Inspection on 18/05/06 for Grovewood House

This inspection was carried out on 18th May 2006.

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 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 House 25/06/07

Grovewood House 02/12/05

Grovewood House 01/06/05

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 Key Unannounced Inspection 18th May 2006 09:00 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 House DS0000000641.V296566.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 House DS0000000641.V296566.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grovewood House Address Main Street South Charlton Alnwick Northumberland NE66 2NB 01665 - 579249 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) Mr Bakr Mrs Bakr Mrs Linda Steele Care Home 34 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (32) of places Grovewood House DS0000000641.V296566.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd December 2005 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. Fees are £378.45 per week for accommodation in a single room. Grovewood House DS0000000641.V296566.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place over seven and a half hours and involved discussion with one of the owners, the manager, residents, relatives and staff, inspection of records and a tour of the building. During the inspection the inspector spoke with five residents, two relatives, four staff and the cook. What the service does well: What has improved since the last inspection? What they could do better: The care planning system could be developed to show more fully how each person’s assessed needs are met. Hand-washing facilities need improvement to prevent the risk of cross infection. Annual training for care staff must include Adult Protection. The system for recording administration of medicines needs review so that the stock of medicine corresponds with the records. More staff training in administration of medicines is required. An annual development plan and quality assurance system must be developed for the home. This should include planning, actions needed and a review process based on a cycle of planning, action and review. Fire training must be provided at appropriate intervals for all staff. Recruitment processes during the past year have not been thorough and could have put residents at risk. Overall the management of the home need to respond to the areas identified that affect the safety of residents. Grovewood House DS0000000641.V296566.R01.S.doc Version 5.2 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. Grovewood House DS0000000641.V296566.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 House DS0000000641.V296566.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Pre admission assessments, which identify needs prior to acceptance into the home are in place. Residents referred for intermediate care are not accepted at Grovewood. EVIDENCE: A new assessment form has been introduced that provides appropriate information about new residents’ needs. Some forms have been completed for residents and these identify activities of daily life as well as care needed. Existing residents have not been assessed using this form. Staff said that the new system provides better information about individual residents’ needs. Intermediate care is not provided at Grovewood. Grovewood House DS0000000641.V296566.R01.S.doc Version 5.2 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 the following standard(s): 7, 8, 9, 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Some residents’ health, personal and social care needs are set out in an individual plan of care, but more work is needed to ensure all residents’ needs are consistently identified. The health needs of residents are appropriately met. The system for recording administration of medicines is not accurate and residents may be a risk. Residents’ privacy and dignity is met. EVIDENCE: The care planning system has not been developed. Care plans have limited information. Social and emotional needs are met but details are not recorded.. Some work has been done since the last inspection. Records do not fully show how residents’ health, personal and social care needs are assessed and met. Recording is not consistent. There is some poor recording with some examples of poor recording evident. The manager is aware of this and welcomed recommendations about improving the care planning system. Residents said that they are satisfied with the care provided and that staff are aware of their needs. Discussion with staff and observation during the inspection showed Grovewood House DS0000000641.V296566.R01.S.doc Version 5.2 Page 10 that the staff have a good understanding of residents’ needs. Residents’ records do not always support this. Records of visits by health care professionals show that residents are able to keep their own General Practitioner on admission and that there is access to other visiting health professionals including district nurses and chiropodists. Individual records and discussion with staff showed that health care needs are identified and met. Assessment tools, to identify specific needs including falls, pressure areas and nutrition, are not used fully. Medication records are kept, but samples checked did not all correspond with stocks of pills. A system is not provided for checking the administration of medicines. Appropriate arrangements are in place to record ordering and disposal of medicines. Not all staff responsible for the administration of medicines have completed appropriate training. The storage of medication is satisfactory. Residents said that staff respect their privacy and dignity. They gave examples such as entering rooms and keeping mail private. Staff respond appropriately to residents. Staff said that respect and dignity are included in induction training. During the inspection staff knocked on residents’ doors and spoke respectfully to residents. Grovewood House DS0000000641.V296566.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activities arranged meet the needs and expectations of residents living at the home. Residents are able to maintain contact with family, friends and the local community with support from staff. Residents receive a wholesome and varied diet, which meets any special dietary needs. EVIDENCE: An activity programme is in place. Recent activities included quizzes, musical events, board games and craft work. There are regular religious services, the hairdresser visits weekly and newspapers are delivered daily. A timetable of events is on the notice board in the main hall. One resident said “we can choose the events we attend and I really enjoy the music events. There is an open visiting policy and residents can entertain their visitors in their rooms or in the home’s sitting and dining areas. Two visitors said that they are made to feel very welcome by staff. Residents can go outside the home with their relatives as they wish and can choose where to spend their time. Some residents have meals served in their rooms. Residents said that they are able to get up in the morning or go to bed Grovewood House DS0000000641.V296566.R01.S.doc Version 5.2 Page 12 in the evening when they like. The manager discussed an issue concerning one resident going out on her own when she has no understanding of the dangers of traffic. The home is in a rural area with little traffic, but this is a hazard. There are no external door alarms fitted yet but consideration is being given to this. The meal served during the inspection was wholesome and well presented. The menus showed that a balanced diet is provided. A menu choice is not provided, however in practice residents said that they can ask for an alternative. There is a need to formalise this on the menus and to show the range of options described by residents at the evening mealtime. Special diets are catered for including soft and pureed meals, low fat and diabetic options. The dining areas are comfortably furnished and tables were well laid. Staff provided appropriate assistance to residents during the meal. The cook has completed food hygiene training. Grovewood House DS0000000641.V296566.R01.S.doc Version 5.2 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 the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure is comprehensive and is accessible to residents and their representatives. There are appropriate arrangements in place to protect residents from abuse, however some staff need further training. EVIDENCE: Guidance is in place for complaints. Residents and relatives are given information about how to make a complaint. Since the last inspection no complaints have been made. One resident said that she would feel happy to speak to the staff or management of the home if she had a complaint or concern. She said she is certain that they would respond to this appropriately. Relatives were confident about the complaint process. Procedures are in place for dealing with allegations of abuse. Only two staff have completed training and the manager is arranging for more staff to attend training courses. Staff could describe the procedure for reporting and dealing with allegations of abuse. Grovewood House DS0000000641.V296566.R01.S.doc Version 5.2 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 the following standard(s): 19, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Most areas of Grovewood House are homely, clean and comfortable for residents. A programme of refurbishment is ongoing to upgrade bedrooms and the manager said that the remaining bedrooms and bathrooms are part of this programme. The assisted bathroom needs upgrading to provide a better environment for the current residents and some other bathrooms would benefit from upgrading as baths and flooring are marked and damaged. There is a need for better sluice facilities to be made available. EVIDENCE: The interior of the home is generally homely and comfortable with some attractive original features in keeping with the age of the house. The furniture in one sitting could be better arranged to make it more homely. Residents sit in a row behind other residents making it more difficult to talk to each other. There are attractive gardens to the side of the house and a gravelled parking area to the front. The front gates lead to the main road and could pose a risk Grovewood House DS0000000641.V296566.R01.S.doc Version 5.2 Page 15 to residents’ safety. As a result of concerns about this the management of the home is considering the use of alarms on the main exits or the use of a keypad entry system. Maintenance records are kept and staff said that repairs are undertaken promptly. The dining room and kitchen have been painted since the last inspection. Residents said that they were comfortable and satisfied with the accommodation. The home was clean and there are appropriate infection control procedures in place. Since the last inspection a hand wash sink has been fitted in the staff toilet. The bedroom areas have wash hand basins fitted for the residents but staff would have to use the resident’s soap or towel to wash their own hands after providing personal care. Staff do not have adequate hand wash facilities in residents bedrooms and bathrooms. Sluice facilities are very limited and staff have to carry soiled equipment around the home. Written guidance is in place for Infection Control and Health and Safety. Grovewood House DS0000000641.V296566.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Adequate staffing levels are maintained during the day and night to meet the needs of the residents. Staff qualifications are below the minimum standard. Recruitment processes are not sufficient to ensure the safety of residents. There is no formal staff development plan to show how staff training can benefit the care of residents, although a range of training opportunities are provided. EVIDENCE: Three care staff, one of whom was a senior carer, two domestic staff and a cook were on duty at the time of this inspection. Residents said they were satisfied that sufficient staff are on duty throughout the day and one said “staff are very nice and they know what I need help with”. All senior staff have completed appropriate training in caring for older people. There is a senior carer on each shift and discussion with staff confirmed this. Two waking care staff are on duty throughout the night. The manager said that the owners and their daughter live next door and can be called on at any time to support staff. All staff employed are more than twenty one years old. There are forty per cent of care staff with National Vocational Qualifications (NVQ) in care at Level 2 or above and induction training is provided for new staff. Six care staff have completed NVQ Level 2 in care or above out of fifteen care staff. Two staff are currently working towards NVQ Level 3 and one is on Grovewood House DS0000000641.V296566.R01.S.doc Version 5.2 Page 17 Level 2 and when these staff complete their courses the home will have achieved more than 50 of staff qualified. Staff recruitment records showed that in the past year some staff have started work before all Criminal Records Bureau and reference checks have been completed. Guidance is in place for recruitment of staff. Staff records do not contain all the information required in Schedule 2 of the Care Homes regulations including evidence of identity and two written references. The staff training plan needs further development to ensure that it links training opportunities to residents’ assessed needs. Training in the past year included Dementia, Adult Protection, NVQ level 2 and 3 and Personal Safety. The recording of individual staff training has improved since the last inspection. Staff said that they feel training opportunities have improved in the last year and that they are relevant to residents’ needs. Grovewood House DS0000000641.V296566.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The manager is experienced in caring for older people and is currently undertaking training in management and care, although she has not yet completed the Registered Manager’s award. The home is run in the best interests of the residents, however this needs to be supported by a valid quality assurance system. Residents financial interests are protected. Residents’ health, safety and welfare is generally promoted and protected, but fire training for staff has not been provided at appropriate intervals which may place staff and residents at risk. EVIDENCE: The Registered Manager is experienced in caring for older people and is due to complete the Registered Manager’s award in the next year. The residents and Grovewood House DS0000000641.V296566.R01.S.doc Version 5.2 Page 19 staff made positive comments about the management style adopted by the manager and owners. They said that they felt able to speak to them and raise any issues they might have. Two relatives said that they felt satisfied that they are kept informed about any issues and that they are made very welcome at the home. There was no quality assurance system or annual development plan available at the time of the inspection. The Manager is aware that more effective systems need to be introduced to regularly reflect, review and plan to ensure residents receive care appropriate to their needs and wishes. Some policies and procedures are being reviewed, but there is no comprehensive system that takes account of residents’ views on the quality of the service. Financial records are good. Individual records are kept to show how money is being spent. Records of health and safety checks of equipment used including fire equipment are kept as required. Some staff training has been provided in safe working practices including moving and handling, food hygiene, first aid and infection control. Staff fire training has not been held at appropriate intervals. Accident records are kept in an appropriate form. Grovewood House DS0000000641.V296566.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Grovewood House DS0000000641.V296566.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? Yes 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 The care planning system requires further development to show how each person’s assessed needs are met. This matter is outstanding from the last inspection report. Adequate hand-washing facilities must be provided to staff to prevent the risk of cross infection. The system for recording administration of medicines must show that the stock of medicine corresponds with the records. More staff training in dealing with medicines is required. Annual training for care staff must include Adult Protection. Staff records must include all areas identified within Schedule 2 of the Care Homes Regulations 2001. An annual development plan and quality assurance system must be developed based on a systematic cycle of planning, action and review. DS0000000641.V296566.R01.S.doc Timescale for action 31/08/06 2. OP26 13 (3) 31/08/06 3 OP9 13 (2) 31/08/06 4 5 OP18 OP29 13 (6) 19 31/08/06 31/08/06 6 OP33 35 30/09/06 Grovewood House Version 5.2 Page 22 7 OP38 23 (4) (d) Fire training must be provided at appropriate intervals for all staff. 30/06/06 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 OP15 Good Practice Recommendations Options should be available on the menus Grovewood House DS0000000641.V296566.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Cramlington Area Office 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 DS0000000641.V296566.R01.S.doc Version 5.2 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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