Inspection on 25/10/07 for Grovelands

This inspection was carried out on 25th October 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 found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Grovelands 05/07/06

Grovelands 22/11/05

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 Jon Fry Key Unannounced Inspection 25th October 2007 10:15 Grovelands DS0000025786.V352997.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 Grovelands DS0000025786.V352997.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. Grovelands DS0000025786.V352997.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grovelands Address 38 Grovelands Road Purley Surrey CR8 4LA 020 8660 1806 F/P 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.V352997.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th July 2006 Brief Description of the Service: The Manor, 38 Grovelands Road in Purley provides care and support for up to fourteen adults with a learning disability. The home is a large detached Edwardian property situated in a quiet residential area of Purley and is well placed to access local transport links, shops and community facilities. The home has fourteen single bedrooms, a good-sized lounge and spacious dining area with an additional lounge area. The kitchen is spacious and there is a laundry room in the basement. There is a garden with lawn and patio area equipped with tables and seating and a barbecue facility. Fees currently range from £585 to £701 per week. Grovelands DS0000025786.V352997.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We spent three and a half hours at the home and talked individually with four people who live there at the time we visited. We also spoke to the manager and three staff members. Records and documents looked at included care plans, staff files and the home’s User Guide. Completed surveys were received from three relatives, friends or advocates of people who live at the home. The home completed an Annual Quality Assurance Assessment (AQAA) to tell us about the service provided, how it makes sure of good outcomes for the people using it and any planned developments. What the service does well: What has improved since the last inspection? What they could do better: The driveway needs to have better lighting for the safety of everyone at the service. The frequency and recording of staff supervision could be improved. Grovelands DS0000025786.V352997.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Grovelands DS0000025786.V352997.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 Grovelands DS0000025786.V352997.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): 1, 2 and 3. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Good information is available to people about the home. The needs of people using the service are fully assessed to make sure that they can be met. EVIDENCE: The Service Users Guide is in a picture format which is more accessible to people who use the service. This document contains good information about the support provided, decision making, room keys, leisure pursuits and how to contact the CSCI. The home plans to develop this document to be even more user friendly in the future. We saw that assessments had been carried out before individuals came to live at the home. Good quality comprehensive information is kept on file for each person. The service has an admissions procedure. Any person coming to live there is able to visit for a meal and will usually have an overnight stay. A review takes place after six weeks to make sure that the individual is happy and the home is able to meet their needs. Grovelands DS0000025786.V352997.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): 6, 7, 8 and 9. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans generally give good information about the support needs of people using the service but we saw that some of these documents need updating. Risk assessments are completed to help people live as independently as they can. EVIDENCE: Two of the three relatives, carers or advocates who completed surveys said ‘always’ when asked if the home meets the needs of the person they know. One person said ‘usually’. We looked at care plans for two people. These documents contained good information about people’s needs, individual wishes and their social and medical history. A newer Person Centred Plan (PCP) had been developed for one individual that included photographs and some really good personalised Grovelands DS0000025786.V352997.R01.S.doc Version 5.2 Page 10 information about the things they liked and disliked. The manager reported that they are still developing the Person Centred Plans and these need to be completed by key workers for all the people living there. Monthly key work sessions were not consistently recorded in the files we looked at. We have recommended that these be kept up to date and record how individuals are progressing in meeting their goals / dreams. Risk assessments are in place around areas such as using cleaning products and electrical equipment. Grovelands DS0000025786.V352997.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): 11, 12, 13, 14, 15, 16 and 17. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individuals are able to take part in activities and be part of the local community. People living there enjoy the food provided. EVIDENCE: Comments from people who use the service included “I go to the pub” and “I go to see Crystal Palace”. Staff members said “they get a good choice of what they want to do” and “there’s always something going on”. Most of the daily activities attended by people are at local colleges, day centres and local community facilities. The organisation runs a day service that most people attend regularly. Grovelands DS0000025786.V352997.R01.S.doc Version 5.2 Page 12 A relative, carer or advocate said “they enable them to have an active life” and encourage the person “to get out at the farm and work which they love to do”. As stated previously, we saw that the new care plans being developed included photographs of things people liked to do and of places in the local community they enjoyed going to. On the day we visited people were being supported to go out shopping locally to buy food and one person went into Croydon to buy some new boots. One person went off to the pub independently and the manager took another individual to see their relative which is a regular trip supported by the home. People who live there told us that they had enjoyed a recent holiday to Blackpool. Staff said that people living there would benefit from having a computer that is just for their use. Individuals currently can only use the computer in the office when it is not being used by staff. We have recommended that is looked at by the organisation. “I like the food” and “the food’s nice” were comments from people we spoke to. The menu we saw for the week included sausage casserole, beef stew, spaghetti and quiche. An alternative is offered at each mealtime. Individuals are asked about the menus in the meetings held for people who use the service. Grovelands DS0000025786.V352997.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. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health care needs of people who use the service are addressed and people have access to appropriate healthcare professionals. Medication is well managed by the service. EVIDENCE: Health plans are in place that show that people using the service have access to health professionals in the community. The records seen for two people documented visits to the dentist, optician, GP and chiropodist. Records of weights are kept and individuals supported to make healthy choices in their diet. A relative, carer or advocate said “I would very much like the dietary programme and preventative healthcare reviewed”. This was to make sure that the individual would be able to stay mobile in the years to come. Good medication procedures and practices are in place. Medication is labelled and stored correctly. We have recommended that the service look at buying a Grovelands DS0000025786.V352997.R01.S.doc Version 5.2 Page 14 wall mounted metal medication cupboard with internal storage for controlled drugs. We saw that medication record sheets are up to date and signed by staff. Grovelands DS0000025786.V352997.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): 22 and 23. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a clear complaints procedure which is accessible to people who use the service. Policies are in place for the protection of vulnerable adults and staff complete training in this important area. EVIDENCE: There have been no complaints about the service since the last inspection took place in July 2006. The complaints procedure is displayed in the home and this is in a pictorial format to help individuals understand the process. Two of the three relatives, carers or advocates who completed surveys said they knew how to make a complaint if they needed to. One person said they did not know the procedure but would ‘sort it out’ with the home if they needed to. The manager reported that they are trying to find someone independent to chair the meetings of people who live at the home. This may help individuals to voice any issues they have. Staff have training around the Protection of Vulnerable Adults. Procedures are available for them to follow if required. Grovelands DS0000025786.V352997.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): 24, 25, 27 and 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a clean, comfortable and homely environment. Individuals are encouraged to personalise their rooms. EVIDENCE: Comments from people living there included “I like my room” and “it’s alright”. One person said their room “gets cold at night”. We looked at three people’s bedrooms and saw that they are decorated and personalised to the individuals taste. The communal areas provide comfortable furnishings and facilities for the people who live there. There are many “homely” touches around such as the people’s artwork creations, murals, photographs of family and friends and social events such as holidays and parties. Grovelands DS0000025786.V352997.R01.S.doc Version 5.2 Page 17 All the bathrooms have been refurbished and people now have a wet room for their use. Radiator covers have also been fitted since the July 2006 inspection visit. We saw that improvements were required to the lighting in the long driveway leading up to the home. A gate would also be helpful to stop cars and other vehicles using the home’s driveway to turn round. We have recommended that the exterior of the building be improved as part of the maintenance schedule for the service. Grovelands DS0000025786.V352997.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): 32, 34, 35 and 36. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff have good training opportunities. The recruitment process is good with systems to make sure that appropriate checks are made. Staff supervision sessions need to take place more often. EVIDENCE: Comments from people living there included “they’re nice”, “the staff are great” and “the staff are alright”. A relative, carer or advocate said “the care personnel are always kind and supportive”. The staff members we spoke to said that they received the training they needed to do their job. Courses attended include epilepsy awareness, food safety, First Aid, Adult Protection and equal opportunities. Two staff are working to complete their Level 2 or 3 NVQ qualification and dementia awareness training is just starting. Grovelands DS0000025786.V352997.R01.S.doc Version 5.2 Page 19 Staff recruitment is subject to thorough organisational procedures that include Criminal Record Bureau (CRB) checks. We looked at records kept for three people and these included all the necessary documents. Staff do receive supervision with their line manager but the frequency of these sessions needs to improve. The manager stated that this had been identified as an area for improvement already. Grovelands DS0000025786.V352997.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): 37, 38, 39 and 42. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well run. Good Health and Safety arrangements are in place. EVIDENCE: A relative, carer or advocate commented “we are most fortunate to have Josie as the manager and I applaud her consistency, professionalism and loyalty to the clients”. The manager clearly knows the people who use the service extremely well and we saw that individuals relate very well to her. One person said “Josie’s alright”. Grovelands DS0000025786.V352997.R01.S.doc Version 5.2 Page 21 Three staff members were spoken to individually. All were very positive about the service and how the staff team worked together to achieve good outcomes for the people living there. Comments about the manager included “really good”, “fantastic” and “firm but fair”. The organisation has systems for assuring quality within its services and has also been working with the British Institute for Learning Disabilities (BILD) to explore ways to improve the service. The home sent questionnaires to people who live there in October 2006 and the results collated. Meetings involving the people who live there take place on a monthly basis. We saw that regular Health and Safety checks are carried out to protect the welfare of people using the service. Good records are kept of these. Grovelands DS0000025786.V352997.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 3 4 X 5 X 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 3 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 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 4 3 X X 3 X Grovelands DS0000025786.V352997.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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) (o) Requirement In order to ensure both the safety of people who use the service and the staff who work there, suitable external lighting must be provided in the driveway of the home. Care staff must have supervision at least six times annually with full records kept (pro-rata for part time staff). This will ensure that care staff are properly supervised and supported to do their jobs well. Timescale for action 01/01/08 2. YA36 18 (2) 01/01/08 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 YA6 Good Practice Recommendations The home should prioritise the completion of new care plans for the people living there. Monthly key work reports should be consistently completed Grovelands DS0000025786.V352997.R01.S.doc Version 5.2 Page 24 and report progress on achieving individual goals / dreams. 2. 3. 4. 5. YA11 YA20 YA24 YA24 The organisation should buy a computer just for the use of people who live at the home. The service should consider buying a metal wall mounted cabinet for the storage of medication. This would include an inner cabinet for storage of controlled drugs. A gate should be provided to prevent vehicles from using it to turn round. The exterior of the building should be renovated as part of the maintenance programme. Grovelands DS0000025786.V352997.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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. Extracts may not be used or reproduced without the express permission of CSCI Grovelands DS0000025786.V352997.R01.S.doc Version 5.2 Page 26 - 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. 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