Inspection on 01/07/05 for Grovely House

This inspection was carried out on 1st July 2005.

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

Grovely House 13/03/07

Grovely House 03/10/05

Grovely House 04/10/04

Grovely House 08/06/04

Grovely House 26/02/04

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

CARE HOME ADULTS 18-65 Grovely House South Newton Salisbury Wiltshire SP2 0QD Lead Inspector Steve Cousins Unannounced 1st July 2005 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. Grovely House DD51_D01_S47627_GROVELYHOUSE_V226660_010705_STAGE4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Grovely House Address South Newton Salisbury Wiltshire SP2 0QD 01722 742066 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) Gelnside Manor Healthcare Services Ltd Mrs Halina Hayward Care home 7 Category(ies) of MD Mental Disorder - 7 registration, with number of places Grovely House DD51_D01_S47627_GROVELYHOUSE_V226660_010705_STAGE4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 4 October 2004 Brief Description of the Service: Grovely is a 7-bedded rehabilitation unit for younger people with acquired brain injury which forms part of the Glenside group of homes situated on the same site. Grovely is not the service user’s permanent home as, on completion of their rehabilitation programme, they will move onto a permanent placement, which suits their individual needs. Accommodation is provided over 2 floors, with a living room, kitchen/diner and activities room, which doubles as both a dining room and a therapy room. A separate flat is part of the registration. Mrs Halina Hayward is the registered manager of the home; she leads a team of care staff. A team of therapeutic staff, including medical staff, physiotherapists, occupational therapists and psychologists are employed to work across the Glenside group The Glenside group of homes is owned by Glenside Manor Health Care Services Ltd., Mr Denis Barry is the nominated responsible individual. He is supported by a senior management team. One catering and laundry department supplies all the registrations on site. A maintenance team also works across the site. The group of homes is situated in the village of South Newton, on the A36, five miles north west of the city of Salisbury. A mainline train station is in Salisbury, the A36 is on a bus route and ample car parking is available on site. Grovely House DD51_D01_S47627_GROVELYHOUSE_V226660_010705_STAGE4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 9.30am and 2.30pm. There were 6 service users in the home. The findings from this inspection are based on a tour of the premises, speaking to service users, the manager and staff, and inspecting a number of records, including care plans. The inspector then met with Halina Hayward, the registered manager, to report the findings of the inspection. What the service does well: What has improved since the last inspection? What they could do better: The current arrangements regarding monitoring of the service are very good, however more service user meetings, in which their view of the service is encouraged and explored, may enhance this further. Work needs to be done to make sure that ramps leading into the home are safe for those who may be unsteady on their feet, and ensuring paving stones on the patio are level. Grovely House DD51_D01_S47627_GROVELYHOUSE_V226660_010705_STAGE4.doc Version 1.30 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. Grovely House DD51_D01_S47627_GROVELYHOUSE_V226660_010705_STAGE4.doc Version 1.30 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 Grovely House DD51_D01_S47627_GROVELYHOUSE_V226660_010705_STAGE4.doc Version 1.30 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, and 4. The service users aspirations and needs are thoroughly assessed and they have the opportunity to visit the home. They are fully involved in the assessment and there is suitable information available for them to make an informed choice. EVIDENCE: A recently revised statement of purpose was available along with a service users guide, which accurately describe the purpose of the home. Care plans contained evidence that comprehensive assessments are undertaken of service users needs and that they are fully involved in the process. Assessments include risk management, physical and mental health needs, social and spiritual needs and treatment and rehabilitation programmes. Assessments involve the multidisciplinary team (MDT), which includes physiotherapists, occupational therapists and clinical psychologist. Some service users are transferred directly from other units at Glenside. This means that they are easily able to visit Grovely House and ensures that staff are aware of their needs prior to admission. Those service users who are transferred from hospitals or other homes are fully assessed prior to admission and they, or their relatives, have the opportunity to visit. Grovely House DD51_D01_S47627_GROVELYHOUSE_V226660_010705_STAGE4.doc Version 1.30 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 standard(s) 6 and 7 Individual plans reflect service users assessed needs and goals. Service users are able to make decisions about their lives and as far as is possible, are supported to achieve independence. EVIDENCE: Individual plans were very comprehensive, based on assessment and regularly reviewed. Service users sign agreement to their plans and those spoken with appeared aware of the purpose of rehabilitation programmes in meeting their personal needs and goals. It was evident through conversation with staff, that they had good insight into service users needs and behavioural traits. One plan detailed interventions to de-escalate possible events that may lead to challenging behaviour. This enabled both coping and improvement strategies to be implemented, which supported the overall rehabilitation process. Conversations with service users and entries in their notes indicate that they are able to make decisions about their lives, and were supported by staff in achieving things. Where this may include a degree of risk, this is fully assessed and appropriate support and guidance is offered. Grovely House DD51_D01_S47627_GROVELYHOUSE_V226660_010705_STAGE4.doc Version 1.30 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 standard(s) 11,14,15,17. There are opportunities for personal development and independence is promoted. Leisure, social, nutritional and relationship needs are met. EVIDENCE: Rehabilitation programmes are in place, which aim to support service users to develop an independent lifestyle and encourage personal development. Service users are fully supported by a range of professionals to achieve this. Leisure time is usually during the evening or at weekends. Group activities are also held and the home has an activities area, which contains exercise equipment, a computer room, quiet room and smoking room. Service users reported contact with friends and relatives and one was leaving with their parent for a weekend break. Visitors are welcome in the home but advised that service users may be attending rehabilitation programmes during the day. In order to prepare them for eventual discharge into the community, service users prepare their own breakfast and evening meal. Lunch is prepared and supplied by the main Glenside kitchen. Service users said they enjoyed the lunch on the day of the inspection. There were no complaints regarding meals. Special diets were provided. Grovely House DD51_D01_S47627_GROVELYHOUSE_V226660_010705_STAGE4.doc Version 1.30 Page 11 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) 19 and 20 Service users physical and emotional health care needs are being met. The arrangements regarding medication ensure the service users safety, and promote independence where appropriate EVIDENCE: Entries in care plans indicated access to GP’s and there was good evidence that staff were monitoring changing health and psychological needs. Referrals were made to other health care professionals and outcomes were recorded. A GP is available on the Glenside campus throughout the week. Evidence in care plans, along with the staff and service user comments, suggested that emotional needs were being addressed. There was access to a clinical psychologist. Two service users said that they felt well supported by the staff, one thought the availability of supporting professionals on site particularly good. A monitored dosage system was in use for the control of medications. One service user, who was soon to leave the home, was self-medicating and risk assessments had been carried out regarding this. Medicines were stored safely and administration recorded. Staff spoken to confirmed that they had received medicine administration training. Grovely House DD51_D01_S47627_GROVELYHOUSE_V226660_010705_STAGE4.doc Version 1.30 Page 12 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 Service users complaints are listened to and action is taken to resolve them. With regard to staff awareness and training, service users are, as far as possible, protected from abuse. EVIDENCE: There were three slightly different versions of the complaint procedure and this was brought to the attention of the manager. There needs to be one definitive version, which states that complaints can be sent direct to the local CSCI office at any time, not only when the complainant is unhappy with a providers investigation. The complaints log indicated that there had been two minor complaints since July 2004. The log indicated the nature of the complaint, the immediate action, follow up action, and any comments. Both complaints had been dealt with promptly. No complaints had been received by the CSCI in the past year. Two service users spoken to said that they would complain to the staff or manager if they had a problem. Conversation with staff indicated that there was an awareness of abuse issues and procedures for reporting suspected abuse. Training was also available. There have been no reports of suspected abuse relating to this service in the past year. Procedures for handling service users money and staff recruitment checks were not reviewed during this inspection, there fore Standard23 was not fully assessed. Grovely House DD51_D01_S47627_GROVELYHOUSE_V226660_010705_STAGE4.doc Version 1.30 Page 13 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) 24,25,28 and 30 Grovely House is a safe, homely environment, which meets the service users needs and lifestyle. The home is clean and hygienic. EVIDENCE: Grovley House is a domestic style dwelling, which has a sitting room, dining room, kitchen and large activity area. Furniture was of an acceptable standard, as was the decoration. There are adequate bathroom and toilet facilities. The home is suitable for wheelchair users. There are accessible patio areas to the rear and side of the home. Service users rooms are lockable and some show evidence of individualisation, however this is limited as the home is not intended as a permanent residence and some service users are not from the local area. All bedrooms are single and there is a self-contained annexe for use by those who are almost ready to leave the home. The home was clean and there were no unpleasant odours. Some service users were responsible for cleaning their own rooms, with staff assistance if required. A washing machine is provided for personal items and there are staff hand washing facilities. There is a central laundry at Glenside. To enhance service users safety, the entrances to the building are CCTV monitored. Grovely House DD51_D01_S47627_GROVELYHOUSE_V226660_010705_STAGE4.doc Version 1.30 Page 14 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) 33 The home has an effective staff team, with sufficient numbers and complimentary skills to support service users assessed needs. EVIDENCE: The manager, her deputy and a senior rehabilitation assistant were on duty at the time of the inspection. The duty rota indicated that there was usually two staff on duty during the day, in addition to the manager, and two at night. The home accommodates up to seven service users. Both staff on duty had obtained an NVQ and were undertaking the next NVQ level. Staff and the manager felt that levels were appropriate and the manager was committed to ensuring that they remained so, stating that extra staff would be on duty if the need arose. A staff member confirmed this. Staff have to undertake some domestic tasks, but this did not seem to impinge on their primary role. Occupational therapy, physiotherapy and clinical psychology staff are also available on the Glenside site and this enables rehabilitation programmes to be more effective. Grovely House DD51_D01_S47627_GROVELYHOUSE_V226660_010705_STAGE4.doc Version 1.30 Page 15 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) 37,39 and 42. The registered manager is qualified, competent and experienced to run the home, and receives appropriate support. Monitoring of standards is good and service users views are sought. Although generally good, some health and safety issues require attention. EVIDENCE: Mrs Hayward has an NVQ 4 in management, is a registered nurse and an NVQ assessor. She had several years experience of managing care for a range of service users. Mrs Hayward is supported by a deputy and a team of senior carers and is line managed by the senior management team at Glenside. Weekly meetings are held with the Operations Manager and the other registered managers at Glenside. The management team regularly monitors standards of service. A recent audit of 186 standards indicated 94 compliance, 5 partial compliance and 1 non-compliance, which is commendable. The records of a recent service users meeting were seen, however these are held infrequently. Satisfaction surveys are available for service users to complete and two had done so in April 2005. Grovely House DD51_D01_S47627_GROVELYHOUSE_V226660_010705_STAGE4.doc Version 1.30 Page 16 Fire safety arrangements were satisfactory and included fire training for staff and service users. A first aid box was available. The ramps leading into the activity room and the garden are designed for wheel chair access. They currently present a risk as there are no handrails fitted for those who are mobile, but unsteady. The paving in the rear patio area is uneven in places and presents a trip hazard. A tour of the home indicated that it was generally free from other health and safety hazards. Grovely House DD51_D01_S47627_GROVELYHOUSE_V226660_010705_STAGE4.doc Version 1.30 Page 17 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 3 x 3 x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x x x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x x 3 x 3 Standard No 11 12 13 14 15 16 17 3 x x 3 3 x 3 Standard No 31 32 33 34 35 36 Score 3 x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Grovely House Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x 2 x DD51_D01_S47627_GROVELYHOUSE_V226660_010705_STAGE4.doc Version 1.30 Page 18 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 YA22 Regulation 22 (7) Requirement Timescale for action 1/8/05 2. YA42 13 (4) 3. YA42 13 (4) The registered person is required to ensure that there is one definitive version of the complaint procedure, which states that complaints can be sent direct to the local CSCI office at any time The registered person is required 1/7/05 to ensure that measures are taken to ensure the safety of those who use the access ramps to the side and rear of the building The registered person is required 1/7/05 to ensure that measures are taken to ensure the safety of those who use the rear patio area, with regard to trip hazards. 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 YA39 Good Practice Recommendations It is recommended that service users meetings be held more frequently Version 1.30 Page 19 Grovely House DD51_D01_S47627_GROVELYHOUSE_V226660_010705_STAGE4.doc Commission for Social Care Inspection Suite C, Avonbridge House Bath Road Chippenham Wiltshire SN15 2BB 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 Grovely House DD51_D01_S47627_GROVELYHOUSE_V226660_010705_STAGE4.doc Version 1.30 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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