Inspection on 06/12/05 for Grove House

This inspection was carried out on 6th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 House 08/09/08

Grove House 20/08/07

Grove House 20/06/06

Grove House 11/08/05

Grove House 21/10/04

Grove House 27/04/04

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

CARE HOMES FOR OLDER PEOPLE Grove House 7 South Hill Grove Harrow Middlesex HA1 3PR Lead Inspector Judith Brindle Unannounced Inspection 6th December 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 DS0000017573.V269495.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 DS0000017573.V269495.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Grove House Address 7 South Hill Grove Harrow Middlesex HA1 3PR 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) 020 8864 5216 020 8864 5216 Mrs Dympna Kritikos Mr N Kritikos Mrs Dympna Kritikos Care Home 4 Category(ies) of Old age, not falling within any other category registration, with number (4) of places Grove House DS0000017573.V269495.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons who can manage the stairs without physical assistance may reside on the first floor. You may only accommodate service users in the bedrooms located on the second storey When they have been subject to an assessment by a competent person representing the service user and nominated by the placing agency. In the case of a service user who is self funding, the assessment must be undertaken by a competent person who is independent of the home - Occupational Therapist, CPN or Care Manager. This assessment must clearly state that the service user is able to ascend and descend the stairs to the ground floor without the assistance of staff. A copy of this assessment must be retained in the home and be available for inspection. Any such assessments held at the home, must be subject to regular external review in accordance with the changing needs, abilities or condition of the service user. 11th August 2005 Date of last inspection Brief Description of the Service: Grove House is a care home that provides personal care and accommodation for up to 4 older people. Mr and Mrs Kritikos own the home. The registered manager is Mrs Kritikos. Grove House is a family owned and run care home. Mr and Mrs Kritikos live on the premises with their family. The home is located in Harrow on a quiet residential road, within a few minutes walk, or short drive from local shops, and other amenities. There are local public transport facilities in the vicinity, which include a public bus and train service. Sudbury Town underground train station is within a few minutes walk from the care home. The home was opened in 1995, and consists of a semi-detached house, with parking for approximately four cars at the front drive area of the house. There is one single bedroom on the first floor, and one on the ground floor. There is a shared bedroom on the ground floor. The home has an enclosed well-maintained garden with a seating area, that is accessible to residents. Grove House DS0000017573.V269495.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place throughout four hours during the daytime in December 2005. There were three residents present during the inspection, and the registered manager/ provider, (and for part of the inspection the other provider), and a care staff member. The inspection focussed on spending the major part of the inspection talking with residents. Records were also inspected. These included resident’s care plans, staff personal records, and records in regard to health and safety. Requirements from the previous inspection were assessed and met. 4 National Minimum Standards for Older Persons were assessed. These were all met or almost met. Commission for Social Care Inspection comment/feedback cards in regard to the service provided by the care home were given to residents (one resident kindly completed a feedback form during the inspection), other feedback forms for relatives/significant others, and health and social care professionals were given to the registered manager by the inspector for distribution. Conditions of registration were met at the time of the unannounced inspection. What the service does well: What has improved since the last inspection? The general quality of the service provided has continued. Records and record keeping have continued to improve. Community based activities have been further developed. Grove House DS0000017573.V269495.R01.S.doc Version 5.0 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 House DS0000017573.V269495.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 DS0000017573.V269495.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): Standard 2 and 3 Residents have a recorded statement of terms and conditions in regard to the service provided by the care home. Arrangements are in place to ensure that residents receive an assessment of their individual needs prior admission to the care home and during the ‘trial’ period to make sure that the care home can meet their needs. EVIDENCE: Three care plans were inspected. These recorded evidence that residents had a contract/statement of terms and conditions with the provider. This documentation was signed by the resident (and or relative/significant other), and the registered manager. The information included fees, and method of payment of these. The care plans inspected recorded assessment of individual residents’ needs. This included assessment of individual mobility needs, mental health needs, personal care needs, and health needs. The assessment information recorded evidence of having been reviewed. There was also evidence of assessment information from funding authorities, and from a local health authority. Grove House DS0000017573.V269495.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): Standard 7, 8 and 9 Arrangements are in place to ensure that residents each have a recorded plan of care to meet their individual needs. Arrangements are in place to ensure that resident’s health care needs are assessed, and met. Medication is administered safely. EVIDENCE: All the residents have an individual plan of care, and support. The three care plans inspected recorded evidence of resident’s involvement in their care plan. Care plan documentation, and information was signed by individual residents, and included assessment of their individual needs. There is recorded staff guidance in regard to meeting the personal care needs of residents, and documentation that identifies their health and welfare needs. This care and support by staff is recorded. A care staff member who kindly spoke with the inspector had knowledge and understanding of residents’ individual needs. Residents’ daily progress records should be recorded in a manner that respects resident’s privacy i.e. recorded separately from other resident’s records. There were gaps in recording of these records. They should be completed at least daily, and following nighttime. The inspector was informed that the financial needs of a resident were to be reviewed by the relevant care management team. The care plans include information includes a comprehensive profile of Grove House DS0000017573.V269495.R01.S.doc Version 5.0 Page 10 the resident, which includes a section in regard to the resident’s background and includes a record of their current needs. The care plans include risk assessment of falls, and risk of pressure sores. There is recorded information in regard to prevention of falls, and prevention of pressure sores. Records inspected following the inspection included risk assessment (in regard to two residents) of risk from traffic when out in the community. Records confirmed that residents had access to healthcare services, which include dental, chiropody, optician, and GP appointments. Residents who kindly spoke to the inspector were positive about the care and support that they received from staff, and confirmed that their needs were being met. The care home has a medication policy. Medication is stored securely. Medication administration records were up to date and fully recorded. Medication profiles were recorded in resident’s care plans. Grove House DS0000017573.V269495.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): Standard 12 and 15 Arrangements are in place to ensure that residents have the choice and opportunity to participate in a variety of activities. Residents receive varied and wholesome meals. EVIDENCE: Community based activities have been further developed. Records informed the inspector that residents had the opportunity to participate in a variety of activities. These included trips out shopping, going out for walks, watching television, rides in the car, reading, and attending church. A resident spoke positively of the activities that she enjoyed. The leisure pursuits that residents enjoyed were recorded in there are plans. A resident spoke of enjoying a recent birthday party, and of her contact with relatives. A menu was available for inspection. Residents informed the inspector that they enjoyed the meals provided. The meal provided during the inspection was judged to be nutritious and wholesome. Drinks were offered frequently to residents. Food eaten by residents is recorded. The changing nutritional needs of a resident were discussed with the registered manager. These needs were recorded, and evidence of these having been reviewed was provided following the inspection. Records confirmed that residents’ weight is monitored. Grove House DS0000017573.V269495.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): EVIDENCE: These standards were not assessed during this inspection. They were assessed during the previous inspection. Grove House DS0000017573.V269495.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): Standard 19 and 26 Residents live in a generally well maintained environment that meets their needs. The home is clean and warm. EVIDENCE: The unannounced inspection included a tour of the premises. The care home is a family run home, in which the registered providers live with their family and the residents. The home is located a few minutes walk from a variety of shops and amenities. Local transport facilities include bus and train services. There needs to be maintenance carried out to an area of the care home located above the front door. The garden is maintained, and there is a covered seating area (with appropriate furniture) that is accessible from the sitting room, and the kitchen that residents spoke of using during the summer months. The care home is warm, well lit, and airy. Residents were observed to access freely the communal areas of the care home. Two residents spoke of being satisfied with their bedrooms. The care home has an infection control policy. Staff complete the cleaning duties. The premises were clean and free from offensive odours during the Grove House DS0000017573.V269495.R01.S.doc Version 5.0 Page 14 inspection. Laundry facilities are located away from the kitchen. There is hand washing facilities sited in the laundry/shower room area. There should be recorded evidence that staff have received training in regard to infection control. Grove House DS0000017573.V269495.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): Standard 28 and 29 Residents are in safe hands. Arrangements are in place to ensure that residents are not at risk from staff recruitment procedures. EVIDENCE: Records informed the inspector that a staff member has completed NVQ level 2 training. A staff member reported that she was completing a skills in care training course, which is college based. Records confirmed that staff had completed a staff induction programme. The registered manager/provider informed the inspector that the other registered provider was planning to complete an NVQ training course. The registered manager has recently completed NVQ level 4 management training. The care home has a recruitment policy. Two staff personnel files were inspected. These contained required information. Evidence that a staff member had signed and dated a contract of employment was provided to the Commission following the inspection. Grove House DS0000017573.V269495.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 33, 36 and 38 The care home is run in the best interests of residents. Staff receive supervision from the registered manager to ensure that they have knowledge and understanding of how to provide residents with appropriate care and support. The health and safety of residents is an issue identified by the service and promoted. Arrangements need to be in place to ensure that regular checks of some systems take place. EVIDENCE: The home has a quality assurance policy. There was some recorded evidence of quality assurance monitoring systems being in place. These include regular review of residents care plans with recorded resident involvement (if able), and relatives and significant others input. Service user satisfaction questionnaires were recorded in care plans inspected. An annual development plan for the care home was not inspected during the inspection and needs to be supplied to the Commission for Social Care Inspection. Grove House DS0000017573.V269495.R01.S.doc Version 5.0 Page 17 Records confirmed that staff receive supervision, but that recorded one to one formal staff supervision was infrequent. This was discussed with the registered manager and she provided recorded evidence (following the unannounced inspection) that recent staff supervision had been completed. The registered person should ensure that care staff receive formal supervision at least six times a year. A care staff member reported that she received regular on-going informal supervision from the registered manager. The registered person informed the inspector that a resident had recently been admitted to hospital. The Commission for Social Care Inspection needs to be notified of any serious illness of a resident at a care home at which nursing is not provided. This was discussed with the registered manager/provider. Records informed the inspector that evidence of some recent safety checks was not accessible. These checks included fire equipment checks, and gas safety checks. Following the unannounced inspection the registered person had these checks completed following the unannounced inspection, and provided the Commission for Social Care Inspection recorded evidence of these checks having taken place. A risk assessment in regard to use, and need of a stair gate was supplied to the Commission following the inspection. The fire risk assessment was not clearly recorded and needs to be recorded clearly with evidence of having been regularly reviewed. Records of at least weekly fire checks need to be in place, and available for inspection. Two doors within the care home (sitting room and a resident’s room) were wedged open. The safety risk was discussed with the registered person. Following the inspection the registered person reported that she had contacted the fire service, and that suitable safe mechanisms would be put in place to enable these doors to be kept safely open at times during the day. This needs to be actioned by the registered person. There was no evidence of a staff member having received fire training. Following the inspection the registered person informed the inspector that this staff member had completed video fire training. It is recommended that fire safety guidance and health and safety guidance is provided to care staff during staff meetings and/or staff supervision sessions. The inspector was informed that the providers had recently received protection of vulnerable adults training. Grove House DS0000017573.V269495.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X 3 X 2 Grove House DS0000017573.V269495.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP19 Regulation 23(2) Requirement Timescale for action 01/03/06 2 OP33 24 3 OP38 12, 13(4) 23(4) 4 OP38 37(d) There needs to be maintenance carried out to an area of the care home located above the front door. An annual development plan for 01/03/06 the care home was not inspected during the inspection and needs to be supplied to the Commission for Social Care inspection. • Following seeking advice 01/02/06 from the Local authority fire service, there needs to be suitable safe mechanisms in place to enable two doors to be kept safely open at times during the day. • Records of at least weekly fire checks need to be in place and available for inspection. • The fire risk assessment needs to be recorded clearly with evidence of having been regularly reviewed. The Commission for Social Care 01/01/06 Inspection needs to be notified of any serious illness of a DS0000017573.V269495.R01.S.doc Version 5.0 Grove House Page 20 resident at a care home at which nursing is not provided. 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 OP7 Good Practice Recommendations Daily residents’ progress records should be recorded in a manner that respects resident’s privacy. • There were gaps in recording resident’s records. Resident’s progress records should be completed at least daily, and following nighttime. There should be recorded evidence that staff have received training in regard to infection control. The registered person should ensure that care staff receive formal supervision at least six times a year. It is recommended that fire safety guidance and health and safety guidance is provided to care staff during staff meetings and/or staff supervision sessions. • 2 3 4 OP26 OP36 OP38 Grove House DS0000017573.V269495.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 DS0000017573.V269495.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. 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