Inspection on 23/11/05 for Grove House

This inspection was carried out on 23rd November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Grove House 10/07/07

Grove House 09/05/06

Grove House 05/07/05

Grove House 28/01/05

Grove House 23/06/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOMES FOR OLDER PEOPLE Grove House Moor Road Ashover Chesterfield Derbyshire S45 OAQ Lead Inspector Janet Morrow Unannounced Inspection 23rd November 2005 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 House DS0000019999.V268285.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 House DS0000019999.V268285.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Grove House Address Moor Road Ashover Chesterfield Derbyshire S45 OAQ (01246) 590222 (01246) 590287 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) Peak Care Limited Jannine Stevens Care Home 31 Category(ies) of Learning disability (1), Old age, not falling registration, with number within any other category (30) of places Grove House DS0000019999.V268285.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 place in the category LD for service user named on proposal of conditions notice. 5th July 2005 Date of last inspection Brief Description of the Service: Grove House is a care home registered to provide care and accommodation for up to 31 older people including 1 place for a named individual with learning disabilities. The home is well established and is part of a care complex that also provides services for very sheltered housing. The home is set in its own grounds and overlooks fields and mature trees in the surrounding countryside. Amenities are available in the village of Ashover including pubs, a post office and small shops. The accommodation is a mixture of older buildings combined with a purpose built extension. There is a choice of lounges and dining rooms. 13 single bedrooms have en suite facilities, there is 1 double bedroom and the remainder are single accommodation. Car parking space is provided. Grove House DS0000019999.V268285.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 5.5 hours. Care records, maintenance records and staff records were examined. Five residents, three staff, one visiting professional and the manager and provider were spoken with. What the service does well: What has improved since the last inspection? What they could do better: Training in adult protection was still outstanding and the home did not have a copy of Derby and Derbyshire Local Authority Social Services procedures. Grove House DS0000019999.V268285.R01.S.doc Version 5.0 Page 6 The retention of staff recruitment information should be improved by having all the necessary documentation in staff files at all times. A record should be maintained of reasons why some items of furniture in individual bedrooms had not been provided and individual heating controls in bedrooms would allow residents to maintain a temperature of their choosing. Using a specific risk assessment for falls would enhance the care provided to those at risk of falling. Residents’ financial records should be improved to show confirmation of cash received. 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 House DS0000019999.V268285.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 House DS0000019999.V268285.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): 3 and 4 There was sufficient admission information available to establish that the home could meet service users’ needs. EVIDENCE: Two residents’ care plans were examined. Detailed assessment information had been obtained for each file examined. All the information required by Standard three was available on the assessment documentation and information from the assessment and care management process was also in place. Discussions with staff indicated that the needs of residents were well known and there was a mix of skills and experience within the staff group to meet the assessed needs of residents. Those residents spoke with praised the staff and said there needs were well catered for; one resident who had lived at the home for a number of years stated that they had never had any request refused. Grove House DS0000019999.V268285.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, 9 and 11 Care planning was thorough and health services were accessed, which ensured that residents’ health care and personal care needs were met. EVIDENCE: Two residents care records were examined. Care plans were in place in both and were reviewed on a monthly basis. Both had been signed by either the resident or their relative, showing that consultation about care had taken place. Where risks were identified, such as risk of falling, there was appropriate action taken to minimise the risk. However, the home did not have a specific falls risk assessment in place; risk of falls was detailed in the moving and handling risk assessment. There was monthly recording of weight and visits by health professionals such as General Practitioner and Community Psychiatric Nurse. There were also charts that recorded when baths had been given as well as daily log recording. Residents spoken with praised the care received with one resident stating they were ‘very satisfied’. Grove House DS0000019999.V268285.R01.S.doc Version 5.0 Page 10 The two previous requirements issued re medication procedures had been complied with. The medication refrigerator temperatures were recorded on a daily basis and the medication policy had included details for homely remedies. There was a policy available on death and dying that included how to deal with residents’ who were terminally ill. Those staff spoken with stated that they were confident in their knowledge of how to care for dying residents. Grove House DS0000019999.V268285.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): 15 Meals were well managed, which enhanced residents’ quality of life. EVIDENCE: The serving of the lunchtime meal was observed and sampled. This showed that food was nutritious and wholesome. All residents spoken with stated that they enjoyed their meals and described the food as ‘good’. The dining areas were pleasant and cheerful and condiments were available for individual use. Those residents requiring assistance were helped in a sensitive manner. Grove House DS0000019999.V268285.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): Procedures were in place to ensure that residents concerns were listened to. There were procedures in place to minimise risk of harm to residents but formal training and additional information from the Local Authority would further enhance the home’s ability to minimise risks. EVIDENCE: A complaints procedure was on display in the home and stated that complaints would be dealt with in twenty days. However, the contact details for the Commission for Social Care Inspection were incorrect. The manager stated that no complaints had been received at the home during the last twelve months and there had been no complaints received at the office of the Commission for Social Care Inspection. A protection of vulnerable adults policy and procedure was in place. However, the home did not have a copy of the Derby and Derbyshire Local Authority Social Services procedures available. Not all staff had attended Derbyshire’s multi agency Protection of Vulnerable Adult Procedures training. However, the manager stated that some training for staff had been cancelled but new dates had been arranged for December 2005 and in 2006. A whistle blowing policy was in place and discussions with staff indicated that they knew what to do if they were concerned about a residents’ welfare. Grove House DS0000019999.V268285.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, 24 and 25 The home was comfortable and well maintained, which ensured residents had a homely environment to live in. EVIDENCE: The home was well maintained and well decorated. Furnishings and fittings were of a high standard. Maintenance records were seen that showed that prompt attention to repairs and refurbishment occurred. There were sufficient toilets and bathrooms and communal space for residents to use. One bedroom was seen and was personalised. However, it did not contain all the items detailed in Standard 24, such as a table to sit at and two double electrical sockets. There was no written record available as to why these items had not been provided. Rooms were heated and ventilated, and radiators and pipework were guarded. However, one bedroom seen was cool even though the radiator was on. The Grove House DS0000019999.V268285.R01.S.doc Version 5.0 Page 14 resident concerned commented that the bedroom was not warm enough. There were no heating controls on the radiator in the bedroom. Grove House DS0000019999.V268285.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 There were sufficient well-trained staff deployed to ensure that residents’ needs were met. Recruitment procedures were thorough and ensured residents were protected. EVIDENCE: The staff rota for the week 21st –27th November was examined. This showed that there were sufficient staff deployed to meet residents needs, as there were three care staff deployed each morning and afternoon. There were no concerns raised regarding staffing by the management, most staff or residents, although comments on quality assurance questionnaires indicated that more staff were required. Training records were available which showed that staff were undertaking mandatory health and safety training, induction training and on subjects relevant to the home. A visiting professional spoken with stated that the home provided a wide range of training and invested well in its work force. National Vocational Qualifications (NVQ) were being undertaken. Nine of seventeen care staff had achieved an NVQ to level 2, a further member of staff was about to complete and two more were signed up to undertake it. This meant that the home had exceeded the target of 50 of care staff achieving NVQ level 2 by 2005. The home is therefore commended for its commitment to NVQ qualification training. Two staff files were examined. One had all the information required by Schedule 2 of the Care Homes Regulations 2001. The second had several items missing, that is; proof of identity, a photograph and evidence of a Criminal Grove House DS0000019999.V268285.R01.S.doc Version 5.0 Page 16 Record Bureau check. This information was provided by fax within twenty-four hours. Grove House DS0000019999.V268285.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, 33, 34, 35 and 38 The home was well run in the interests of residents and has strong management support. Health and safety was promoted. EVIDENCE: The manager was competent to run the home and was due to complete National Vocational Qualifications (NVQ) training in management in 2006. She was able to demonstrate in discussion that she was familiar with the conditions associated with old age. Quality assurance systems were in place and the home employed an external company to undertake quality surveys annually. The results of the most recent survey were seen and comments such as ‘good attention from staff’ and ‘very helpful’ were recorded. 100 of respondents stated that they would recommend the home to others. The home had also undertaken a staff survey in September 2005 and the results of this suggested that there was a good staff team. The proprietor had also developed a plan to address any less favourable comments in the surveys. Grove House DS0000019999.V268285.R01.S.doc Version 5.0 Page 18 The home had financial systems in place to administer residents’ personal finances. However, where cash was being given, only one member of staff had signed the record and there was no signature from the resident to confirm they had received the money. A business plan for the home was available which was clear about spending priorities for the year and the provider stated that the home was financially viable. A valid insurance certificate was on display. Health and safety issues were addressed with staff undertaking training in first aid, fire safety, food hygiene, infection control and moving and handling. Training records and staff interviewed confirmed that access to training was good. Maintenance records were examined and these confirmed that equipment was serviced regularly. For example, fire alarms had been serviced in October 2005, the lift in November 2005 and gas safety was checked in February 2005. However, the home could not supply an up to date electrical wiring safety certificate at the time of the inspection, although this was made available by fax the same day. Grove House DS0000019999.V268285.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 X X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 X X 2 3 X STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 3 X X 3 Grove House DS0000019999.V268285.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP18 Regulation 18(1a&ci) Requirement The remainder of the staff must attend training for Derbyshires multi agency Protection of Vulnerable Adult Procedures. From inspection report 25.05.04 and 5.7.05. The registered person must ensure that all mandatory training is completed. From previous report of 5.7.05. Still within timescale. There must be adequate furniture in all bedrooms. Reasons not to provide items must be recorded. Timescale for action 01/01/06 2. OP30 18 (1) (c) 01/12/05 3 OP24 16 (2) (c) 01/03/06 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 OP8 Good Practice Recommendations A specific risk assessment for falls should be used. DS0000019999.V268285.R01.S.doc Version 5.0 Page 21 Grove House 2 3 4 5 6 OP16 OP25 OP29 OP35 OP38 The complaints procedure should contain the correct details for the Commission for Social Care Inspection. All bedrooms should have individual heating controls. Recruitment information should always be available in staff files. Residents should be asked to sign for cash handed over by the home. Where a resident is not able to sign, two staff should sign. Equipment maintenance certificates should be readily available. Grove House DS0000019999.V268285.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 House DS0000019999.V268285.R01.S.doc Version 5.0 Page 23 - 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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