Inspection on 21/06/05 for Grovewood

This inspection was carried out on 21st June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Grovewood 23/05/07

Grovewood 28/02/06

Grovewood 26/01/05

Grovewood 06/05/04

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

CARE HOMES FOR OLDER PEOPLE Grovewood 13 Woodlands Road Dacre Hill Bebington, Wirral CH42 4NT Lead Inspector Beate Roth Unannounced 21 June 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 Older People. 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. Grovewood v236004 f52 f02 s18891 grovewood v236004 210605 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Grovewood Address 13 Woodlands Road Dacre Hill Bebington Wirral CH42 4NT 0151 645 5401 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) Soundpace Limited CRH Care Home 32 Category(ies) of OP Old age (32) registration, with number of places Grovewood v236004 f52 f02 s18891 grovewood v236004 210605 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 26/01/05 Brief Description of the Service: Grovewood is registered to provide personal care to 32 older people. There are 8 double and 16 single bedrooms, at present only 5 bedrooms are being used as double rooms. All bedrooms except one have en-suite facilities. Bedrooms in the older part of the home are on three floors, reached by stair lifts. The single rooms in the two-storey extension can be reached by 5-person passenger lift. The communal areas of Grovewood include lounge, dining room, conservatory, a smaller lounge/dining room and a visitors’ room/ library. There are no bathrooms on the ground floor. There are two bathrooms with assissted baths and a separate shower that is accessible to wheelchair users on the first floor and a further bathroom on the third floor. Due to the number of stairs at the home, the home has limited suitability for independent wheelchair users. There is level access to the garden to the rear of the home, which includes a patio area with garden furniture for the summer. The home is close to local shops and amenities. The home is situated on a bus route. Grovewood v236004 f52 f02 s18891 grovewood v236004 210605 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over half a day. During the inspection time was spent in the office examining records and policies and procedures and talking to the acting manager, proprietor and deputy manager. A tour of the home was undertaken. Staff were observed delivering care to service users. The inspector spoke to service users and to staff. What the service does well: What has improved since the last inspection? What they could do better: Service users need to be provided with contracts on admission to the home. The service user care plans must contain clear information as to how staff are to meet the needs of service users. Improvements need to be made to the adult protection procedures at the home to ensure service users are protected from abuse. Further work needs to take place around promoting the privacy of service users who share bedrooms. Further staff need to complete an NVQ (or Grovewood v236004 f52 f02 s18891 grovewood v236004 210605 stage 4.doc Version 1.40 Page 6 equivalent) qualification in care of the elderly and work needs to take place to ensure that induction and foundation training are provided that meet the National Training Organisation Workforce Training Targets. 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. Grovewood v236004 f52 f02 s18891 grovewood v236004 210605 stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Grovewood v236004 f52 f02 s18891 grovewood v236004 210605 stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2 and 3 Service users are fully assessed before they are admitted to the home in order to ensure their needs are met. Service users need further information to be able to make a decision about whether to live at the home and whether the home is providing the services agreed. EVIDENCE: Since the last inspection the statement of purpose has been amended. So an informed choice can be made the statement of purpose needs to make clear that the home will have limited suitability for some service users because of the number of stairs in the home. It is understood that this is discussed as part of the admission process. The records for 3 new service users were examined. A contract was available for one service user, this provided all the information outlined in this standard. A contract was not available for the remaining service users who had been living at the home for over 3 months. A contract is to be available for each service user on admission to the home. Grovewood v236004 f52 f02 s18891 grovewood v236004 210605 stage 4.doc Version 1.40 Page 9 The assessments for 3 new service users were examined. Assessments are There was undertaken by the acting manager or the deputy manager. evidence of appropriate assessments being carried out before new service users move to the home. There was also evidence that information is gathered from social workers and health professionals to inform the assessment. Grovewood v236004 f52 f02 s18891 grovewood v236004 210605 stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 10 Staff are not provided with the information they need to meet the needs of service users. The health care needs of service users are met. Service users are treated with respect. EVIDENCE: A sample of service user plans were seen. These plans identify the current needs of service users but do not provide sufficient information for staff around the action to be taken to meet these needs. All care plans need to provide clear guidance to staff. The records at the home and a discussion with the acting manager indicated that referrals are made to health professionals in accordance with the needs of service users. A record is made of visits by health professionals and the outcome is documented. The accident book was examined and is satisfactorily maintained. The CSCI has been notified of any significant events at the home. Staff were observed to treat service users with respect. Staff receive guidance on promoting the dignity of service users during induction training. Grovewood v236004 f52 f02 s18891 grovewood v236004 210605 stage 4.doc Version 1.40 Page 11 8 bedrooms in the home are registered as double rooms, however at present only 5 bedrooms are shared. Mobile screens are available in the home but no screening is provided on a permanent basis in the shared rooms. It continues to be recommended that options for promoting privacy in shared bedrooms are considered with service users and implemented. This will enable real choice to be available. There is no separate visitors’ room, but the room used for a library and as a staff smoking room can be used for this purpose. The acting manager confirmed that visiting health professionals see service users in private in their own rooms. Grovewood v236004 f52 f02 s18891 grovewood v236004 210605 stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 13 The needs of service users are met by the arrangements for visitors to the home, the flexibility of daily routines and the activities available. EVIDENCE: Observations and a discussion with service users and staff indicated that the routines of daily living are flexible. There is a list of weekly activities available. The acting manager reported that this is drawn up following consultation with service users. This includes arm chair aerobics, craft work, board games, outings to the local park, pubs and shops, karaoke. Service users have access to a well maintained garden which has a patio area with seating. An activities co-ordinator post is available but is currently not filled. The service users guide indicates that visitors are welcome at reasonable times. A visitor to the home reported that the staff make them feel welcome. Service users reported that visitors are encouraged and that they are able to see visitors in private as they wish. Grovewood v236004 f52 f02 s18891 grovewood v236004 210605 stage 4.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home has a satisfactory complaints system. Improvements need to be made to the adult protection procedures at the home to ensure service users are protected from abuse. EVIDENCE: The home has a written complaints procedure that states complaints will be responded to within 28 days. The complaints procedure is contained in the service users guide. Service users reported that if they wished to raise any issues about the standards of the service provided they would speak to the acting manager or deputy manager. No complaints have been made to the home or to the CSCI since the last inspection. The adult protection procedure has been revised since the last inspection. It now provides a definition of abuse and clearly indicates the agencies that must be contacted following an allegation of abuse. However, the procedure refers to staff investigating an allegation of abuse. This would not be the appropriate course of action to take. Allegations of abuse are to be referred to social services. The procedure needs to be amended accordingly. Some personal allowances are held on behalf of service users. A sample of records were inspected against the allowances remaining and found to be in order. Grovewood v236004 f52 f02 s18891 grovewood v236004 210605 stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26 The home is well maintained and there is a good standard of cleanliness and hygiene, providing service users with a pleasant environment to live in. EVIDENCE: All parts of the home seen on the day of this inspection were in good condition, tidy and well decorated. In general, the home provides a safe environment. All radiators in bathrooms, bedrooms and en-suites have been covered by low temperature surfaces. Window restrictors were fitted in the sample of bedrooms inspected. The acting manager reported that all hot water outlets have been regulated to 43 degrees, a test of the water found that in the top floor bathroom the water was 46 degrees centigrade. The acting manager reported that until the temperature is adjusted he will ensure that measures are put in place to protect service users from the risk presented. Grovewood v236004 f52 f02 s18891 grovewood v236004 210605 stage 4.doc Version 1.40 Page 15 The home employs sufficient domestic staff and on the day of this inspection the premises was found to be very clean and malodour free. The practices and policies and procedures available promote cleanliness and hygiene. Grovewood v236004 f52 f02 s18891 grovewood v236004 210605 stage 4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 30 There are sufficient numbers of staff to meet the needs of service users. Service users would benefit from staff receiving recognised care training. EVIDENCE: The rota and a discussion with the staff and the acting manager indicated that there are sufficient numbers of staff to meet the needs of the service users living at the home at the time of the inspection. At present 2 of the 19 care staff have an NVQ qualification in care of the elderly. Steps are being taken to reach a minimum of at least 50 . 7 members of staff are currently undertaking this qualification. 4 staff are to begin the next available course. The induction for all new staff covers all policies and procedures, care practices and the operation of the home. The acting manager reported that he is working on developing the induction and establishing foundation training to meet the National Training Organisation workforce training targets. Grovewood v236004 f52 f02 s18891 grovewood v236004 210605 stage 4.doc Version 1.40 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33 and 38 The safety of service users is generally well promoted. The quality assurance systems benefit service users but need further improvement. EVIDENCE: The acting manager has been in post since 01/03/05. The acting manager reported that he has over 2 years management experience and has qualifications relevant to the position. The acting manager has submitted an application to the CSCI so as his competence for this position can be assessed. Grovewood v236004 f52 f02 s18891 grovewood v236004 210605 stage 4.doc Version 1.40 Page 18 There are quality assurance processes in place, there is a suggestions box, service user questionnaires, a “Residents and Families Committee” is held where matters relating to service users welfare and social events are discussed. Minutes of the committee meeting are kept. The acting manager and staff obtain the views of service users. The acting manager reported that the individual views of staff are obtained in supervision. Staff meetings are held. An annual development plan for quality assurance has been made available. There are no records of the proprietors monthly checks of the home. It is understood that one of the owners does spend at least 2 days per week at the home. A sample of safety check records were examined and found to be in order. The gas had recently been checked, the certificate of safety was not available and is to be forwarded to the CSCI. Training records showed that staff are given appropriate training in safe working practices. A record needs to be made of the fire safety training provided to staff. Grovewood v236004 f52 f02 s18891 grovewood v236004 210605 stage 4.doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 x 2 x x x x 2 Grovewood v236004 f52 f02 s18891 grovewood v236004 210605 stage 4.doc Version 1.40 Page 20 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 1 Regulation 4, 5 Requirement The statement of purpose and service user guide must make clear that access around the home may be limited for some service users due to the number of stairs. A contract must be made available for each service user on admission to the home. The service user care plans must contain clear information as to how staff are to meet their needs. The adult protection procedure must be amended to indicate that all allegations of abuse are to be reported to social services without delay. Steps must be taken to ensure that service users are not at risk of harm from water that exceeds 43 degrees centigrade. A written programme of staff training to meet NTO requirements must be drawn up and implemented (previous timescale of 26/04/05 not met). The registered provider must ensure that a monthly written report on the conduct of the care home is made available to the v236004 f52 f02 s18891 grovewood v236004 210605 stage 4.doc Timescale for action 21/07/05 2. 3. 2 7 5 15 21/06/05 21/06/05 4. 18 13 21/07/05 5. 19 13 21/06/05 6. 30 18 21/09/05 7. 33 26 21/06/05 Grovewood Version 1.40 Page 21 8. 9. 38 38 23 23 manager of the home and to CSCI. A record must be made of fire safety training provided to staff. A copy of the gas safety certificate is to be forwarded to CSCI. 21/06/05 21/07/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 10 28 Good Practice Recommendations It is recommended that options for privacy screening be discussed with service users and placed in rooms, so that real choice is available. A minimum of 50 of staff are to hold an NVQ qualification or equivalent. Grovewood v236004 f52 f02 s18891 grovewood v236004 210605 stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Liverpool Area Office 3rd Floor 10 Duke Street Liverpool, L1 5AS 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 Grovewood v236004 f52 f02 s18891 grovewood v236004 210605 stage 4.doc Version 1.40 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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