Inspection on 23/05/06 for Grove Court (Woodbridge)

This inspection was carried out on 23rd May 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 (Woodbridge) 23/05/07

Grove Court (Woodbridge) 10/10/05

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 Iain Smith Unannounced Inspection 23rd May 2006 09:30 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.V296128.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Grove Court (Woodbridge) DS0000024401.V296128.R01.S.doc Version 5.2 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 raphy.perez@efhl.co.uk Elizabeth Finn Homes Ltd 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.V296128.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Condition of Registration 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. 10th October 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.V296128.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection of Grove Court Care Home, Woodbridge and took place during the hours of 09.30 and 16.30 on Tuesday 23rd May 2006.The inspection followed the older person’s methodology where all key standards were assessed. This included interviewing three service users; each with a wide range of needs, examining their care plans, assessing records, policies and procedures. Three members of staff were selected to be interviewed, one registered nurse, the receptionist and a carer. Their files were examined including their training records. Thirty service user questionnaires were sent to the home prior to the inspection day and 13 were collected at the end of the inspection, this represented a 43 return. The report has been written using accumulated evidence gathered during the inspection and relevant comments from the questionnaires have been included. A tour of the premises took place and additional staff were spoken to during the day including registered nurses, carers, catering and housekeeping staff. The manager, clinical care manager Carol Denny and administrator Sally Barton all participated throughout the inspection day and fully contributed to the process. What the service does well: The home offers a safe and secure environment for the service users. Prior to each service user’s admission to the home, either the manager or the clinical care manager visits them to assess their needs and makes a judgement if their care needs can be met by the home. This assessment forms the base for an initial 36-hour care plan; this will be developed in to a long-term care plan. Each service user has a copy of their care plan located in their room, therefore, they are aware of the agreed care to be delivered. There is a variation in the activities offered to each service user. Visits are arranged outside the home in addition to those on a daily basis arranged in the morning and afternoon. One service user stated that they could choose the activities they wished to attend and that no pressure was put on any service user. Training and development was positive for all staff. Evidence was found in files and staff stated that they received regular training to update their skills and knowledge. Supervision was evidenced and this ensures that staff have the opportunity to discuss their practice, training and development. Grove Court (Woodbridge) DS0000024401.V296128.R01.S.doc Version 5.2 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. Grove Court (Woodbridge) DS0000024401.V296128.R01.S.doc Version 5.2 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.V296128.R01.S.doc Version 5.2 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): 3 and 6. No service user moves into the home without having their care needs assessed. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. EVIDENCE: The home demonstrated that all service users have their needs assessed prior to their admission. The manager and clinical care manager share the responsibility for visiting prospective service users and undertaking the assessment. The assessment includes requesting information relevant to personal care, nutrition, mobility and medication. The three care plans that were examined included a comprehensive assessment. This information is then used to compile the service users initial care plan when they are admitted to the home. Grove Court accommodates one service user who is admitted for intermediate care. There were no service users in the home on the day of inspection receiving this element of care. Grove Court (Woodbridge) DS0000024401.V296128.R01.S.doc Version 5.2 Page 9 The manager stated that the home employs two physiotherapists on a part time basis to assist with their intermediate service user. This enables the service users to be rehabilitated and utilise the appropriate equipment, for example hoists and walking frames. Grove Court (Woodbridge) DS0000024401.V296128.R01.S.doc Version 5.2 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 the following standard(s): 7,8,9 and 10. The service users health, personal and social care needs are set out in an individual plan of care and the registered person ensures access to services to meet assessed needs. The home has a policy and procedure for medication and staff adheres to it. EVIDENCE: The home operates a comprehensive assessment procedure where each prospective and current service users have their needs assessed. The assessment completed prior to the service user’s admission to the home is used to create an initial 36-hour care plan for each person. The information in this plan will inform staff of the service user’s care needs. The information includes personal care needs, mobility and continence. The care plans that were examined included a clear 36-hour plan with specific care details. Following this plan, a review takes place with the service user; their representative and clinical care manager. A longer-term care plan is then developed to inform staff of the required care, and a copy of the computerised record is given to the service user. Three service users who were interviewed each stated that their care plan was in their room, each of the plans were seen. Grove Court (Woodbridge) DS0000024401.V296128.R01.S.doc Version 5.2 Page 11 One of the service users stated that they signed their care plan and agreed with the care. Each of the questionnaires that were returned stated that the service users had a copy of their care plan. The health care needs for service users are met, with evidence of nutrition, continence and pressure sore assessments. The three care plans examined each included a nutritional assessment based on the Malnutrition Universal Screening Tool (MUST) model. The assessment is discussed with the service users representative and there was evidence that one service user had yogurt introduced in to their diet to ensure added nutrition. Two service users stated that they had access to a chiropodist and dentist The medication policy was relevant to the home. It stated clearly the responsibilities of the staff, including the supply of medication, receipt of medicines and the administration practice. Two of the care staff files examined each included evidence of medication training; therefore, the staff gained the skills and knowledge required. There was one controlled drugs (CD) cabinet in the home. One CD drug was checked and tracked with the service user’s name, name of the drug, record in the CDC book and with two registered nurse signatures, therefore verifying the correct administration and recording procedure. A record of each person who is recognised as permitted to administrate medication was seen displayed in the clinic room. Privacy and dignity of each of the service users is essential and staff demonstrated throughout the inspection that they paid particular regard to this. Service users were addressed in the term preferred. The three care plans stated the preferred name for the service users. Another service user was receiving a visit by a friend in his own room therefore maintaining social contacts whilst residing in the home. Grove Court (Woodbridge) DS0000024401.V296128.R01.S.doc Version 5.2 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 the following standard(s): 12,13 and 15. Service users find the lifestyle experience in the home matches their expectations and preferences in addition to maintaining contact with their families and friends. Service users receive wholesome, appealing balanced diets in a pleasant surrounding. EVIDENCE: The home has a member of staff, the activities co-ordinator, who is responsible for organising, delivering and ensuring a variety of activities are offered to all the service users. The home has a dedicated activities area on the first floor overlooking one of the lounges. There is a small snooker table, paintings by the service users displayed on the wall and books and other reading material available for service users. The activities person was seen to be leading a discussion group during the afternoon of the inspection. A programme of events was seen in each of the service users rooms. One service user stated that they were able to select the activity they wished to attend. Examples of other activities were painting, mobile library, musical movement and scrabble. The home has a small licensed bar in one of the lounges and the opening times are displayed for service users to attend and enjoy a social drink. Grove Court (Woodbridge) DS0000024401.V296128.R01.S.doc Version 5.2 Page 13 A number of visitors were in the home during the inspection, some were visiting service users in their own rooms; others were in the lounge having a cup of tea. One relative stated that they were able to visit whenever they wished and the staff would make them feel welcome. Three service users stated that they had a boat trip recently on the local river. One service user’s questionnaire stated that there is “endless trouble taken to keep our marbles active”. The lunchtime was observed prior to and during the meal. On the menu were two main courses, mushroom stroganoff and sweet and sour chicken. Other meals were available for example salads. Not all of the service users use the main dining room, as some prefer to take their meals in their own room. One service user stated that ‘I can have my meals wherever I wish depending on how I feel’. The dining room was set out with eight tables each with four chairs and the names of the service users were displayed on the table. There were some tables not set for lunch as a number of service users were having lunch in their own room. On each of the tables was a cloth with a place mat, cutlery, condiments and a small pot of flowers. There was adequate space between the tables for wheelchair users and those with walking frames. The manager stated that the head chef would meet with each service user within the first six weeks of their stay to ascertain their likes and dislikes. Grove Court (Woodbridge) DS0000024401.V296128.R01.S.doc Version 5.2 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 the following standard(s): 16 and 18. The registered provider ensures that there is a clear, accessible complaints procedure. The provider ensures that service users are safeguarded from abuse with relevant procedures. EVIDENCE: Each of the service users who were seen had a service user guide in their rooms and this document included the home’s complaints procedure. The procedure stated clearly the home’s commitment to receive and investigate complaints. No complaints have been received in the home since the last inspection. However CSCI had received one complaint relating to the home. The complaint was referred to the organisation for investigation. This complaint was investigated appropriately and a report sent to the CSCI. Three service users stated they were aware of the complaints procedure. Service users are protected from abuse with the home having an appropriate policy and procedure. Staff stated that they were involved in the protection of vulnerable adults (POVA) training. This training was included in the staff files that were examined. One POVA allegation was reported since the last inspection. This was investigated appropriately and the manager produced a report as the result of an investigation. Grove Court (Woodbridge) DS0000024401.V296128.R01.S.doc Version 5.2 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 the following standard(s): 19 and 26. Service users live in a safe, well-maintained environment. The home is clean, pleasant and hygienic. EVIDENCE: The service users live in a pleasant environment with a number of lounges each with a view of plants, flowers shrubs and the countryside. The lounge areas are spacious with a variety of chairs and tables. The service users stated they were able to choose if they wished to sit in their rooms or in the lounge area. One service user stated that there were ‘lovely views’ from the lounge in which they were sitting. The communal spaces offered sufficient area for visitors to sit with their relatives in private. The dining room was arranged to accommodate tables and chairs with sufficient space between each table for service users to walk with their walking frames. Grove Court (Woodbridge) DS0000024401.V296128.R01.S.doc Version 5.2 Page 16 Access to the outside of the building and the grounds is planned for mobile service users and wheelchair users to take advantage of the area. All areas in the home and outside are accessible with the use of ramps and a lift inside the building. The home employs two members of staff who are jointly responsible for the maintenance of the buildings and grounds. Grove Court (Woodbridge) DS0000024401.V296128.R01.S.doc Version 5.2 Page 17 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 numbers and skill mix of staff meets service users needs. The registered person operates a thorough recruitment procedure based on equal opportunities and staff are trained and competent to do their jobs. EVIDENCE: The home has three care bases; each base has nominated staff who are responsible for the delivery of care to the service users. Two of the bases have a trained member of staff responsible for each day shift, with five carers. These two base staff are responsible for service users with nursing care needs. The other care base staff is an NVQ Level 2 member of staff, with one other carer responsible for service users who are less dependant. The staff who are in charge of each shift are responsible for the allocating duties to each member of staff. The staff team also assist each other throughout the shift and there was evidence of this during the inspection. Therefore the home has adequate staff to care for the service users needs. In addition and as a support to the care staff, there is a clinical care manager and a head of care for the home. The recruitment procedures were assessed in the home. Three staff files were examined. Each of the files contained an application form, two written references and a criminal records bureau (CRB) enhanced check. The files included an induction programme and evidence of training and development. One member of staff stated that when they commenced employment three months ago they were ‘welcomed as part of the team with general support’. Grove Court (Woodbridge) DS0000024401.V296128.R01.S.doc Version 5.2 Page 18 Staff training was evidenced in the three staff files that were examined. One member of staff stated that had ‘plenty of training relevant to their post’. This included health and safety, assessor training, appraisal skills and the safe handling of medicines. The manager explained the training matrix that the home operates. This identifies the relevant training staff required to meet the needs of the service users. Examples of the training were palliative care, tissue viability and managing incontinence. One registered nurse stated that ‘I get good support and advice from the clinical care manager’. Grove Court (Woodbridge) DS0000024401.V296128.R01.S.doc Version 5.2 Page 19 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): 31,33,35,36 and 38. The home is run and managed by a person who is fit to be in charge. The home is run in the best interests of the service users and the service users financial interests are safeguarded. Staff are appropriately supervised and the health, safety and welfare of service users are promoted and protected. EVIDENCE: The registered manager has the responsibility for the home and has a deputy manager in place. This person has the responsibility for taking charge of the home in the absence of the manager and also takes responsibility for the clinical practices in the home. There are clear lines of accountability and this is reflected in the job descriptions. The home demonstrated that a service user questionnaire was completed in October 2005.The questionnaire was part of the quality assurance and monitoring of the home and the practices. The survey included questions relating to housekeeping, catering and activities. Grove Court (Woodbridge) DS0000024401.V296128.R01.S.doc Version 5.2 Page 20 Overall the survey was positive and the comments from the service users were identified on the questionnaire. A person within the company, but not an employee of the home completes monthly Regulation 26 reports. The provider submits these reports to the Commission for Social Care Inspection therefore evidencing the home is adhering to the requirements for an unannounced visit. The manager ensures that staff follow the policies and procedures. In relation to the financial procedures, the administrator evidenced that three service users monies, transactions and records were correct. Each of the three service users who were interviewed had a placement contract. The contract identifies the charges for their stay at the home. Each member of staff is appropriately supervised. The home has a supervision contract with the staff. This identifies the supervisor and supervisee’s responsibility for ensuring supervision is delivered. In addition, each member of staff completes a supervision attendance record and this is kept safely in a locked cabinet. The three staff who were seen each stated they had received supervision at least two monthly. This system of supervision is assessed as good practice. Safe working practices are essential in the home. The manager demonstrated that relevant training in safe working practices were completed by all staff. There was evidence of staff training in personal files and as an electronic record. Examples of this training were health and safety, first aid, food hygiene and manual handling. Grove Court (Woodbridge) DS0000024401.V296128.R01.S.doc Version 5.2 Page 21 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 X 3 X X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Grove Court (Woodbridge) DS0000024401.V296128.R01.S.doc Version 5.2 Page 22 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. Standard Regulation 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. Refer to Standard Good Practice Recommendations Grove Court (Woodbridge) DS0000024401.V296128.R01.S.doc Version 5.2 Page 23 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. 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