Inspection on 15/05/07 for Grove House & Grove Lodge

This inspection was carried out on 15th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Grove House & Grove Lodge 26/09/06

Grove House & Grove Lodge 08/02/06

Grove House & Grove Lodge 11/10/05

Grove House & Grove Lodge 23/11/04

Grove House & Grove Lodge 29/07/04

Grove House & Grove Lodge 24/02/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Grove House/Grove Lodge 13 & 14 Norton Close Borehamwood Hertfordshire WD6 5DW Lead Inspector Pat House Unannounced Inspection 15th & 18th May 2007 10:00 Grove House/Grove Lodge DS0000019398.V339563.R01.S.doc Version 5.2 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/Grove Lodge DS0000019398.V339563.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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/Grove Lodge DS0000019398.V339563.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grove House/Grove Lodge Address 13 & 14 Norton Close Borehamwood Hertfordshire WD6 5DW 0208 953 6443 0208 953 6443 H 3071@mencap.org.uk H4037@mencap.org.uk Royal Mencap Society 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) Manager post vacant Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Grove House/Grove Lodge DS0000019398.V339563.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th September 2006 Brief Description of the Service: Grove House and Grove Lodge, known as numbers 13 and 14 Norton Close, are a pair of semi-detached houses situated at the end of a cul-de-sac in a residential area about one mile from Borehamwood town centre. Each House is self-contained with its own kitchen, dining room, lounge and bathroom but is jointly managed by staff whose office is in Grove house. The home has a shared garden to the rear of the building, accessible via a ramp and which includes raised decking, a patio area with a barbeque and some grass and borders. There are parking bays to the front of the buildings. Grove House accommodates six service users and Grove Lodge accommodates three service users who each have their own single room. The service users residing in the Lodge are more independent than those in the House. However, all current service users are able to make decisions about the running of the home and able to use the transport and leisure facilities available nearby. Although the charity Mencap provides the care services in the home, the building is owned and rented from a Housing Association. The Statement of Purpose, Service User’s Guide and latest CSCI inspection report for the home are kept in the office and are available on request. A copy of the Service User’s Guide, in user-friendly format, is also displayed on the home’s notice board. Current fees for the home range from £367.82 to £421.90 per week. Grove House/Grove Lodge DS0000019398.V339563.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days with one inspector. The manager was not on duty on the first inspection day (15/5/07), and consequently some records were not available. A second visit was therefore made on 18/5/07 when the manager was able to provide the additional information, which completed the inspection. Some residents were at home on both days in Grove House and were able to share their views about the home and how it is run. Staff were also spoken with and all parts of the home were visited briefly, except for some individual bedrooms, which were locked. A selection of records was checked and the procedure for administering medication was examined. There have been no new residents admitted to the home since the last inspection and there are no vacancies. What the service does well: What has improved since the last inspection? The manager has updated the Statement of Purpose and Service User’s Guide and all residents now have a written contract. Some repairs have been made in the Lodge, and the garden has been tidied. Volunteers have also been booked to provide more improvements to the garden. Risk assessments have been produced covering hazards linked to the needs of the residents with epilepsy and the medication policy is up to date. All staff have either enrolled to do, or have completed NVQ training. Grove House/Grove Lodge DS0000019398.V339563.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Grove House/Grove Lodge DS0000019398.V339563.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Grove House/Grove Lodge DS0000019398.V339563.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,2 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are given detailed information about the home and have their needs fully assessed before they become a resident. This means that all parties can be sure that services provided at the home can meet individual needs and that prospective residents can make an informed choice about where to live. EVIDENCE: The written Statement of Purpose and Service User’s Guide have been recently updated and are also produced in a user-friendly format, which include pictorial guides. Residents spoken with during the visit all said they had copies of the Guide and understood what it meant. All residents have a formal contract with the home, which is also produced in a user-friendly format. The service user records, which were examined, contained copies of the care summaries from referring agencies and full assessments completed by senior staff in the home. These records contained all appropriate details and initial care plans had been drawn up from this information. Grove House/Grove Lodge DS0000019398.V339563.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7 and 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Procedures in the home include competing detailed individual plans and risk assessments for the residents who are fully involved in this planning and in making choices about all aspects of their daily lives. EVIDENCE: A selection of care plans was checked, after the people concerned were spoken with. The care planning was thorough and meaningful and in all cases a wide range of individual risk assessments had been completed. Two of the residents, who go out from the home independently, have risk assessments, which result in mobile phone checks being made to confirm their safety. During the inspection, one of these residents had arrived at their destination and rang staff at the home, as agreed, to confirm they had arrived safely. It was recommended at the last inspection that more risk assessments were needed for meeting the needs of the two residents who have epilepsy. These records have been completed and further assessments are being finalised for Grove House/Grove Lodge DS0000019398.V339563.R01.S.doc Version 5.2 Page 10 managing any associated nighttime risks. The changing nature of the needs of the current residents, and the varying levels of independence over the two buildings, make it essential that all risks are reviewed regularly and control measures updated when necessary. The manager and staff are clear about these needs and regularly review their planning. Care staff have received training in Person Centred planning and are working with the residents to complete Person Centred plans. Residents spoken with said they had been fully involved in these plans and those seen were completed well with a variety of personal goals included. The residents also said they were fully involved in the running of the home and were always supported by staff to make decisions about their daily lives. This involvement was apparent at this, and at previous inspections. The residents have control, to varying degrees over handling their own finances. One person manages their own Building Society account and collects their own personal allowance unaided. A risk assessment has been completed for this. Grove House/Grove Lodge DS0000019398.V339563.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents in the home are supported to have active social lives and maintain family and community links. Procedures in the home ensure that residents also make their own decisions about their daily lives, including choices of meals. This all ensures that residents enjoy a healthy and well- balanced lifestyle. EVIDENCE: Most residents attend Day Centres and some choose to go to a weekly club in the evening. The home has a computer for the use of residents but some also have laptops in their rooms. A new cycling exercise machine has been provided and staff were completing a risk assessment for its use. There is a pay phone in the hall and evidence was seen that one resident had been out to vote at the recent local election. Records showed that family members often stayed until quite late, visiting their relative and residents spoken with said they chose when they went to bed and got up. Three of the male residents are going with staff on a holiday to Blackpool and some of the ladies said they hoped to go to Grove House/Grove Lodge DS0000019398.V339563.R01.S.doc Version 5.2 Page 12 Paris with staff in the autumn. A group of residents discussed their social life during the visit and said they frequently went out together in the evening to shows and parties and had barbeques in the summer. Lists on the wall showed the rota for the residents to complete their domestic tasks and those spoken with said they all had input into choosing the meals in the home and enjoyed the food provided. A copy of the report from a recent Environmental Health visit showed that there was only one small requirement made, and this had now been complied with. Grove House/Grove Lodge DS0000019398.V339563.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures followed in the home ensure that residents are supported with personal care in a way they choose and have their health needs met. The system for administering medication in the home is sound and helps to protect the residents. EVIDENCE: Service user records seen had visits to and from doctors and hospitals documented. There was evidence of other specialist involvement and one resident has been referred to a dietician and sees this professional at the day centre. The care plans contain a section entitled “My health Plan” and residents are involved in these records, which are in user-friendly format. At the previous inspection, new specialist lighting was seen and the resident who has been using this equipment said it had benefited their ability to see clearly in the home. A resident with hearing difficulties was wearing their hearing aid and residents said that any health problems they had were promptly dealt with by staff and Health professionals. Residents also said that they chose how and when staff assisted them with any personal care needs. Grove House/Grove Lodge DS0000019398.V339563.R01.S.doc Version 5.2 Page 14 Procedures for the administration of medication were checked and records were all in order. There were records in place for medication held at the day centre and a risk assessment in place for a resident who handles their own medication. Grove House/Grove Lodge DS0000019398.V339563.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures in the home ensure that residents are protected from abuse and are confident that any concerns they might have will be listened to and dealt with. EVIDENCE: The home has written policies about making a complaint and covering Adult Protection. The complaints’ policy, in user-friendly format was displayed in the home and residents confirmed they were fully aware of the procedure. The complaints book was seen, and all issues recorded were from residents and had been appropriately dealt with. Staff had received training in Adult Protection and were aware of Hertfordshire County Councils procedures and the home’s own Whistle Blowing policy. Grove House/Grove Lodge DS0000019398.V339563.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally resident’s benefit from living in a home, which is well maintained, clean and hygienic although some areas in the Lodge and the laundry need more attention to maintain an adequate standard. EVIDENCE: The carpet in Grove House has been replaced and window blinds have been ordered for both floors. The bathrooms, bedrooms and communal areas were all well decorated and clean. To promote infection control procedures white paper towels were being used in the bathrooms. Bedrooms in the Lodge were mostly locked, as the occupants were out. There are call alarms in the hallway and landing in this building but this provision is being reviewed in the general risk assessments around residents with epilepsy. It is acknowledged that the residents in the Lodge are quite independent and look after their own environment to a large degree. However, the door to the garden needed some adjustment and there were no paper towels in the toilet Grove House/Grove Lodge DS0000019398.V339563.R01.S.doc Version 5.2 Page 17 or bathroom during the visit. The kitchen blind was also broken and the floor in the bathroom appears to need replacing. The manager said he will be checking the maintenance again in the Lodge and will order any necessary repairs. There are two tumble dryers in the laundry and one is not working, and was out of order at the last inspection. The manager said that a part had been ordered for this machine and it should soon be repaired. Flooring in the laundry also needs repairing or replacing. Grove House/Grove Lodge DS0000019398.V339563.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents in the home benefit from receiving support from a staff group who are well trained and provide a professional service. The home’s recruitment procedures also ensure that residents are protected from abuse. EVIDENCE: The residents spoken with felt that, generally, there was enough staff on duty in the home. One person with deteriorating eyesight now has regular visits from a volunteer who takes them out. There are also extra staff hours provided for shopping trips. However, some staff members felt that there were times, especially at night or in the early morning when more staff were sometimes needed. There is also one resident in the Lodge whom staff felt would benefit from having more individual staff input so that cooking skills could be developed and they could become more independent. The manager will keep the staff complement under review, especially as the needs of the residents change over time. Levels of staff training are very good and it is commendable that all staff members have either completed or are undertaking level 3 NVQ training. Grove House/Grove Lodge DS0000019398.V339563.R01.S.doc Version 5.2 Page 19 A selection of staff files were checked and evidence was seen that sound recruitment procedures are followed in the home and that all employment checks are in place before staff start work. Grove House/Grove Lodge DS0000019398.V339563.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from living in a well run home where their views are listened to and acted on and where the welfare of both residents and staff are promoted. EVIDENCE: Residents and staff spoken with praised the manager of the home and said they found him approachable and always available to listen to their views. The manager has applied for registration with the CSCI and the procedure for this is under way. Staff confirmed that meetings are held monthly and minutes are taken. Residents meetings are also minuted and residents spoke about what was discussed. Grove House/Grove Lodge DS0000019398.V339563.R01.S.doc Version 5.2 Page 21 There is a Quality Assurance programme in place, which is initiated by the Head office of Mencap and ensures the views of residents, families and other stakeholders are sought. The Health and Safety statement for the home was seen and the corresponding poster was displayed. Generic risk assessments had been completed for the home and a discussion took place about extending the range of the areas covered. Fire records were checked and appropriate drills and tests were documented. Records of accidents and incidents were also seen and were well documented. Grove House/Grove Lodge DS0000019398.V339563.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 x 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 x 4 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Grove House/Grove Lodge DS0000019398.V339563.R01.S.doc Version 5.2 Page 23 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Grove House/Grove Lodge DS0000019398.V339563.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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