Inspection on 18/10/05 for Grove House - City of York Council

This inspection was carried out on 18th October 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 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 - City of York... 23/12/08

Grove House - City of York... 21/11/07

Grove House - City of York... 30/11/06

Grove House - City of York... 21/03/06

Grove House - City of York... 09/03/05

Grove House - City of York... 09/06/04

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

CARE HOMES FOR OLDER PEOPLE Grove House - City of York Council Grove House 40-48 Penleys Grove Street York North Yorkshire YO31 7PN Lead Inspector David Martin Unannounced Inspection 18th October 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 - City of York Council DS0000034935.V259958.R02.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 - City of York Council DS0000034935.V259958.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Grove House - City of York Council Address Grove House 40-48 Penleys Grove Street York North Yorkshire YO31 7PN 01904 628250 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) City of York Council Mrs Ann Morton Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Grove House - City of York Council DS0000034935.V259958.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. All Service Users for Intermediate Care (up to a maximum of 11) will be accommodated within Intermediate Care Unit and be in the category OP. 09/03/05 Date of last inspection Brief Description of the Service: Grove House is a care home run by City of York Council and is registered to provide a service for 22 older people of either gender aged over 65 years who do not have any specialist requirements. There are an additional 11 places for people aged 65 years and above who require ‘Intermediate Care’ or rehabilitation. Grove House was purpose-built approximately 40 years ago and is located within a short walk of local facilities in Monkgate. The centre of York is within 1 mile. The accommodation is provided in single rooms on two floors. The upper floors are accessible via passenger lift. There is an enclosed rear garden. Grove House - City of York Council DS0000034935.V259958.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on 18 October 2005. It was unannounced and took 4 hours to complete. The majority of time was spent with the service users in the home at the time of the inspection and with the staff on duty. There were opportunities to observe staff interaction with the service users. A sample of service user files was examined and a check was made as to whether the home had complied with recommendations from the last inspection. Feedback was given at the end of the inspection to the Registered Manager. What the service does well: What has improved since the last inspection? What they could do better: A review of the leadership of the Intermediate Care Unit should be carried out to ensure it is run in the best interests of service users. .The quality of care planning needs to be improved to assist the staff in understanding and meeting the care needs of individual service users. Fire safety is compromised by the practice of holding open fire doors by unauthorised means. An Immediate Requirement Notice was issued regarding this matter. To safeguard service users from abuse, staff should receive appropriate training. Grove House - City of York Council DS0000034935.V259958.R02.S.doc Version 5.0 Page 6 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 - City of York Council DS0000034935.V259958.R02.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 - City of York Council DS0000034935.V259958.R02.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&6 Prospective service users have information about the home prior to admission but the manager has no say over admissions to the Intermediate Care Unit. EVIDENCE: The manager visits prospective service users in their own homes or in hospital. This was confirmed in the case notes of the service user most recently admitted to the home. One service user said she had known nothing about the home prior to admission but had been visited by a member of staff. She was not unhappy with this. Intermediate care is provided for up to 11 people. The staff in this unit said that, on the whole, referrals to the unit are appropriate. They said that the registered manager is not responsible for decisions about admissions and that this falls to the Intermediate Care team which is separate to the home. The manager should review her role in this process. Grove House - City of York Council DS0000034935.V259958.R02.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 - 10 Service users health and personal care needs are met despite the absence of good quality care planning for the majority of service users. EVIDENCE: In the last inspection report there was a requirement that care plans were developed for all service users which included specific detail as to how service users’ needs are to be met. To date some work has been done but the manager is aware that there is more to do to improve the quality of care planning. This work needs to be given priority. Care planning in the Intermediate Care Unit is provided through the Intermediate Care Team and is up-dated regularly. The systems for the administration of medication were in good order. Service users said that the staff are kind, helpful and respectful. This was borne out in observation of staff interaction with service users. Grove House - City of York Council DS0000034935.V259958.R02.S.doc Version 5.0 Page 10 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 - 15 Service users expressed satisfaction with the standard of service they receive. EVIDENCE: On the day on inspection, service users said they were happy living in the home and no one was able to identify any particular shortcomings. There are no in-house church services although one or two resident attend the local church. Service users said that they are able to see their relatives and friends at times convenient to them. The cook expressed some concern about the lack of variety in the food provided but service users said that the food was good and that choices are available at each meal. Grove House - City of York Council DS0000034935.V259958.R02.S.doc Version 5.0 Page 11 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 & 18 There are policies and procedures in place to protect service users from abuse but staff training in this area is required. EVIDENCE: City of York has produced a complaints leaflet and there are policies and procedures in place. The complaints record contains no recent entries. The home has a copy of the latest version of the multi-agency procedures for the protection of vulnerable adults (POVA). Some staff said they had not received training in safeguarding older people and were not aware of guidance and advice issued in ‘No Secrets’. They did, however, understand the need to report any concerns. The staff said they had not received the Codes of Practice issued by the General Social Care Council but this was refuted by the manager. Grove House - City of York Council DS0000034935.V259958.R02.S.doc Version 5.0 Page 12 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, & 26 Service users live in a home which is generally well-maintained. EVIDENCE: Communal and service users’ own rooms are comfortably furnished and are in good decorative order. Service users’ bedrooms have been decorated with personal items such as photographs and ornaments. Each has its own individual look. Bathrooms and toilets were clean and in good order. Service users said that staff respond promptly to the alarm call system. The system was not working properly at the time of the inspection but was being repaired. The carpet in the lounge opposite the main entrance to the home was badly stained in one area and a ‘club’ style chair was ripped. Both matters require attention. Grove House - City of York Council DS0000034935.V259958.R02.S.doc Version 5.0 Page 13 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 – 30 The home is not staffed in the best interests of service users. EVIDENCE: There are a number of staffing matters that need to be resolved. There are some absences in the staff team and this has created pressure in covering vacant shifts. The manager was unclear about the plan to deal with this in the long term. There are no staff records maintained on the premises. This is a longstanding issue which has yet to be actioned by the City of York. The home has yet to reach the target requiring a minimum of 50 of care staff to have achieved NVQ2 qualifications. This is also a longstanding issue. Staff in the Intermediate Care Unit (ICU) expressed concern that weekend staffing levels are reduced from those during the week. The service manager for the home has explained that the reduction in staffing occurs because there are no admissions and discharges and there is less input from outside professionals. The staff also expressed the view that there is a lack of management input in the ICU and that the work is achieved through a collective effort rather than team leadership. The service manager is aware of this and steps are being taken to resolve it. The registered manager has a formal weekly meeting with staff from the unit. Grove House - City of York Council DS0000034935.V259958.R02.S.doc Version 5.0 Page 14 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 & 38 There are shortfalls in the management of the home which have some impact on the care of service users particularly in the Intermediate Care Unit. EVIDENCE: The staff consider the management team to be approachable and knowledgeable but, as indicated in previous sections of this report, there are issues that the manager must deal with to ensure the service is delivered effectively. A recommendation made in the last inspection report that a survey of the views of service users has not been actioned. A check was made of the monies held on behalf of service users and this showed that the records were not accurate. Since the last inspection, action has been taken to respond to requirements regarding the safety of the gas and electricity supply and equipment. Grove House - City of York Council DS0000034935.V259958.R02.S.doc Version 5.0 Page 15 Many of the doors in the Intermediate Care Unit were held open with rubber door wedges. An Immediate Requirement Notice was issued regarding this matter. Fire doors should only be held open by means authorised by the Fire Authority Grove House - City of York Council DS0000034935.V259958.R02.S.doc Version 5.0 Page 16 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 X X 2 HEALTH AND PERSONAL CARE Standard No Score 7 1 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 1 1 X X X X X X 3 STAFFING Standard No Score 27 1 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 1 x x 1 Grove House - City of York Council DS0000034935.V259958.R02.S.doc Version 5.0 Page 17 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 OP7 Regulation 15 Requirement Timescale for action 01/02/06 2 OP18 13 3 OP19 23 An up-to-date care plan should be maintained for each individual service user (Previous timescale of 30/06/05 not met). A plan should be prepared to 01/01/06 ensure all staff participate in training on the safeguarding of service users from abuse. The following issues should be 01/01/06 addressed: The stained carpet in the lounge should be cleaned or replaced. • The torn chair in the lounge should be repaired. Staff records should be maintained in the home. The reduction in staffing levels at weekends should be reviewed to ensure that the home is staffed in the best interests of service users and is safe. The arrangements for the leadership of the Intermediate Care Unit should be reviewed. The record of monies held on behalf of service users should be maintained accurately DS0000034935.V259958.R02.S.doc • 4 5 OP30 OP27 17 18 01/01/06 01/01/06 6 7 OP27 OP35 18 17 01/01/06 01/01/06 Grove House - City of York Council Version 5.0 Page 18 8 OP38 23 Fire doors must only be held open by means authorised by the Fire Authority. An Immediate Requirement Notice was issued. 18/10/05 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 5 6 Refer to Standard OP6 OP18 OP18 OP28 OP31 OP33 Good Practice Recommendations The registered manager’s role in the admission of service users to the Intermediate Care Unit should be reviewed. A copy of ‘No Secrets’ should be made available to staff. Staff should be encouraged to read the Codes of Practice issued by the General Social Care Council. A minimum of 50 of the staff team should have NVQ2 qualifications in care. The Register Manager should obtain an NVQ4 in care. A survey of the views of service users should be carried out. Grove House - City of York Council DS0000034935.V259958.R02.S.doc Version 5.0 Page 19 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 - City of York Council DS0000034935.V259958.R02.S.doc Version 5.0 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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