Inspection on 22/11/05 for Grovelands

This inspection was carried out on 22nd November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Grovelands 25/10/07

Grovelands 05/07/06

Grovelands 01/08/05

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 22nd November 2005 9:30 Grovelands DS0000025786.V268108.R01.S.doc Version 5.0 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 Grovelands DS0000025786.V268108.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Grovelands DS0000025786.V268108.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Grovelands Address 38 Grovelands Road Purley Surrey CR8 4LA 020 8660 1806 020 8660 1806 themanor@thfce.wanadoo.co.uk 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) THF Care Estates Limited Miss Josephine McHugh Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Grovelands DS0000025786.V268108.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st August 2005 Brief Description of the Service: The Manor, 38 Grovelands 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 DS0000025786.V268108.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s second inspection for the year 2005/06. It was an unannounced inspection and took place over two and quarter hours. Some times were spent looking at the records and talking to the manager, staff and service users. A tour of the building was also carried out. Requirements and recommendations from the previous inspection were also discussed with the manager. They are all thanked for their time and assistance. What the service does well: What has improved since the last inspection? The home has now in place a comprehensive Statement of Purpose, and Service User’s Guide, a copy of which is issued to each service user. Both are well presented and cover the information required by the Care Homes Regulations (2001), including the aims and objectives of the home and the facilities and services provided. All service users have contracts in place and these are signed by all parties concerned. The complaints and abuse procedures have been amended accordingly. Care staff are receiving supervision on a regular basis, which contributes to the standards of care being provided to service users. Grovelands DS0000025786.V268108.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Grovelands DS0000025786.V268108.R01.S.doc Version 5.0 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 Grovelands DS0000025786.V268108.R01.S.doc Version 5.0 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 the following standard(s): 1 and 5 The Statement of Purpose, and Service User Guide provide prospective service users with details of the services the home offers. This enables them to make an informed decision about admission to the home. EVIDENCE: It was previously required that 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 home has now in place a comprehensive Statement of Purpose, and Service User’s Guide, a copy of which is issued to each service user. Both are well presented and cover the information required by the Care Homes Regulations (2001), including the aims and objectives of the home and the facilities and services provided. The manager stated that she is planning to have the Service User’s Guide available to service users in pictorial format. It is recommended that a review date is included on both documents. Service users or their recognised representatives are provided with a costed contract/statement of terms and conditions of occupancy that are agreed between each prospective service user and/or representative and the home. It was previously required that the registered person must ensure that all service users contracts are signed by all parties concerned. Three contracts were sampled at random and they were all signed accordingly. Grovelands DS0000025786.V268108.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8 Choice and decision making for service users is promoted to a high standard enabling their involvement and opportunities to contribute to the operation of the home. EVIDENCE: Regular house meetings are held and service users are invited to make a contribution. While none are able to contribute to, for example, the development of policies and procedures, staff ensure that they do consult the service users with regard to the day-to-day functioning of the home. It was evident that service users took an active role in the daily operation of the home and were involved in planning the menus and arranging their social/leisure activities. Grovelands DS0000025786.V268108.R01.S.doc Version 5.0 Page 10 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 the following standard(s): 13 and 16 Service users are encouraged to explore opportunities to enhance their quality of life as well as maintain and participate with friends and the local community, with the aim of maximum integration. The daily routines and house rules promote service users’ rights, and ensure equality and that all rights are enjoyed by service users. EVIDENCE: The home encourages the use of community facilities and the service users regularly go bowling, to the cinema, and the local swimming pool. There are shops within walking distance. They use local pubs and go into nearby Croydon to restaurants and cafes. Staff are encouraged to spend one to one time outside the home with the person they key work. The home has its own transport in the form of a people carrier. The service users all have freedom passes and are encouraged to use public transport if it is appropriate. Some of the service users go to church on a regular basis. Service user, who was at home at the time of this inspection, appeared to enjoy a high level of independence at the home. Routines can be very flexible Grovelands DS0000025786.V268108.R01.S.doc Version 5.0 Page 11 and are well observed to take into account all the service users individual needs. Grovelands DS0000025786.V268108.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 20 Service users’ medication is also well managed to ensure maximised good health. EVIDENCE: It was previously required that the manager must ensure that medication administration records are accurately completed at all times. The medication administration records were audited. In general, medication records, including medicines received, administered and returned were all being appropriately maintained. Medication profiles in respect of each service user were also available. Grovelands DS0000025786.V268108.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 22 and 23 Complaints are generally managed well, which should ensure that service users’ and relatives’ concerns are listened to. The home’s policies and procedures help protect service users from abuse and help staff if they need to tell someone about any bad care practice they may observe. EVIDENCE: It was previously required that the complaints procedure is amended to include the name, address and telephone number of the Commission.This is now in place. There have not been any complaints made to the home since the last inspection. The home has a detailed adult protection procedure; the procedure states that any member of staff who is being investigated would be suspended pending the investigation. The adult protection procedure has been amended to include how to report allegation of abuse in line with requirement made at the last inspection. Grovelands DS0000025786.V268108.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 24,27 and 29 The overall impression when visiting this home is that it is homely, comfortable clean and hygienic and the staff successfully promote an environment which contributes to the service users health and emotional well-being. 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 however the front and back staircases need redecorating. The manor has four toilets, three bathrooms and two showers. The toilets were clean and in working order. The bathrooms and toilets are located close to the service user’s bedrooms and other communal areas. The service users are fully mobile and there are no adaptations in the home with the exception of a flashing doorbell for a service user who is deaf. Grovelands DS0000025786.V268108.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 and 36 The home’s recruitment procedures protect the service users through vigorous staff vetting. Care staff are receiving supervision on a regular basis, which contributes to the standards of care being provided to service users. EVIDENCE: 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 registered manager advised that all the homes care staff are receiving at least six supervisions a year covering good care practices and career development. From staff files sampled at random there were evidence that staff are being supervised on a regular basis. Grovelands DS0000025786.V268108.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42 The health, safety and welfare of service users and staff are not being protected, as fire safety is not being adhered to. EVIDENCE: It was previously required that the manager must ensure that the door guard on the lounge door is repaired for the safety of service users and staff. This requirement was still oustanding at the time of this inspection . A follow up visit was carried out on the next day and the door guard was repaired and working properly. The Registered Person must ensure that fire doors are not wedged open unless held open by a magnetic door holder that responds to the fire warning system. It was also noted that the temperature of one the radiators was reading 50 degrees centigrade. The manager is required to ensure that the maximum surface temperature of space heating devices do not exceed 43 degrees. The manager is also required to carry out risk assessment to identify potential risks of burning from hot surfaces and to assess the vulnerability of those who may be at risk. The results of the risk assessment should be recorded on the Grovelands DS0000025786.V268108.R01.S.doc Version 5.0 Page 17 individual service user care plans, which should include an assessment of capabilities and needs. To ensure the well being of service users, the surface temperature of radiators should be reduced 43 degrees centigrade or cool to touch cover fitted. Grovelands DS0000025786.V268108.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 X X X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X 3 X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X 3 X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X 3 X 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Grovelands Score X X 3 X Standard No 37 38 39 40 41 42 43 Score X X X X X 1 X DS0000025786.V268108.R01.S.doc Version 5.0 Page 19 YES 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 YA24 Regulation 23(2)(b) Requirement The Registered Provider must ensure that the front and back staircases are redecorated. The Registered Person must ensure that fire doors are not wedged open unless held open by a magnetic door holder that responds to the fire warning system. The manager is required to ensure that the maximum surface temperature of space heating devices do not exceed 43 degrees. The manager is required to carry out risk assessment to identify potential risks of burning from hot surfaces and to assess the vulnerability of those who may be at risk. The results of the risk assessment should be recorded on the individual service user care plans, which should include an assessment of capabilities and needs. Timescale for action 31/01/06 2. YA42 23(4)(c) 22/11/05 3. YA42 13(4) 06/12/05 4. YA42 13(4) 06/12/05 Grovelands DS0000025786.V268108.R01.S.doc Version 5.0 Page 20 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 1 Good Practice Recommendations It is recommended that a review date is included on the Statement of Purpose and Service User’s Guide. Grovelands DS0000025786.V268108.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 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 DS0000025786.V268108.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!