Inspection on 03/10/05 for Grovely House

This inspection was carried out on 3rd October 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 01/07/05

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 Announced Inspection 3rd October 2005 01:45 Grovely House DS0000047627.V255254.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 Grovely House DS0000047627.V255254.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. Grovely House DS0000047627.V255254.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Grovely House Address South Newton Salisbury Wiltshire SP2 0QD 01722 742066 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) Glenside Manor Healthcare Services Ltd Mrs Halina Hayward Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places Grovely House DS0000047627.V255254.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st July 2005 Brief Description of the Service: Grovely is a 7-bedded rehabilitation unit for people with acquired brain injury that 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 support staff. A team of therapeutic staff, including medical staff, physiotherapists, speech and 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 Andrew Norman 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 DS0000047627.V255254.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place on the 3rd October 2005 between 1:45 pm and 5.15pm. There were seven 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. Inspection of staff recruitment and training records took place on the 5th October 2005 and Mary Collier, pharmacy inspector, also visited the home on this date to assess the arrangements regarding medications. The inspector met with Mrs Hayward, the registered manager and Mr Norman, the responsible individual, to report the findings of the inspection. What the service does well: What has improved since the last inspection? What they could do better: There were very few complaints about the home apart from some people feeling that the meals could be improved. Recruitment procedures need to be more robust as not all of the required documents relating to staff were in place. Grovely House DS0000047627.V255254.R01.S.doc Version 5.0 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 DS0000047627.V255254.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 Grovely House DS0000047627.V255254.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): 2, 3 and 4. The service users aspirations and needs are thoroughly assessed, they have the opportunity to visit the home and Grovely House has the capacity to meet their needs. EVIDENCE: There had been no new admissions since the previous inspection in July 2005 however care plans seen 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. The home is able to meet the needs of those admitted for rehabilitation following brain injury. Specialist services are available on site, staff have the skills and experience to deliver the service and clear information regarding their rehabilitation is available. The home has also demonstrated that it can meet the needs and preferences of varied religious and ethnic groups. 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 DS0000047627.V255254.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): 6. 7 and 9 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 are very comprehensive, based on assessment and regularly reviewed. Service users sign agreement to their plans. Those spoken with appeared aware of the purpose of their programmes in meeting personal needs and goals; although some felt frustration at their perceived slow progress, they commented that staff were supportive and resources were available to help them reach their goals. The manager reported that two service users were soon to return to the community and placements were being arranged. As the main aim of the unit is to rehabilitate service users so that they may maintain a lifestyle in the community, it is acknowledged that this may involve elements of risk. Full and detailed individualised risk assessments are in place for all service users, and where risk is identified, care plans are in place to reduce this. A self contained flat is available for service users who are to be discharged in order to try and evaluate how they would cope with a reduction in support. Grovely House DS0000047627.V255254.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): 14 and 17. Service users have the opportunity to participate in social and leisure activity. Nutritional needs are met, but not all are happy with the meals provided. EVIDENCE: A mixture of therapeutic and social activity is available and service users are given the option to participate. A ’social club’ has been set up each Thursday and service users have the opportunity to meet others from the Glenside campus. This was seen as a positive development by those spoken with. Service users are able to go out of the home if they wish although some degree of supervision may be required. Leisure time is usually during the evening or at weekends. Group activities are also held and the home has an activities area, a computer room, quiet room and smoking room. The four service users comment cards received indicated an overall satisfaction with the home although three responded ‘sometimes’ and one replied ‘no’ to the question, do you like the food? One complaint about food had been recorded. The main kitchen provides lunch and a choice is available. Service users prepare their own breakfast and evening meals as part of their rehabilitation programmes. There is a separate dining area. Grovely House DS0000047627.V255254.R01.S.doc Version 5.0 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 the following standard(s): 18 and 20 Service users receive support in the way they prefer and require. The systems for the handling of medication are good and service users are well supported to manage aspects of their own medication. EVIDENCE: Some current service users are able to look after their own personal hygiene needs but some require prompts, supervision or support to achieve this. Comment cards receive indicated that service users felt well cared for and that their privacy was respected. Service users spoken to were happy with the support provided by staff. The home has a comprehensive medication policy and up to date homely remedies list. All records are appropriately kept and medication stored securely. The same medication disposal system is used as that required for homes with nursing. Service users are given the opportunity to self medicate under a risk assessment and on-going review process. Medication for social leave is recorded. Team leaders are trained in the administration of specialist medication. If required, it is recommended that two trained nurses witness the disposal of controlled drugs in the DOOP system. Grovely House DS0000047627.V255254.R01.S.doc Version 5.0 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 the following standard(s): 22 and 23 Service users complaints are listened to and action is taken to resolve them. As far as possible, service users are protected from possible abuse, although recruitment practice needs to improve. EVIDENCE: The complaints procedure was on view in the home. No complaints had been received by CSCI and the homes complaints log indicated two minor complaints had been received, which had been promptly dealt with. Service users indicated that they knew who to go to if they were unhappy about their care. A policy regarding protection of vulnerable adults is available and the manager and staff have experience in, and awareness of, procedures regarding abuse. Staff also receive mandatory training in abuse awareness. Comment cards received indicated that service users felt safe in the home and that the staff treated them well. Recruitment procedures need to be more robust with regard to obtaining CRB checks and references. Findings are detailed in the ‘Staffing’ section of this report and there are three statutory requirements relating to this. Grovely House DS0000047627.V255254.R01.S.doc Version 5.0 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 the following standard(s): 24, 25, 27, 28 and 30 Grovely provides 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. To enhance service users safety, the entrances to the building are CCTV monitored. Grovely House DS0000047627.V255254.R01.S.doc Version 5.0 Page 14 The main laundry is provided in a separate two-storey building on site. The laundry staff provide a service to all the units at Glenside; infection control measures were in place and all equipment was working. Two staff were on duty the day of the inspection and they confirmed that they were generally able to cope with the workload during the week, however at weekends staff sickness levels had caused some concern. The management team were aware of this issue. The current layout of the laundry over two floors necessitates staff carrying laundry upstairs to be ironed and stored. Mr Norman reported that there were plans to redesign and extend the laundry to incorporate all services on the ground floor and to provide an extra washing machine. Grovely House DS0000047627.V255254.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): 32, 33, 34 and 35 The home has an effective well trained staff team, with sufficient numbers and complimentary skills to support service users assessed needs at all times. In some instances, recruitment procedures do not fully protected service users. EVIDENCE: Two service users felt that there were enough staff on duty in the home. Minimum staffing levels are three support workers in the morning, two in the afternoon and two at night, although it is acknowledged that extra staff are often on duty to meet the needs of the service users who may exhibit challenging behaviours. The home accommodates up to seven service users. New staff are recruited via the Glenside human resources department and the registered managers do not always have the opportunity to undertake interviews, although they do meet candidates to show them around the individual units. Recruitment procedure appears non discriminatory. A selection of staff recruitment records for all of the Glenside units was reviewed. In the main appropriate documentation was in place, however in one instance a CRB check had not been obtained for a staff member who had been employed for almost two years and in two other cases, references from previous employers, one of whom had been a care provider, had not been obtained. Should a person with a criminal record be employed, full details of Grovely House DS0000047627.V255254.R01.S.doc Version 5.0 Page 16 any convictions should be on file. It is also desirable that written evidence of a risk assessment process, indicating their suitability for employment, be available. Records indicated that staff had received induction, foundation and mandatory training. Further training in relevant subjects such as dementia care and cognitive rehabilitation therapy is also provided. NVQ training is provided and the training manager stated that ‘most units’ had up to 50 of staff with an NVQ. Grovely House DS0000047627.V255254.R01.S.doc Version 5.0 Page 17 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): 37, 39, 40 and 42 The registered manager is qualified, competent and experienced to run the home, and receives appropriate support to do so. Comprehensive quality monitoring is undertaken and policies and procedures aim to safeguard service users rights and best interests. Health and safety arrangements are satisfactory. 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. A deputy and a team of senior carers support Mrs Hayward and she is line managed by the senior management team at Glenside. Weekly meetings are held with the Operations Manager and the other registered managers. Effective quality monitoring systems are in place, elements of which involve seeking service users views. The management team undertakes regular audits of the service and action plans are developed to address findings. Service user Grovely House DS0000047627.V255254.R01.S.doc Version 5.0 Page 18 meetings are now held monthly and recorded. Comprehensive, updated policies and procedures are available for all the Glenside services. Accidents are recorded and audited. Fire safety records were complete and fire safety arrangements were satisfactory and included fire training for staff and service users. A first aid box was available and staff are trained in first aid. The ramps leading into the activity room and the garden are designed for wheel chair access. Following a requirement of the previous inspection in July, handrails have been ordered to reduce the risk for those who are ambulant but unsteady. A tour of the home indicated that it was free from health and safety hazards. Arrangements for maintenance of services and equipment were not reviewed during this inspection. Grovely House DS0000047627.V255254.R01.S.doc Version 5.0 Page 19 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 x 4 4 3 x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 3 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 X 3 3 X 3 LIFESTYLES Standard No Score 11 x 12 x 13 x 14 3 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x 3 3 2 3 x CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Grovely House Score 3 x 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 4 3 x 3 x DS0000047627.V255254.R01.S.doc Version 5.0 Page 20 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 YA34 Regulation Requirement Timescale for action 03/10/05 2 YA34 3 YA34 19(1a,b,i) The registered person is Sch2(7a,b) required to ensure that all staff have undertaken a Criminal Record Bureau check. 19(4,c) The registered person is 03/10/05 Sch 2(3) required to ensure that two written references, including, where applicable, a reference to the person’s last period of employment, be obtained for all new staff. 19(1,a,b,i) The registered person is 03/10/05 Sch2(a,b) required to ensure that details of any criminal offences of which a staff member has been convicted are recorded. 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 2 Refer to Standard YA17 YA20 Good Practice Recommendations It is recommended that service users be consulted about the meals provided. It is recommended that two trained nurses should witness DS0000047627.V255254.R01.S.doc Version 5.0 Page 21 Grovely House 3 4 YA34 YA34 the disposal of controlled drugs in the DOOP system. It is recommended that registered managers be involved in interviewing potential staff members. It is recommended that when staff with a criminal record are employed, a risk assessment process that indicates their suitability for employment is undertaken, and written evidence of this process be available. Grovely House DS0000047627.V255254.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham 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 DS0000047627.V255254.R01.S.doc Version 5.0 Page 23 - 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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