Inspection on 01/06/05 for Grovewood House

This inspection was carried out on 1st 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 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 House 25/06/07

Grovewood House 18/05/06

Grovewood House 02/12/05

Grovewood House 21/10/04

Grovewood House 08/06/04

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

CARE HOMES FOR OLDER PEOPLE Grovewood House Main Street South Charlton Alnwick, Northumberland NE66 2NB Lead Inspector Anne Urwin Brown Unannounced 1 June 2005 13:00 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 House B53-B03 S641 Grovewood House V222294 010605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Grovewood House Address Main Street South Charlton Alnwick Northumberland NE66 2NB 01665 579249 N/A N/A Mr Bakr 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) Mrs Linda Steele CRH 34 Category(ies) of DE(E) Dementia - over 65 (2) registration, with number OP Old age (32) of places Grovewood House B53-B03 S641 Grovewood House V222294 010605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: There are no conditions of registration. Date of last inspection 21 October 2004 Brief Description of the Service: Grovewood House is located in the village of South Charlton, a few miles north of Alnwick. The house is set in its own grounds and has been converted and extended to accommodate up to thirty-four elderly people. There are attractive gardens to the front and side of the building. The accommodation is arranged on two floors and stair lifts are fitted. Public transport is very limited and the main links are by bus from Alnwick or train from Alnmouth. Grovewood House B53-B03 S641 Grovewood House V222294 010605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection lasted four hours and involved discussion with the Manager, residents and staff, inspection of records and a tour of the building. During the inspection five residents, four care staff and the cook were spoken to. What the service does well: What has improved since the last inspection? What they could do better: Grovewood House B53-B03 S641 Grovewood House V222294 010605 Stage 4.doc Version 1.30 Page 6 Care plans would be improved by including more information about outcomes for residents and more detailed assessments. Records of reviews are not available within individual residents’ records. The recording of fire training needs to be improved to show how often individual staff receive training and this needs to include night staff. Moving and Handling, Food Hygiene and First Aid training for staff should be regularly updated. Vinyl flooring in bedrooms provides a cold and institutional feel that can affect residents’ dignity. It should only be fitted after other alternatives have been explored. Residents’ laundry should not be taken into the dining room. A quality assurance system should be devised to ensure residents and their representatives have an opportunity to comment on the service provided. 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 House B53-B03 S641 Grovewood House V222294 010605 Stage 4.doc Version 1.30 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 House B53-B03 S641 Grovewood House V222294 010605 Stage 4.doc Version 1.30 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) 3, 6 Residents have some of their needs assessed before moving into the Home, but more information is required. The assessment is not consistently recorded. No residents have been assessed and referred soley for intermediate care. EVIDENCE: Samples of residents’ records were inspected and all contained a written assessment. Information in the assessments did not cover all the areas identified within the National Minimum Standards. Assessments were not always dated and signed by staff. Some records contained copies of assessments from the Care Manager. The Manager said that each resident has an assessment carried out by the Home’s staff. Most residents said that the staff asked them when they were admitted what they needed help with. The Manager reported that no residents are admitted for intermediate care. Grovewood House B53-B03 S641 Grovewood House V222294 010605 Stage 4.doc Version 1.30 Page 9 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, 9 Individual action plans are available for each resident that would benefit from more detail. The system for assessing risks is not consistently implemented. Arrangements to ensure residents’ health care needs are met are not always Residents are protected by the Home’s policies and procedures for dealing with medicines. EVIDENCE: Individual action plans are prepared for each resident. Each resident’s objectives are recorded and how these are achieved, but there is not enough detail about the outcomes for each resident. Only one file had a copy of a review carried out by the Care Manager. Residents said that they thought staff kept records, but they had not seen their records. Two residents said that they did not want to see their records. Residents said that staff knew what they needed help with. Health care objectives are recorded for some residents. In records seen at the inspection there was little information about their health care needs within the care plan. The Manager was able to confirm that residents are well supported by local health care staff. Records of visits by healthcare staff are kept. Residents said that they were satisfied that they could request a doctor’s visit Grovewood House B53-B03 S641 Grovewood House V222294 010605 Stage 4.doc Version 1.30 Page 10 and that staff knew about the health needs. No assessments relating to nutritional needs or incidence of pressure areas were available. The Manager said that staff are to receive training in assessing nutritional needs and a system will be introduced when this is completed. Written guidance is in place for the administration of medication. Records are kept in an appropriate form of administration of drugs. None of the residents looks after their own medication at the time of this inspection. Arrangements for storing medication are satisfactory. Grovewood House B53-B03 S641 Grovewood House V222294 010605 Stage 4.doc Version 1.30 Page 11 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) 14, 15 Residents are helped to exercise choice and control over their lives. There is a set menu that changes weekly providing a good varied diet. Alternatives are provided on request and special diets are available. Some staff have not had Food Hygiene training. EVIDENCE: Two residents confirmed that they looked after their own money. Written guidance is in place regarding handling of residents’ money. The Owner takes sole responsibility for the management of any money held on a resident’s behalf. Three residents money was checked and found to balance against the money held. Copies of receipts for money spent are held. Residents confirmed that they were able to bring in personal items for their rooms. Two residents were not aware that they could see the records kept about them by staff, although both said they would not wish to. Weekly menus showed that there is a good variety of food available. There is not an alternative at each meal, but residents said that if they did not like the meal they would get something else. The Manager said that hot and cold drinks are available at any time. The cook confirmed that special diets are provided when required. Residents stated that they could have their meals served in their rooms or in the dining rooms. They also said they were happy Grovewood House B53-B03 S641 Grovewood House V222294 010605 Stage 4.doc Version 1.30 Page 12 with the food provided. Nutritional assessments have not been introduced, but the Manager said that this will be done when staff have completed training. The cook confirmed that she has completed Food Hygiene training. Grovewood House B53-B03 S641 Grovewood House V222294 010605 Stage 4.doc Version 1.30 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, 18 Residents are confident that their complaints will be taken seriously and acted upon by staff. Systems are in place to protect residents from abuse. No staff training has been provided for staff about dealing with allegations of abuse. EVIDENCE: There is a detailed complaints procedure and a complaint record is available. No complaints have been made since the last inspection. Residents said that they would feel able to make a complaint if they wished to staff or the Manager or owners. Staff were able to describe how they would help a resident to make a complaint. Written guidance is in place for dealing with any suspicions or allegations of abuse. No staff training has been provided. Some staff were not clear about procedure to be followed if any allegation of abuse is made. No allegations of abuse have been made since the last inspection. Grovewood House B53-B03 S641 Grovewood House V222294 010605 Stage 4.doc Version 1.30 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, 26 The Home is comfortable and regular maintenance is carried out. A written plan for maintenance and renewal of the furnishings and décor of the Home is not available. The Home was clean, tidy and generally hygienic during the inspection except for items of personal laundry being left lying in the dining room. EVIDENCE: A tour of the building was carried out, although every bedroom was not seen at this inspection. Areas of the Home seen during the inspection were clean and tidy. The grounds are well maintained and residents can easily access the garden. In one room there was an unpleasant odour and the Manager said that steps are being taken to address this. There is a record of maintenance kept, but no formal programme of renewal is available. A number of bedrooms have vinyl flooring instead of carpet fitted. The Manager stated that this was because of continence problems. Inspection of care plans for these residents using the rooms did not always confirm that this was the case. The use of vinyl flooring in bedrooms is increasing and is not backed up by written assessments of issues relating to continence. No risk Grovewood House B53-B03 S641 Grovewood House V222294 010605 Stage 4.doc Version 1.30 Page 15 assessments are in place for increased risk of falls on wet vinyl floors. The laundry is done in an outbuilding. One member of staff has completed Infection Control training. Items of residents’ clothing including underwear were lying in the dining room during the inspection. Grovewood House B53-B03 S641 Grovewood House V222294 010605 Stage 4.doc Version 1.30 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, 29, 30 Staffing is sufficient to meet the needs of the residents. Residents are protected by the recruitment policies and practice. Recruitment policies are followed consistently. Some elements of training are met, while areas like first aid and fire training has not been regularly updated. EVIDENCE: There is a minimum of three staff on each shift during the day. The Manager confirmed that there are two waking staff on duty at night. Inspection of the rotas confirmed this level of staffing is maintained and that there are enough staff to meet the needs of the current residents. There are three senior staff who help with supervising staff in the absence of the Manager or one of the owners. The Manager reported that there is a settled staff team at the time of the inspection. Residents said that they were satisfied that there are enough staff on duty and that staff respond quickly if they need help. Staff said that there are enough staff to cover the rota. The Manager described the procedure for recruiting staff to work at the Home. This included two reference checks and a Criminal Records Bureau (CRB) check prior to staff starting work. Files of recently appointed staff seen during the inspection contain evidence of CRB checks and references. The Manager described the training provided during the last year and this included Fire training, First Aid, Prevention of Falls, Moving and Handling, Basic Food Hygiene and Infection Control. There are three staff undertaking training Grovewood House B53-B03 S641 Grovewood House V222294 010605 Stage 4.doc Version 1.30 Page 17 in care. Five staff have completed training in care. Some staff had not had fire training and first aid training at appropriate intervals. Grovewood House B53-B03 S641 Grovewood House V222294 010605 Stage 4.doc Version 1.30 Page 18 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) 33, 35, 38 No system is in place to ask residents about their views on how the service is run. Records and receipts are kept for any money held on behalf of residents. The Owner keeps money held on behalf of residents in his accommodation. The health, safety and welfare of residents and staff is addressed in some areas, but fire training records are inadequate. EVIDENCE: The Manager reported that there is no quality assurance system in place. She described how residents and relatives are asked about their views at reviews, but there is no process for using this information to plan changes to the service. Records of money held on behalf of residents are maintained and copies of receipts were available. The Owner holds the money and keeps it in his house next door to the Home. Grovewood House B53-B03 S641 Grovewood House V222294 010605 Stage 4.doc Version 1.30 Page 19 Written guidance is available for Health Safety. Staff said that they were aware of this. Training has been provided for some staff in Moving and Handling, First Aid, Fire Safety, Food Hygiene and Infection Control. The Manager said that more training is arranged for staff. There is not always a trained first aider on each shift. Records of accidents are available in an appropriate form. Fire records showed that weekly fire alarm tests are carried out. There was no record of fire instruction for staff, but the Manager said that this has been done. Night staff have not been involved in fire drills. Grovewood House B53-B03 S641 Grovewood House V222294 010605 Stage 4.doc Version 1.30 Page 20 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 x x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 2 STAFFING Standard No Score 27 3 28 x 29 3 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 x x 1 x 3 x x 2 Grovewood House B53-B03 S641 Grovewood House V222294 010605 Stage 4.doc Version 1.30 Page 21 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 3 Regulation 14 Requirement An assessment of needs must be undertaken for each resident prior to admission. The assessment should include all areas identified within Standard 3 of the National Minimum Standards for Older People. A review of the current care planning system must be undertaken to ensure that the health, personal and social care needs of each person are clearly set out. Copies of reviews must be held in each persons file. Residents laundry must not be left in the dining room. Alternative arrangements for folding residents clothes must be found to protect residents privacy and dignity. The use of vinyl flooring in bedrooms must be considered only after other alternatives are explored. Risk assessments should be carried out to ensure that any risk of falls is minimised when vinyl floors are wet. A system must be introduced to B53-B03 S641 Grovewood House V222294 010605 Stage 4.doc Timescale for action 31.08.05 2. 7 15 31.08.05 3. 26 16 31.07.05 4. 19 16 31.07.05 5. 33 24 31.08.05 Page 22 Grovewood House Version 1.30 6. 38 23 review the quality of care provided in the Home. Fire training must be provided at 31.07.08 appropriate intervals and records kept of all staff taking part. Night staff must have regular fire training. 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 Good Practice Recommendations Grovewood House B53-B03 S641 Grovewood House V222294 010605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Northumbria House Manor Walks Cramlington, Northumberland NE23 6UR 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 House B53-B03 S641 Grovewood House V222294 010605 Stage 4.doc Version 1.30 Page 24 - 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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