Inspection on 01/08/05 for Grovelands

This inspection was carried out on 1st August 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

Grovelands 25/10/07

Grovelands 05/07/06

Grovelands 22/11/05

Grovelands 07/03/05

Grovelands 11/11/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Grovelands 38 Grovelands Road Purley Surrey CR8 4LA Lead Inspector Mohammad Peerbux Unannounced Inspection 1 August 2005 9:30am 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 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 Stationary 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. Grovelands G53 S25786 Grovelands V212589 010805 stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Grovelands Address 38 Grovelands Road, Purley, Surrey, CR8 4LA Telephone number Fax number Email 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 8660 1806 020 8660 1806 THF Care Estates Limited Miss Josephine McHugh Care Home 14 Category(ies) of Learning Disability registration, with number of places Grovelands G53 S25786 Grovelands V212589 010805 stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 7 March 2005 Brief Description of the Service: The Manor, 38 Groveland’s Road Purley is owned staffed and managed by THF Care Estates. The home is registered to provide residential care to fourteen adults with learning disabilities. The Manor is a substantial detached Edwardian house constructed around 1912, with a more recent single storey extension. The home also has an annexe to the side of the house comprising of a lounge bedroom and bathroom. The living accommodation is spread over three floors. The home is situated in a quiet residential area in Purley close to local shops, local buses and Purley Station.There is ample space in the front of the home for parking. Grovelands G53 S25786 Grovelands V212589 010805 stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first inspection for the year 2005/06. It was an unannounced inspection and took place over three hours. Some times were spent looking at the policies and procedures, talking to the manager, staff and to some of service users. They are all thanked for their time and assistance. A tour of the building was also carried out and some service users were met in their rooms. Service users spoken to stated that they were happy with the care being provided. Overall the home continues to provide a good standard of care. What the service does well: What has improved since the last inspection? What they could do better: The manager must ensure that the Statement of Purpose and Service User’s Guide are two separate documents and that they contain all the relevant information. The registered provider must ensure that all parties concerned sign all contracts so service users are aware of the services they are being offered. Medication administration records must be accurately completed at all times. Grovelands G53 S25786 Grovelands V212589 010805 stage4.doc Version 1.40 Page 6 The complaints procedure must be amended to include the name, address and telephone number of the Commission and the adult protection procedure must be reviewed to state how to report allegation of abuse . The registered manager must ensure that formal supervision sessions are held with all care staff at least six times a year, and that these sessions are recorded and signed by both the supervisor and supervisee. The door guard on the lounge door must be repaired for the safety of service users and staff. 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. Grovelands G53 S25786 Grovelands V212589 010805 stage4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Grovelands G53 S25786 Grovelands V212589 010805 stage4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4 and 5 The Statement of Purpose and Service User Guide are inadequate and do not provide sufficient information for prospective service users to be clear about the services the home provides to meet their needs. The home is able to demonstrate that service users needs are being properly assessed, and that the range of needs presented is being appropriately met. The necessary information and opportunity to visit the home is being made available to service users, enabling an informed choice regarding the suitability of the home to be made. Service users in the home are not always aware of the services they are being offered as no signed contracts were in place. EVIDENCE: The Statement of Purpose and Service User’s Guide are incorporated in one document and do not contain all the relevant information as per regulation 4 and 5.The manager must ensure that the Statement of Purpose and Service User’s Guide are two separate documents and that they contain all the relevant information. Service users are only admitted to the home after a full assessment of their needs has been carried out by the home and the Placing Authority for Grovelands G53 S25786 Grovelands V212589 010805 stage4.doc Version 1.40 Page 9 individuals referred through Care Management, involving the prospective service user/recognised representative. It was noted that the home also carries out a very comprehensive needs assessment. It was clear from care plans sampled at random that service user’s needs are being met. Records revealed that service users are in regular contact with other health and social care professionals. From observation of the interaction between staff and service users it was evident that the staff team has managed to achieve good verbal and non-verbal communication with all the service users and that the home was providing more than adequate care. All service users are afforded the opportunity to visit the Home prior to moving in. Admissions are then made on a trial basis. Service users or their recognised representatives are provided with a costed contract/statement of terms and conditions of occupancy which are agreed between each prospective service user and/or representative and the home. However three copies of contract were sampled and they were signed only by the registered manager. The registered manager must ensure that all parties concerned sign all contracts so service users are aware of the services they are being offered. Grovelands G53 S25786 Grovelands V212589 010805 stage4.doc Version 1.40 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,9 and 10 The service users have comprehensive individual care plans with detailed information on their needs and personal goals. Individual care plans include consultation with service users and are regularly updated by the key-worker to reflect current needs. The home operates a risk management strategy thus enabling the service users to participate in activities in the home and in the community with appropriate support. EVIDENCE: Three service users’ care plans were sampled, it was noted that they were all up to date and well maintained. Overall, the plans demonstrated a thorough needs assessment, which clearly set out how current and anticipated needs would be met. The plans checked established individualised procedures for service users likely to challenge the service, focusing on positive management strategies. The home reviews the care plan of the service users every six months. Documentary evidence was available to show that the annual review included the care manager and/or other professionals from the placing authority. Grovelands G53 S25786 Grovelands V212589 010805 stage4.doc Version 1.40 Page 11 The rights of service users to make decisions about their own lives is central to the ethos of the home, support and guidance is given in all areas to ensure that service users are making decisions which are in their best interests. A risk assessment is in place for each service user. Potential risks are identified all aspects of their daily living both inside and outside the home. The home is able to demonstrate that this standard is met as individualised care plans were in place for each service user that referred to action required to minimise identified risks and hazards. The home has a confidentiality policy in respect of personal information held in relation to service users. General service user’s documentations (i.e. service user plan, medical appointments and reviews) are kept locked in the staff office on the ground floor of the home. Grovelands G53 S25786 Grovelands V212589 010805 stage4.doc Version 1.40 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,14,15 and 17 The service users at the home are offered the opportunity to engage in age appropriate activities with an emphasis on using community based facilities. The daily routines and house rules promote service users’ rights, to encourage independence. Dietary needs are well catered for and a well balanced diet is provided, to ensure a nutritious diet based on personal preferences. EVIDENCE: The inspection findings indicated staff work very closely with the service users to develop independent living skills at the home. It was observed staff assisting users with making decisions about tasks, activities inside and out of the home. Evidence recorded in individual care plans also indicated staff assigned as key workers to service users, offer support, advice and other input that help to enhance and develop independent living skills. Grovelands G53 S25786 Grovelands V212589 010805 stage4.doc Version 1.40 Page 13 During the week the service users attend local daycentres. These include Hallmead day Centre, Peter Sylvester Centre and Tandridge Hill Farm. The service users each have a programme of activities at the centres. One of the service users is not attending any daycentre at present however the manager is actively looking into this issue. The evidence examined plus discussions held with service users and staff, indicated each service users is supported to access a range of community events. Some are designed specifically for people with learning disability; others are generic and open to all members of the local communities. The home has an ‘open’ visitor’s policy and simply recommends that visitor’s telephone to say they are coming to ensure there loved one will be available. Visitors can be seen in any of the homes communal areas as well as the service user’s bedrooms. The home had adequate setting where meals are consumed. The staff stated that service users are asked to choose the meals they want to eat. However the service users are encouraged to choose food that are healthy and of nutritional value. Grovelands G53 S25786 Grovelands V212589 010805 stage4.doc Version 1.40 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20 and 21 Personal care is carried out in a way that residents prefer so that dignity and choice are maintained. Service users’ physical and emotional health needs are met by this home. Service users have been consulted on issues around aging and death, thus ensuring their cultural needs and individual wishes will be carried out. The system for administration of medications is poor and potentially place service users at risk. EVIDENCE: The findings indicated most service users are able to exercise some level of independence in their personal care needs with appropriate support from staff where needed. The overall impression gained from observing how service users live at the home, indicated a good culture of semi-independent living, with most users have reasonable control over their lives and support from staff where needed. The recorded information on case notes and medical records indicated staff and the manager carry out assessment of each user’s health care needs. The evidence also indicated that appropriate medical links are maintained, with information and reminders about medical appointments. Grovelands G53 S25786 Grovelands V212589 010805 stage4.doc Version 1.40 Page 15 The medication administration records were audited. The home’s medication policy indicates that when medications are administered there should be two signatures however on several instances there were only one signature. The manager must ensure that medication administration records are accurately completed at all times. The manager stated that most of the service users and their respective families have been consulted about their wishes concerning terminal care and death, including religious and cultural customs to be observed, in the event of a service user’s death. Written acknowledgment of these discussions has been placed on each service users files. Grovelands G53 S25786 Grovelands V212589 010805 stage4.doc Version 1.40 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The home has policies and procedures in place to deal with complaints however it needs amending to include the name, address and telephone number of the Commission. The policies and procedures on abuse also need amending to include how allegation of abuse should be reported. This will ensure that service users feel safe and protected. EVIDENCE: The current complaints procedure is a good and gives clear step-by-step guide of how to make a complaint. However it does not give the name, address and telephone number of the Commission. The manager is required to review the complaints procedure to include this information. A record of complaints made about the operation of the home is appropriately maintained and includes details of any investigations, its outcome and action taken (if any). The home has a detailed adult protection procedure however it must be amended to include how to report allegation of abuse. The manager has attended the ‘training for trainers’ adult abuse awareness training course which she then cascades to the care staff. Grovelands G53 S25786 Grovelands V212589 010805 stage4.doc Version 1.40 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,28 and 30 The home is generally hygienic and clean, homely and comfortable; this environment therefore facilitates the service users’ health and emotional wellbeing. EVIDENCE: The home is suitable for its stated purpose. It is accessible, meet service users’ individual and collective needs in a comfortable and homely way. Service users’ bedroom are personalised to reflect their individual needs, and personalities. Overall the home was decorated to a reasonably good standard throughout and appeared to be very comfortable, bright and warm. All the bedrooms are single occupancy. There are thirteen single bedrooms and an annex with a lounge, bedroom and bathroom. The annex has its own entrance and can also be accessed through the kitchen. Grovelands G53 S25786 Grovelands V212589 010805 stage4.doc Version 1.40 Page 18 The inspection findings indicated the home provides adequate living and bedroom spaces for each service user. Some of the bedrooms were checked. They were decorated to a good standard. The rooms contained a variety of personal furniture and fittings that reflected the individual’s personality. The ground floor of the home is very spacious. The accommodation includes a spacious lounge, which was large enough for all the service users to sit together if they wished. The dining room area was again domestic in nature and contained suitable tables and chairs. The garden was well maintained. The home is kept very clean and hygienic and free from offensive odours throughout. Systems are in place to control infection in accordance with relevant legislation and published professional guidance. Grovelands G53 S25786 Grovelands V212589 010805 stage4.doc Version 1.40 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34 and 36 The staff team at the home have a range of skills and ability, which appear to meet the needs of the service users. Morale was positive and staff professional in their manner during the inspection. However one-to-one supervision sessions are still not being carried out on a regular basis and this could affect the quality of the work that the staff do. EVIDENCE: The manager stated that all staff have a job description in place. The job descriptions contain the main purpose, tasks, including household and administrative tasks staff are expected to perform and be responsible for. The manager advised that three members of the current staff team have achieved NVQ level 2 and one staff is currently doing NVQ level 3. The manager has nearly completed the Registered Managers Award (RMA) as she is waiting for the last unit to be assessed. The home arranges for a least three members of staff to be on duty at times throughout the day and evening. Two staff sleep-in at night. Current staffing levels are consistent with minimum standards. Grovelands G53 S25786 Grovelands V212589 010805 stage4.doc Version 1.40 Page 20 As part of the inspection process staff files were sampled at random and found to contain photographs, application forms, references, criminal record checks, application forms and copies of identification. The supervision records were sampled and it was noted that the staff are not having regular supervision. The registered provider must ensure that formal supervision sessions are held with all care staff at least six times a year, and that these sessions are recorded and signed by both the supervisor and supervisee. Grovelands G53 S25786 Grovelands V212589 010805 stage4.doc Version 1.40 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,39 and 42 The home management generally provides leadership, guidance and direction to staff to ensure service users receive consistent quality care. The health, safety and welfare of service users and staff are not being protected, as fire safety is not being adhered to. EVIDENCE: Josie McHugh is the manager of the Manor, 38 Groveland’s Road. Ms McHugh has worked at The Manor since 1991 in various positions. She became the home manager in 1997. Ms McHugh has a City and Guilds Advanced Management in Care Award as well as a D32 and D34 N.V.Q. Assessors Award. She has nearly completed the Registered Managers Award (RMA) and is waiting for the last unit to be assessed. It was obvious that service users choices were catered for and respected in the home and that the home was run to the needs of the service user. Service Grovelands G53 S25786 Grovelands V212589 010805 stage4.doc Version 1.40 Page 22 users spoken to on the day of the inspection seemed happy, confident and comfortable in their surroundings. Service users families are consulted about the conduct of the home and their views are regularly sought by means of the telephone, invitations to reviews, and for some, regular visits to the home, where relatives are able to meet and talk directly with care staff and the manager. The home has recently been accredited with “Investor In People”. One health and safety issue arose during this inspection. The door guard on the lounge door was not working properly and the door was wedged open. The manager must ensure that the door guard is repaired for the safety of service users and staff. Certificates relating to health and safety were up to date. Gas safety, fire safety and portable appliance testing certificates were seen. Grovelands G53 S25786 Grovelands V212589 010805 stage4.doc Version 1.40 Page 23 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 3 2 Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 x 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 x 3 3 x 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 x 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Grovelands Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 x x 2 x G53 S25786 Grovelands V212589 010805 stage4.doc Version 1.40 Page 24 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. 1. Standard 1 Regulation 4 and 5 Requirement The manager must ensure that the Statement of Purpose and Service User’s Guide are two separate documents and that they contain all the relevant information. The registered manager must ensure that all parties concerned sign all contracts so service users are aware of the services they are being offered. Timescale for action 31/10/05 2. 5 17(2) 31/10/05 3. 20 13(2) The manager must ensure that 01/08/05 medication administration records are accurately completed at all times. The manager is required to review the complaints procedure to include the name, address and telephone number of the Commission. The adult protection procedure must be amended to include how to report allegation of abuse . The registered provider must ensure that formal supervision sessions are held with all care staff at least six times a year, and that these sessions are recorded and signed by both the 30/09/05 4. 22 22(7)(a) 5. 6. 23 36 13(6) 18(2) 30/09/05 31/10/05 Grovelands G53 S25786 Grovelands V212589 010805 stage4.doc Version 1.40 Page 25 supervisor and supervisee. 7. 42 23(4)(c) The manager must ensure that the door guard on the lounge door is repaired for the safety of service users and staff. 01/08/05 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. Refer to Standard Good Practice Recommendations Grovelands G53 S25786 Grovelands V212589 010805 stage4.doc Version 1.40 Page 26 Commission for Social Care Inspection 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Grovelands G53 S25786 Grovelands V212589 010805 stage4.doc Version 1.40 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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