Inspection on 09/05/06 for Grove House

This inspection was carried out on 9th 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 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 23/11/05

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 Marie Bonynge Key Unannounced Inspection 9th May 2006 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.V293512.R01.S.doc Version 5.1 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.V293512.R01.S.doc Version 5.1 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.V293512.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 place in the category LD for service user named on proposal of conditions notice. 23rd November 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.V293512.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place over one day in May and the duration of the visit was 6 and a half hours. 28 residents were accommodated who had low to medium dependency needs. Inspection methods used included a tour of the communal areas of the building, the kitchen, medication storage area and the bedroom of one resident. Discussions took place with three relatives, 6 residents, 4 members of staff, the registered manager and the provider. Case tracking was used for 3 residents and their care plans and associated records were examined. Training records, staff files, certificates of maintenance and staffing rotas were also sampled. Some residents were unable to contribute directly to the inspection process because of communication difficulties, but they were directly observed during the visit to see how well their needs were met by staff. The previous inspection took place on 23/11/05. Two of the three requirements have been met and all of the recommendations have been met. What the service does well: Residents and their representatives spoke highly of the care provided by Grove House and commented that staff were ‘approachable’, ‘kind and caring’. Two residents said that they would recommend the home and staff commented that one of the best things about the home was the way in which the staff team worked together to give residents good care. A generally well maintained, comfortable and homely environment is provided. Residents said that they were pleased with the standard of accommodation and with the furnishings of their bedrooms. The food is of a good standard with residents individual needs being catered for and special diets being provided. There is a strong commitment to staff training and staff are keen to extend their learning in order to meet the needs of residents. Grove House DS0000019999.V293512.R01.S.doc Version 5.1 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 House DS0000019999.V293512.R01.S.doc Version 5.1 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.V293512.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Assessment information was obtained that assisted in the home being able to meet the identified needs of residents. EVIDENCE: Three residents care plans were examined as part of the case tracking process. These indicated that comprehensive assessment information had been obtained prior to the admission of residents into the home. The manager of the home or the deputy completed the homes own assessment that included a life history of the person and their likes and dislikes. Two of the care plans were signed and the third was in the process of being completed for a newly admitted resident. A statement of purpose and service user guide were in place and two relatives who were spoken with said that they had been provided with the information they wanted when making a descision about the home. Grove House DS0000019999.V293512.R01.S.doc Version 5.1 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 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Care planning was generally good and access to health services was provided. The personal and healthcare needs of residents were generally well met. EVIDENCE: As part of the case tracking process, three residents care plans were examined. These indicated that the documentation had continued to improve since the last inspection. Sufficient detail was provided to enable staff to ascertain the action that needed to be taken to ensure that all aspects of the health, personal and social care needs of the individual could be met. Discussions with care staff showed that they were aware of the needs of residents and they were increasingly involved in the formulation and development of the care plans. Some of the daily records were being completed each day, however a number were sporadic and did not provide sufficient detail to fully monitor the care of residents. A recommendation has been made in respect of this. Grove House DS0000019999.V293512.R01.S.doc Version 5.1 Page 10 A risk assessment was present for residents identified as being at risk from falls and one resident had been referred to a specialist service for falls prevention. Relatives said that they felt involved in the care of the person they were visiting and were kept up to date with any changes in their care. Records clearly indicated the involvement of other health care professionals such as the dentist, optician and chiropodist. There were said to be good relationships with the community health care team including GPs and District Nurses. A referral had been made to the District Nurse for a resident who was identified as being at risk from developing pressure ulcers. One resident said that staff were quick to respond to any request and other comments included that staff respect my need for privacy. Two relatives commented that staff were caring and kind. Medication systems were generally in good order with policies and procedures having been developed in accordance with the recommended guidance. The temperature of the medicines fridge was being recorded and monitored, however the maximum and minimum temperatures were outside of the recommended range. A recommendation has been made in respect of this. Grove House DS0000019999.V293512.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Activities and recreation are provided that generally meet with the expectations and preferences of residents. The meals are good and are taken in pleasant dining areas. EVIDENCE: The home employs an activities co ordinator and care staff are also involved in providing activities for residents. The care records showed that residents were involved with pastimes which suited their individual preferences. One resident told the Inspector that they had been for a walk into the village that morning, accompanied by a member of staff and this was something they often enjoyed doing. The home overlooks open fields and some residents said that they enjoyed sitting outside to look at the views and to walk in the well maintained gardens. A variety of seating areas are provided to enable residents to sit outside. A calendar of events was displayed on the notice board and residents were aware of the activities available. Examples of these were bingo, music and movement and singing along to the organ. Grove House DS0000019999.V293512.R01.S.doc Version 5.1 Page 12 Discussions with residents and their relatives indicated that the routines of daily living were generally flexible to suit the preferences of individuals. Visitors to the home said that they felt welcome and that staff were friendly and helpful. Residents and relatives commented that the food was of a good standard and alternatives were provided in accordance with the likes and dislikes of residents. Assistance at meal times was discreet and sensitive. Grove House DS0000019999.V293512.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Policies and procedures were in place that assisted in ensuring that the welfare of residents was safeguarded. Staff attitudes and awareness underpin these policies and procedures. Residents feel that their concerns are taken seriously and acted upon. EVIDENCE: A complaints procedure was available that indicated a swift response would be taken in the event of a complaint. No complaints had been received by the home and none had been received by the CSCI. A complaints book was kept and discussions with residents and relatives indicated that they felt if they had any concerns they would be listened to and appropriate action taken. Two relatives said that they would approach the provider directly and two residents said that they would approach the manager or a member of staff if they needed to. Minor complaints and the action taken were not being recorded, a recommendation has been made in respect of this. A copy of Derbyshires protection of vulnerable adults Policies and procedures were in place that assisted in ensuring that the welfare of residents was safeguarded. Staff attitudes and awareness underpin these policies and procedures. Residents feel that their concerns are taken seriously and acted upon. policy and procedures was in the home and the manager had attended a training course regarding the policy and procedures. A number of staff had Grove House DS0000019999.V293512.R01.S.doc Version 5.1 Page 14 accessed the relevant training and the remainder of staff were booked to attend a course. Discussions with staff indicated that they were aware of what to do if they had concerns about a residents welfare. Grove House DS0000019999.V293512.R01.S.doc Version 5.1 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, 20, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents live in a home that is generally well decorated, comfortable and well maintained. EVIDENCE: Residents who were spoken to commented that they were pleased with their individual accommodation and said that the home was comfortable, pleasant and furnished very nicely. One resident showed the Inspector their bedroom that was personalised and arranged to suit the preferences of that person. An ongoing programme of redecoration and replacement of furniture was in place. The care plans had been updated to include the reasons where particular items of furniture had not been provided such as where additional space was required for equipment. A passenger lift was provided that some residents were able to use independently.The home was clean and free from offensive odours. Grove House DS0000019999.V293512.R01.S.doc Version 5.1 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 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The homes recruitment practices assisted in the safeguarding of residents. The home has a commitment to training that supports staff in the work they do. EVIDENCE: A sample of staffing rotas was examined that included the week of this visit. These indicated that the home was staffed in accordance with the recommended guidance and to meet with the assessed needs of residents. There were 28 residents accommodated with either medium or low dependency needs. Residents and staff spoken with said that staffing levels were generally satisfactory and met with the needs of residents. Relatives commented that there was always a member of staff available if required. Additional administrative hours were provided and the registered manager was allocated dedicated management time. There were three care assisstants on duty for the morning and afternoon / evening shifts and two care assisstants at night. The staffing rotas did not clearly indicate the separation between care hours and laundry / cleaning hours where a member of staff was employed for both duties. A reccommendation was made in respect of this. Grove House DS0000019999.V293512.R01.S.doc Version 5.1 Page 17 Training records were sampled that indicated that a comprehensive training programme was in place that reflected the needs of those residents accommodated. A recent training event had covered Dealing with distress. Staff said that this had been a useful exercise and had assisted in understanding the needs of those residents with dementia. The home has continued to invest in training for National Vocational Qualifications and has again exceeded the target of 50 of care staff achieving NVQ 2. The home is commended for exceeding this standard. Staff commented that one of the best things about the home was the commitment to training and having the opportunity to access learning that was relevant to their job. Two staff files were examined that demonstrated the home had a thorough recruitment procedure and included the information required by regulations. Both files contained CRB checks, proof of identity and two written references. Grove House DS0000019999.V293512.R01.S.doc Version 5.1 Page 18 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, 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home is well run in the interests of residents, with a strong and approachable management team. These assist in ensuring the health, safety and welfare of residents and staff. EVIDENCE: The registered manager has completed the NVQ level 4 training in management. Discussions with residents, relatives and staff indicated that the home is well run with strong management support. The provider and manager were said to be approachable and staff were confident that their suggestions or concerns would be listened to and acted upon. A system for quality assurance was in place that included resident questionaires, the results of these were Grove House DS0000019999.V293512.R01.S.doc Version 5.1 Page 19 collated and acted upon. The management team demonstrated a strong commitment to improvement in the home. The proprietor has a strong hands on approach in the home. Although the proprietor is present in the home on a daily basis, formal regulation 26 provider visits were not being recorded. A recommendation has been made in respect of this. Certificates of maintenance were examined that indicated that health and safety issues were addressed and that equipment was serviced regularly, these included gas safety, electrical systems and appliances. The manager was aware of the need to complete Regulation 37 notices informing the CSCI of events such as deaths and serious accidents, however not all events covered by Regulation 37 had been notified. A requirement was made in respect of this. Accident records were being completed for some accidents but not all of those that had been recorded in the daily records. A recommendation has been made in respect of this. Grove House DS0000019999.V293512.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A 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 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 X X X 3 X 3 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 X 3 X 2 3 Grove House DS0000019999.V293512.R01.S.doc Version 5.1 Page 21 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. Previous timescale 05/07/05. All incidents covered by regulation 37 must be notified to the CSCI. Timescale for action 01/10/06 2. OP37 37 1 b c d efg 01/06/06 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. 2. 3. 4. Refer to Standard OP7 OP9 OP16 OP27 Good Practice Recommendations Daily records should be completed more regularly and contain further detail. Action should be taken when the maximum and / or minimum temperatures of the medicines fridge are outside the recommended range. Minor complaints should be recorded to include the action taken and outcome. The staffing rotas should clearly indicate the separation DS0000019999.V293512.R01.S.doc Version 5.1 Page 22 Grove House 5. 6. OP33 OP37 between care hours and laundry / cleaning hours where a member of staff is employed for multiple duties. Regulation 26 visits should be recorded. Accident records should be completed for all accidents including falls. Grove House DS0000019999.V293512.R01.S.doc Version 5.1 Page 23 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. 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