Inspection on 23/05/07 for Grovewood

This inspection was carried out on 23rd May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Grovewood 28/02/06

Grovewood 21/06/05

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 Manidipa Choudhury Key Unannounced Inspection 23rd May 2007 09:30 X10015.doc Version 1.40 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 Grovewood DS0000018891.V335649.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 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 DS0000018891.V335649.R01.S.doc Version 5.2 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 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) grovewoodreshome@btconnect.com Soundpace Limited Miss Monica McAusland Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Grovewood DS0000018891.V335649.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th November 2006 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 4 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 a lounge, conservatory, dining room, a smaller lounge/dining room and a visitors’ room/library. There are two bathrooms with assisted baths and a separate shower that is accessible to wheelchair users on the first floor and a further bathroom on the third floor. There are no bathrooms on the ground 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. The garden has 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. Fees at Grovewood range from £378.91 to £400.00. Grovewood DS0000018891.V335649.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place on one day for a period of 7 hours. During the visit care records and associated documents, staff files and management records were examined. Discussions were held with 2 staff members, 2 residents and a visitor to the home. Comments from the relative were very positive regarding all aspects of the home and its management. Throughout the visit staff were observed going about their duties in a cheerful manner and clearly had a good rapport with the residents. Meals were seen to be well presented and appetising and the mid-day meal was clearly enjoyed with discrete assistance being offered to those residents who needed it. Maintenance of privacy and dignity was observed at all times and staff were seen to encourage residents to make choices whenever appropriate. Resident’s health needs are well met and access to other health care professionals and services is promoted. What the service does well: What has improved since the last inspection? Care planning documentation and risk assessments for service users have improved since the last inspection. The Service User Guide has now been appropriately updated and circulated to all the service users. This ensures that Grovewood DS0000018891.V335649.R01.S.doc Version 5.2 Page 6 prospective service users have the information they need to make an informed choice about where to live. Grovewood’s recruitment practises have also improved, and the staff files seen during the inspection included documents specified in paragraphs 1 to 9 of schedule 2 of the Care Homes Regulations 2001 to ensure that all staff are suitable to work with vulnerable adults. Fire drills are now being held and documented on a regular basis for both day and night staff. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Grovewood DS0000018891.V335649.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Grovewood DS0000018891.V335649.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 and 6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective service users or their representatives have sufficient information to make an informed decision on where they wish to live and may be confident that their needs will be fully assessed and that those needs can be met prior to accepting a place at the home EVIDENCE: The home’s Statement of Purpose and Service User Guide are comprehensive. The Service User Guide has been updated following the last inspection on 13/11/06, and copies have been distributed to current service users and copies are made available to prospective service users when viewing the home. Grovewood DS0000018891.V335649.R01.S.doc Version 5.2 Page 9 A random selection of service users files were reviewed and contracts or Statement of Terms and Conditions were in place. Examination of a selection of service users care files demonstrated that an assessment of needs had been carried out prior to admission. However in some cases the pre-admission assessment was incomplete. It is recommended that the pre-admission assessments are completed fully prior to admitting any service users. The pre-admission assessments are carried out by the registered manager and in some cases included information obtained from involved social workers and other health care professionals. Grovewood encourages prospective service users and their representatives to visit the home as often and as for as long as they wish. Service users are offered the opportunity of a four-week trial to enable them to assess the care before making a final decision. The home is not registered for intermediate care. Grovewood DS0000018891.V335649.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9, and 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Care planning and medication management processes are consistent, promoting the health, welfare and safety of residents. Residents privacy and dignity are respected at all times EVIDENCE: During the inspection four service users were case tracked. Pre-admission assessments are always completed. However, in some cases the pre admission assessments have not been fully completed. It is recommended that all preadmission assessments are fully completed so that a service user plan of care can be generated from a comprehensive assessment, and provides the basis Grovewood DS0000018891.V335649.R01.S.doc Version 5.2 Page 11 for the care to be delivered. All the service users have appropriate contracts. The service user care plans are comprehensive. The registered manager needs to ensure that monthly reviews of all care plans are undertaken. Whenever bed rails are used, the registered manager needs to ensure that a competent person undertakes appropriate risk assessments. Daily reports were comprehensive and gave a good account of the care given and how the resident had spent their day. However, in one case a particular service user has had 3 falls recently, and in two occasions this is not reflected in the daily dairy sheet. It is recommended that the registered manager provides appropriate guidance and training to all staff members to ensure that daily diary sheets are appropriately recorded. Appropriate risk assessments have been completed. Risk assessment documentation has improved considerably, but there is still some scope for improvement. It is recommended that the registered manager develops an appropriate format for undertaking a detailed risk assessment of a service user’s mental state. Supporting documentation such as activity records and relatives communication sheet were in place and being used effectively. The care files provided evidence that the multi-disciplinary team was involved whenever required for the ongoing care of residents. Records showed regular assessment of health needs from GPs, district nurses and dentists. Residents have the choice of remaining with their own GP if possible or registering with a GP at the local practice. All staff members responsible for medication administration have completed an appropriate course in safe handling and administration of medications. Medication Administration Record sheets were examined, and found to be satisfactory. In the case of one service user who had been very recently admitted, and whose medicine had not yet been blistered, two minor problems were found with the medicine counts. It is recommended that the pharmacist always signs the medication returns book appropriately. Throughout the course of this visit staff were seen to treat residents with respect and guidance on the promotion of dignity and respect is included in the induction training for new staff. The relative of a service user who visits the home regularly said that the carers are “attentive and helpful”. Another service user commented that the staff are all “very nice”. Grovewood DS0000018891.V335649.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is excellent. Residents benefit from flexible routines and are positively encouraged to make choices in relation to all aspects of their daily life thereby promoting wellbeing for all. A varied range of activities is available to cater to a wide range of preferences. Individual preferences are catered for as and when possible. EVIDENCE: The daily routines at Grovewood are as flexible as possible and service users are encouraged and facilitated to make choices and exercise as much control over their lives as possible. During conversation service users made it clear that they are encouraged to make choices such as time to go to bed or get up in the morning and that those choices are respected. Grovewood DS0000018891.V335649.R01.S.doc Version 5.2 Page 13 The home employs an activities co-ordinator for 20 hours per week and a good variety of activities such as exercises, baking, quizzes and crafts are provided in addition to external entertainers. The activities co-ordinator also organises activities like table-top games, language games,maths games, physical and cognitive games, and gardening. Grovewood is planning to hold a plants sale to raise funds for certain activities. The activities co-ordinator has recently organised trips out to Storeton woods and the Art Gallery. Grovewood has recently bought a seven-seater car for service users to go out and about. The activities co-ordinator can drive it. Grovewood is in the process of completing risk assessments for taking service users out in the car. The activities coordinator organises a number of art and craft activities. The service users make Easter, Christmas and Thank you cards. Some service users are very good at painting, and a collection of their works was seen during the course of the inspection. Some of their paintings are sold. The opportunity for one to one activities with a member of staff or the activities co-ordinator is also available for those service users who do not wish to participate in the group activities. Service users spoken to were very positive in relation to the amount of activities available. The relative of a service user spoken to said that the “range of activities available is fantastic”. Another service user who has been staying at the home for four years said that she “likes the activities”. A staff member who has been working at the home for 5 months said that the home has a “good range of activities” and most of the service users seem to enjoy this. The activities co-ordinator keeps excellent record of activities. Individual records are kept for all service users on a daily and monthly basis. There is recorded evidence of the level of motivation of each service user for any specific activity. The activities co-ordinator analyses this information on a regular basis to plan future activities and consult individual service users to find out their choice of preferred activity. Photographic evidence of activities organised at the home is also kept. The registered person explained that they are planning to construct an activities room in the back garden. This is still in the planning stage. The activities co-ordinator attends appropriate training programs from time to time. Spiritual care is provided by a weekly communion service at the home to which all service users are welcomed regardless of faith. Any service users wishing to attend a local church service would be facilitated to do so. Grovewood has an open visiting policy and visitors arriving at the home from early morning and throughout the day evidenced this. It was observed that residents were able to see their visitors either in one of the communal areas or their own room according to their own preference. Grovewood DS0000018891.V335649.R01.S.doc Version 5.2 Page 14 Service users were very complimentary with regard to the standard of meals served at Grovewood. The mid-day meal was observed being served and was hot, looked appetising and was well presented. Staff members were available to offer discrete assistance to those service users who required it. Menus are varied and provide a choice of meal The two dining areas provide pleasant environments for residents to have their meals. Low-fat diets and diabetic diets are catered for. At present Grovewood have two service users who are on a pureed diet. One staff member spoken to said that the food is “presented nicely”. Choices are always available. She has never heard residents complaining about the food. Another staff member who has been working at the home for just over a year said that the food served at the home is “good”, and lots of “fresh stuff” are used to prepare meals. A service user who has been staying at the home for four years commented that the food is “very good” and appropriate choices are always available. A relative of a service user said that his mother is “happy with meals”. Grovewood DS0000018891.V335649.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users or their representatives can be confident that any complaints will be taken seriously and that systems are in place to protect service users from abuse. EVIDENCE: The home has a complaints policy and procedure in place, which includes appropriate timescales for investigation and responses. There have been no complaints made to the CSCI since the last inspection. There have been two complaints made directly to the home since the last inspection and all were resolved satisfactorily within the relevant timescales. All service users are registered on the electoral roll and assistance is provided as required to enable service users to exercise their rights. No referrals have been made to the Adult Protection Unit in the last 12 months. The home has policies and procedures in place in relation to Protection of the vulnerable Adult including Whistle Blowing and the ‘No Secrets’ Grovewood DS0000018891.V335649.R01.S.doc Version 5.2 Page 16 document. The home also has appropriate policies on adult protection and prevention of abuse, accident policy, missing resident procedure, equal opportunity policy and anti-discrimination policy. Staff training records showed that some staff members have received training in adult abuse, its various forms, recognition and procedures to follow. The registered manager needs to ensure that all staff members are appropriately trained in abuse awareness. The accident records were seen. A particular service user has had 5 falls in the last three months. However, the falls risk assessment has not been appropriately updated. It is recommended that service user risk assessments are reviewed and updated on a regular basis, or as and when required due to circumstances. If a particular service user is having a lot of falls, the registered manager needs to ensure that concrete strategies are put in place to manage this. It is also recommended that the registered manager conduct monthly or quarterly audits of service user accidents to identify any trends and identify service users who are at a greater risk of falls. It is also recommended that the registered manager signs all accident forms to evidence that she has seen them. Grovewood DS0000018891.V335649.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The standard of the environment at Grovewood is good providing a safe, homely and comfortable place to live. EVIDENCE: A tour of the home was carried out in the company of the manager, which included the laundry and kitchen. Discussion with the manager took place in relation to the service users in one shared room who do not wish for a privacy screen to be used in their room. Service users choices should be clearly Grovewood DS0000018891.V335649.R01.S.doc Version 5.2 Page 18 documented within the care plan to demonstrate that the facility has been offered and refused. The standard of furnishings is good and lighting is domestic in character. There are sufficient bathrooms and toilets situated throughout the home to meet the needs of service users. Service users are enabled to maximise their independence via a range of specialised equipment and relevant aids. Handrails, stair lifts and assisted bathrooms are available together with a call system available in rooms and all areas of the home. During the tour of the home it was evident that service users are encouraged to personalise their rooms with their own memorabilia and personal possessions. The laundry and kitchen were both clean and well organised with appropriate equipment in place. Relevant COSHH documentation for laundry chemicals was available in the main office. Fridge and freezer temperatures were documented and stores were well stocked. At the time of this visit the home was clean, tidy and free from any odours. A staff member who has been working at the home since 5 months commented that the home is always “clean and tidy” and “warm”. Another staff member said that the level of “cleanliness is good”. A service user said that home is always clean and his own room is “comfortable”. Grovewood DS0000018891.V335649.R01.S.doc Version 5.2 Page 19 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff members are well trained and deployed in sufficient numbers and skill mix and the recruitment procedures are robust as they should be to support and protect the residents. EVIDENCE: Staff members are deployed in sufficient numbers and skill mix to meet the assessed and changing needs of the residents. The home has sufficient number of cleaners, laundry staff, cook and kitchen assistants. The registered person confirmed that they rarely use agency staff. In an emergency they use their own bank staff. Only in extreme cases have they used agency staff, and they do have a written confirmation from the specific agency they use to say that all their staff members have appropriate CRB checks. Grovewood DS0000018891.V335649.R01.S.doc Version 5.2 Page 20 The home has achieved the 50 target of staff having at least the NVQ 2 qualification. 92 of staff members have either achieved or are in the process of training to achieve NVQ level 2 and 3 qualifications. There has been an improvement in the staff recruitment procedures followed at Grovewood since the last inspection. 4 staff files were checked during the inspection. Appropriate recruitment procedures have been followed in all cases. All staff members have appropriate CRB and POVA checks. They all have an appropriate application form and 2 valid references. Appropriate job descriptions and contracts have been issued. All new staff members have been inducted, and this has been appropriately documented. The staff induction procedure is quite comprehensive, and includes a wide variety of topics. Annual performance appraisals are done. Staff supervision is done, but on an average of two a year. It is recommended that the registered manager ensure that all staff members receive at least 6 supervision sessions a year. Training is ongoing for both care and trained staff. Training includes first aid, manual handling, food hygiene, fire training and adult protection and abuse. A member of staff with a valid first aid qualification is on duty at all times. A number of staff members have not done any training on adult protection and abuse. The registered manager must ensure that all staff members have appropriate training on this topic. A staff member, who has been working at Grovewood for over a year commented that the home has a “stable staff team”, and the management are very supportive about training. Grovewood DS0000018891.V335649.R01.S.doc Version 5.2 Page 21 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37,and 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Grovewood is well managed with good leadership and open management promoting the health, safety and welfare of service users. EVIDENCE: Currently working towards the registered managers award the manager is well supported by the responsible individual and has a clear vision and sense of direction. Her management style is open and transparent as evidenced in Grovewood DS0000018891.V335649.R01.S.doc Version 5.2 Page 22 conversations with staff and relatives whilst maintaining a focus on managing the home in the best interests of residents. The manager stated that the home has an open door policy and she is available for staff and residents at all times. Staff spoken to confirmed that the manager is approachable and that the home has an open and positive atmosphere. A random selection of monies held for service users were checked and found to be correct. Appropriate receipts were seen for expenditure made on service users behalf. The home is insured and the certificate is displayed as required. Safety, inspection and service certificates were checked for the fire alarm and extinguishers. Fire risk assessment has been done. Fire alarms and emergency lighting are tested and recorded on a regular basis. Fire drills are held and recorded in an appropriate manner. Appropriate COSHH assessments have been done and the records found to be satisfactory. Room temperature and water temperature records are kept. Records for bath are being kept, but not for showers. It is recommended that shower temperature records are monitored and recorded. Other safety and maintenance certificates including electricity certificate, gas certificate, lift and stair lift servicing certificates were checked. A few defects were noted during the servicing and maintenance of the bath lift. No clarifications could be found whether these defects were rectified subsequently. It is recommended that the registered manager seeks appropriate clarification regarding this issue, and this should be clearly recorded. The gas certificate too needs to be updated. The registered manager needs to ensure that the gas certificate is appropriately updated. As far as Quality Assurance is concerned, Grovewood produces an annual development plan. It has not been produced this year, as they are in transition. Former partners who owned 50 of the home are in the process of selling their shares to the registered person who is the owner of the other 50 . They wish to retire. Solicitors and Accountants are involved at this stage to finalise the process. Grovewood has a residents and family forum. The Registered person explained that they try to hold two meetings a year. Invitations are sent out to family members of residents. The next meeting is due on the 28th of June. The last residents and family forum meetings were held on 20/09/06 and 08/03/06, and the minutes were seen during the inspection. An employee opinion survey was conducted around March 2007. A comprehensive report has been collated from the information gathered through the survey. The report indicates a high level of staff motivation and job satisfaction. The registered manager explained that two staff meetings are held in a year, and minutes are appropriately recorded and kept. Grovewood has conducted a service user survey in 2006. They plan to do this on a yearly basis. The individual completed survey forms were shown during the Grovewood DS0000018891.V335649.R01.S.doc Version 5.2 Page 23 inspection. It is recommended that the registered manager analyses the information gathered through the survey forms, collates the data and produces a comprehensive report based on this vital information. It should indicate Grovewood’s strengths as a care home, and also areas of improvement. The relative of a service user who visits the home on a regular basis and whose mother has been residing at the home for the past 3 years, commented that his mother is “completely happy” and “very satisfied”. He said that the home’s management are “superb” and “fabulous”. A service user who has been residing at the home for the past 4 years commented that the home is “lovely” and that she now regards Grovewood as her “home”. She also commented that the management are “helpful and approachable”. A staff member who has been working at the home for the past 5 years said that the “management is helpful”, and that she is “supervised”. Grovewood DS0000018891.V335649.R01.S.doc Version 5.2 Page 24 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 2 Grovewood DS0000018891.V335649.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15 Requirement Care plans must be kept under review and updated in order that staff have clear directions to enable them to meet identified and changing needs. Case plans must be reviewed on a monthly basis, and clearly documented. This requirement remains outstanding from the last inspection. 2. OP8 13 The registered manager needs to ensure that whenever bed rails are used for service users, a competent person undertakes appropriate risk assessments, and that the staff members handling the bed rails are appropriately trained. The registered manager needs to ensure that all staff members are appropriately trained in abuse awareness, its various forms, recognition and procedures to follow. The registered manager ensures DS0000018891.V335649.R01.S.doc Timescale for action 31/08/07 15/08/07 3. OP18 13 30/09/07 4. OP38 13 31/07/07 Page 26 Grovewood Version 5.2 the health and safety of service users and staff by regular servicing of boilers and central heating systems under contract by competent persons. 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 OP3 OP7 Good Practice Recommendations It is recommended that the pre-admission assessments are completed fully prior to admitting any service users. It is recommended that the registered manager provides appropriate guidance and training to all staff members to ensure that daily diary sheets for all service users are appropriately recorded. It is recommended that the registered manager develops an appropriate format for undertaking a detailed risk assessment of a service user’s mental state. It is recommended that the registered manager ensure that the pharmacist always signs the medication returns book appropriately. It is recommended that service user risk assessments are reviewed and updated on a regular basis, or as and when required due to circumstances. If a particular service user is having a lot of falls, the registered manager needs to ensure that concrete strategies are put in place to manage this. It is also recommended that the registered manager conduct monthly or quarterly audits of service user accidents to identify any trends and identify service users who are at a greater risk of falls. It is recommended that the registered manager signs all DS0000018891.V335649.R01.S.doc Version 5.2 Page 27 3. OP8 4 OP9 5 OP18 6 OP18 7 OP18 Grovewood accident forms to evidence that she has seen them. 8 OP36 It is recommended that the registered manager ensure that all staff members receive at least 6 supervision sessions a year. Records for bath are being kept, but not for showers. It is recommended that shower temperature records are monitored and recorded. It is recommended that the registered manager analyses the information gathered through the service user survey forms, collates the data and produces a comprehensive report based on this information. It should indicate Grovewood’s strengths as a care home, and also areas of improvement. Appropriate action should be taken following this survey, based on the service users opinion. 9 OP25 10 OP33 Grovewood DS0000018891.V335649.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Grovewood DS0000018891.V335649.R01.S.doc Version 5.2 Page 29 - 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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