurse stated that this that a nutritional assessment was included. A who is a trained nurse, has been nominated to and liase with the catering manager. The trained project was entitled ‘dining with dignity’. Grove Court I54-I04 S24401 Grove Court V239002 050713 Stage 4.doc Version 1.40 Page 14 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 standard(s) 16 and 18. Arrangements are in place to minimise risk so that the safety and welfare of the residents are promoted. The policies and procedures of the home ensure that residents are safeguarded from abuse and harm. EVIDENCE: The complaints and prevention of vulnerable adults policies were available in the home. Staff training records evidenced that both the policies and procedures were included as part of the induction and ongoing training. The complaints procedure was seen to be part of the statement of purpose and service user guides. Grove Court I54-I04 S24401 Grove Court V239002 050713 Stage 4.doc Version 1.40 Page 15 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 standard(s) 19,20,23,24,25 and 26. The home provides a safe and attractive environment to all residents where policies and procedures are in place to protect all those who live there. EVIDENCE: The home offers an attractive environment where all residents have their own single bedroom. The lounge areas have comfortable, domestic style furniture and furnishings, with all areas are carpeted. Three bedrooms were visited and there was evidence that the residents were able to bring in some of their own possessions. Examples were pictures, ornaments and books. One resident stated they had’ a lovely room’. Each bedroom door has a doorknocker and the name of the resident displayed. Grove Court I54-I04 S24401 Grove Court V239002 050713 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27and 30. The staffing numbers and skill mix are appropriate for the home. The training and development is relevant and gives the staff the skills and experience to meet the needs of each resident. EVIDENCE: The three care bases have allocated members of staff including a trained nurse in charge of each of the three shifts. The trained nurses are registered with the Nursing and Midwifery Council (NMC). Staff training is evident for all staff. The manager stated that the home has a training and development timetable. This was seen and the ongoing record is maintained on computer. The timetable evidenced that first aid, managing continence and dementia care training were planned for some staff and other staff had completed the training. All the training that the home had planned was assessed as relevant and gave the staff the skills and experience to deliver the care to the residents. Other examples of the training included moving and handling, customer care and diabetic care. Grove Court I54-I04 S24401 Grove Court V239002 050713 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33 and 38. There is clear leadership within the home and that ensures residents receive consistent quality care through training and communication. EVIDENCE: The manager is a trained nurse, registered with the Nursing and Midwifery Council (NMC). They have completed the registered managers award, the diploma in management studies and a train the trainer protection of vulnerable adults course. The management approach of the home creates an open, positive and inclusive atmosphere. There was evidence of staff and management meetings in addition to a residents and relatives meeting. One member of staff stated that the company have good values and standards’. Grove Court I54-I04 S24401 Grove Court V239002 050713 Stage 4.doc Version 1.40 Page 18 The home has introduced a care planning and medication audit. The deputy manager/ clinical care coordinator has the responsibility for the completion of the monthly audit. This has ensured the home has a consistent approach to quality monitoring of these two areas of care and is assessed as positive. Training related to health and safety, basic food hygiene and infection control was evident in the staff training records. The home monitors resident’s falls and accidents. This enables the manager to identify the risks in the home and plan for a safer environment and monitor resident care. Grove Court I54-I04 S24401 Grove Court V239002 050713 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 4 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x x 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x x x x 3 Grove Court I54-I04 S24401 Grove Court V239002 050713 Stage 4.doc Version 1.40 Page 20 No Are there any outstanding requirements from the last inspection? 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 Regulation None Requirement Timescale for action 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 None Good Practice Recommendations Grove Court I54-I04 S24401 Grove Court V239002 050713 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection 5th Floor, St Vincent House 1 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. 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