Inspection on 02/12/05 for Grovewood House

This inspection was carried out on 2nd December 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Grovewood House 25/06/07

Grovewood House 18/05/06

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 Unannounced Inspection 2nd December 2005 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 House DS0000000641.V266447.R02.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V266447.R02.S.doc Version 5.0 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.V266447.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st 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 DS0000000641.V266447.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over half a day and involved discussion with the manager, residents and staff, inspection of records and a tour of the building. During the inspection inspectors spoke with six residents, four staff and the cook. What the service does well: What has improved since the last inspection? 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. Grovewood House DS0000000641.V266447.R02.S.doc Version 5.0 Page 6 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.V266447.R02.S.doc Version 5.0 Page 7 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 Residents have an assessment carried out, but this is not detailed enough. More information is required about each person to ensure that care plans are based a full assessment of need. EVIDENCE: Residents’ records showed that assessments do not cover all the areas identified in Standard 3. Not all residents’ files contain a full assessment. Areas not covered include daily living skills, social and emotional needs. Grovewood House DS0000000641.V266447.R02.S.doc Version 5.0 Page 8 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, 10 Each resident has an individual plan of care, but further work on the care planning system is required to ensure a record of how each person’s health, personal and social needs are met. Residents are treated with respect and their right to privacy is upheld. EVIDENCE: The care planning system requires more development to show how each person’s assessed needs are met. At present there is limited information within individual plans with little attention given to how social and emotional needs are met. Recording is not consistent with some examples of poor recording evident in plans seen. Health care interventions are not always recorded within residents’ records. Many records are not signed and/or dated and there was evidence of inconsistent recording by staff. Daily recordings must be made on separate sheets to protect residents’ confidentiality. Evidence was available of good pieces of work with individuals, but poor recording meant that records often did not show this. Risk assessments are now in place and are well recorded. Grovewood House DS0000000641.V266447.R02.S.doc Version 5.0 Page 9 The staff are given training regarding understanding the residents rights to privacy and the need for them to provide care with this in mind. Those residents spoken to confirmed that the staff knock on their bedroom doors prior to entering and one said “the staff don’t intrude” although they offer assistance sensitively and give them support as necessary. Grovewood House DS0000000641.V266447.R02.S.doc Version 5.0 Page 10 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 Residents are satisfied with the flexibility of their routines for daily living and activities, which are appropriate to meet their cultural, social, religious and recreational interests and needs. Arrangements for residents to maintain contact with family/friends/representatives and the local community are suited to each individual’s needs. EVIDENCE: The manager confirmed that residents are encouraged to take control of their daily routines. Residents confirmed that they are able to make choices about how they spend their day and said they were satisfied with the activities available. Organised activities are available and staff said that residents are able to choose whether or not they are involved. Residents confirmed this. Regular activities include games, craft work, video and music evenings, quizzes and religious services. Residents can have visitors at any time and are able to use their own rooms, the small library or the dining room to receive them. Relatives are welcomed to the home the manager confirmed. Relatives are given information within the residents’ guide about visiting. Local children are expected before Christmas to give a performance of their nativity play and local people come every year to sing carols. Residents said they were satisfied with the arrangements for visitors and that staff welcome them. Grovewood House DS0000000641.V266447.R02.S.doc Version 5.0 Page 11 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): 18 Resident are protected from abuse. EVIDENCE: Written guidance is in place for dealing with allegations of abuse. Training for the manager and one of the senior staff in dealing with allegations of abuse is arranged for next week. Staff were able to describe appropriate action to be taken in the event of an allegation of abuse being made. No allegations of abuse have been made at the home since the last inspection. Policies and procedures are in place for handling residents’ money. All residents have lockable storage in their rooms to keep valuables and money. Grovewood House DS0000000641.V266447.R02.S.doc Version 5.0 Page 12 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, 20, 21, 22, 23, 24 & 26 The home is comfortable and maintained in a safe condition, with regular maintenance carried out. The residents have pleasant bedrooms with their own possessions with sufficient numbers of toilet and bathroom areas. The Home was clean, tidy and generally hygienic, however hand washing facilities must be improved to reduce the risk of cross infection. 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. The bedrooms were personalised to the choices of the residents and contained those items they needed for their well-being. There is a record of maintenance kept. A number of bedrooms were identified in the last inspection as having vinyl flooring instead of carpet fitted. The Manager again stated that this was because of continence problems. The use of vinyl flooring in bedrooms is not Grovewood House DS0000000641.V266447.R02.S.doc Version 5.0 Page 13 always backed up by written evidence that they are required. Although it is acknowledged that the flooring is not usual in bedroom areas the choice of colours are in line with the current social fashion for wooden effect flooring however the home must ensure that this is in line with the choices of the current residents of the individual rooms. An audit of those rooms with vinyl flooring should be undertaken and the Manager should satisfy herself that the care being provided to address the continence problems is effective. Once this is done if the Manager still feels that vinyl flooring is necessary then this should be made clear in the care plans of those individuals with the agreement of the family recorded. The laundry is done in an outbuilding; this was tidy on the day with an adequate facility for sluice washing as necessary. The storage of clean linen prior to them being returned to the residents bedrooms is now in the main building and was organised on the day. The home generally has appropriate control of infection procedures however the staff toilet does not have hand-washing facilities. The bedroom areas have facilities 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 must be given adequate hand wash facilities. Grovewood House DS0000000641.V266447.R02.S.doc Version 5.0 Page 14 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, 30 Residents’ needs are met by the number and skill mix of staff, although it was evident that staff on duty at the time of the inspection did not correspond with the rota. Staff training was being carried out but not being recorded effectively to show if it was fully up to date. 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. The rota did not correspond with the staff on duty and the manager said at times changes were not recorded. Residents said they were satisfied that sufficient staff are on duty throughout the day. All senior staff have completed appropriate training in caring for older people. There is a senior carer on each shift. Two waking care staff are on duty throughout the night. The manager reported that the owners and their daughter live next door and can be called on at any time to support staff. No staff are employed who are aged less than twenty one years. The fire training is up to date for all staff and fire drills are being carried out as necessary for which recording is in place although some improvement was suggested to make it more useful for identifying future training needs for staff. The recording of training including moving and handling was not up to date so did not reflect the staff achievements; this must be improved to give a fairer picture of the situation. Grovewood House DS0000000641.V266447.R02.S.doc Version 5.0 Page 15 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, 35, 36, 38 The manager is experienced in caring for older people and is currently undertaking training in management and care. Residents’ financial interests are safeguarded by appropriate records. The owner keeps money held on residents’ behalf in his own accommodation. Staff do not receive formal supervision at regular intervals. Residents’ health, safety and welfare are promoted and protected. EVIDENCE: The manager is currently undertaking management and care training that leads towards a manager’s award. She has been manager of the home for some time and was previously involved in working for her parents in the home. She has completed fire training since the last inspection and is to undertaken abuse training next week. Grovewood House DS0000000641.V266447.R02.S.doc Version 5.0 Page 16 Records are kept of any money held on residents’ behalf and receipts for any items bought are also available. Samples of the money held were checked and these balanced with the money held. The money is kept in the owner’s accommodation and was brought in during the inspection. Grovewood House DS0000000641.V266447.R02.S.doc Version 5.0 Page 17 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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 3 2 X 3 Grovewood House DS0000000641.V266447.R02.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? NO 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 OP3 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. This requirement is outstanding from the last inspection. 2. OP7 15 The care planning system requires further development to show how each person’s assessed needs are met. The use of vinyl flooring must be reviewed and if found necessary it should be made clear in the care plans of those individuals with the agreement of the family recorded. Adequate hand-washing facilities must be provided to staff to prevent he risk of cross infection. Staff training was being carried out but not being recorded effectively to show if it was fully DS0000000641.V266447.R02.S.doc Timescale for action 31/01/06 31/01/06 3. OP19 23 (2) 31/01/06 4. OP26 13 (3) 31/03/06 5. OP30 18 (1) 31/03/06 Grovewood House Version 5.0 Page 19 up to date. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Grovewood House DS0000000641.V266447.R02.S.doc Version 5.0 Page 20 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. 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