Inspection on 09/11/06 for Ings Grove House

This inspection was carried out on 9th November 2006.

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

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Larchfield Manor

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The Grove Waltham

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Ings Grove House Doctor Lane Mirfield WF14 8DP Lead Inspector Bronwynn Bennett Unannounced Inspection 9th November 2006 09:10 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 Ings Grove House DS0000067961.V311649.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. Ings Grove House DS0000067961.V311649.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ings Grove House Address Doctor Lane Mirfield WF14 8DP 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) 01924 326475 01924 326476 www.kirklees.gov.uk Kirklees MC Rita Neil Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40), Physical disability (40), Physical disability of places over 65 years of age (40) Ings Grove House DS0000067961.V311649.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Can only admit service users over the age of 50 years. Date of last inspection NA Brief Description of the Service: Ings grove House is a purpose home registered to provide respite care, short stay and intermediate care for up to forty service users. The rooms provided are single, en-suite and provide a nurse call system. All rooms have their own television. There are two floors that may be accessed via a lift. The home is located in its own grounds and there are car parking facilities. Ings Grove House is situated adjacent to parkland close to Mirfield town centre and is situated near the local shops and facilities. The home is staffed twenty-four hours a day and there are waking night staff on duty. The provider informed the Commission for Social Care Inspection on 13/10/06 that the fees are £498.25. There are additional charges for hairdressing, newspapers and private chiropody. Information about the home and the services provided are available from the home in the statement of purpose and the service user guide. Ings Grove House DS0000067961.V311649.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit carried out by two inspectors. The visit began at 9.00am and finished at 3.35 pm. During this visit the inspectors spoke to some service users, some of the staff and the home’s manager Ms Rita Neil. The inspectors read care records, audited a sample of medications, reviewed staff recruitment and training records, and carried out a tour of the home. Prior to this visit the Commission for Social Care Inspection sent sixteen questionnaires to service users who have used the services provided at Ings Grove House. Six completed questionnaires were returned. There were twentyfour service users living at the home on the day of this visit. Surveys were sent to fourteen service users relatives and one GP. The inspector received responses from eight relatives. Other information used as part of this inspection process includes notifications from the home to the Commission for Social Care Inspection about deaths, illnesses, accidents and incidents at the home, and a pre inspection questionnaire completed by the manager. The inspector would like to thank everyone for their assistance during this inspection process. What the service does well: There has been positive comments made about the staff team both during this visit and from the surveys received by the Commission for Social Care Inspection. In addition some positive interactions were seen between the service users and the staff during this visit. A relative who responded to the survey said the layout of the building is excellent and some of the service users spoken with during this visit said that they are satisfied with the standard of accommodation offered at Ings Grove House. This is a newly built home that provides pleasant and homely surroundings and on the day of this visit was clean and odour free. 82 of the care staff working in the home has achieved NVQ (National Vocational Qualification) level 2 or above. Ings Grove House DS0000067961.V311649.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Ings Grove House DS0000067961.V311649.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 Ings Grove House DS0000067961.V311649.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): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users needs are assessed prior to admission into the care home. Accommodation and facilities are provided for intermediate care services in order to maximise resident’s independence and help them return home. EVIDENCE: The care records looked at showed that pre-admission assessments are carried out. A service user said they were given the opportunity to look around the home before their stay. The manager said that the needs of service users are assessed prior to admission and visits to the home are supported and encouraged prior to admission. Intermediate care is provided at the home and the relevant accommodation and facilities are provided for this care. The relevant professional staff are provided as part of this service to enable rehabilitation. Ings Grove House DS0000067961.V311649.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally service users health, personal and social care needs are set out in the individual plan of care. Greater care is required to ensure the service users are sufficiently protected by the homes medication policy and procedure. Generally service users are treated with dignity and respect. EVIDENCE: During this visit the home was noted to have a relaxed and friendly atmosphere and good interaction was observed between the service users and the staff. Staff were observed treating the service users in a respectful and dignified manner. Ings Grove House DS0000067961.V311649.R01.S.doc Version 5.2 Page 10 The service users who responded to the survey said they receive the care and support they need. One comment from a service user was that the staff are kind and helpful and took care of all their needs. All the relatives’ surveys said that they were satisfied with the overall care provided at Ings Grove House. The care records for four service users were audited. All the records had a care plan in place and there was some good information relating to the preferred care and routines of individual service users. However, there were some gaps in the records and some documentation was not fully completed, dated or signed. Risk assessments were in place and service users have assessments for nutrition and tissue viability (to measure the risk of developing a pressure sores). Not all service users weights were recorded on the relevant records and this should be addressed. Movement and handling assessments were looked at. Two were noted to be brief and lacked the specific information that may be required by the carer to ensure safe movement and handling. The home’s medication system was audited and the medication for two service users was checked. Both medications could be fully reconciled with the records kept by the home. It was noted in the care records looked at that service users are supported to manage their own medication and self medicate. However, there was no risk assessment in place to ensure service users are safe when self-medicating. In addition there was no formal process available to prompt staff to monitor that service users are self-medicating correctly and safely. The home should develop a robust risk assessment to assess the risk when a service users chooses to self medicate. And should develop a policy and procedure for staff to monitor this activity. Ings Grove House DS0000067961.V311649.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users religious, social and recreational needs are generally being met, and they are supported to maintain contact with their family and friends. The service users are able to exercise choice and control over their lives. The home provides the service users with a varied and nutritious diet. EVIDENCE: A range of activities is provided and the home has a part time activities coordinator. Activities extend to all individuals and planned events are displayed on the homes notice board. TVs are provided in all service users rooms and there is a selection of videos and films available. Religious observance is respected and a local church is to carry out regular visits to the home. The service users spoken with said there is a choice of activity for them to participate in if they wish. Service users who responded to the survey said that there are generally activities arranged by the home. Ings Grove House DS0000067961.V311649.R01.S.doc Version 5.2 Page 12 Service users are supported to manage their own finances if they wish to do so and lockable facilities are provided in service users’ rooms. Bedrooms were seen during a tour of the home and a service user spoken with said they were satisfied with the standard of accommodation provided. The manager said that visitors are free to visit the home when they wish. There are private facilities provided for visiting where required. All the relatives that responded to the survey said that they are welcomed at the home by the staff, and are able to visit their friend or relative in private. The home offers a two weekly menu. There is a choice of food available and the home is able to provide service users with specialist diets. The service users spoken with during this visit said the food is good and they are offered a choice of food. Four service users that responded to the survey said that they like the meals provided at the home. Ings Grove House DS0000067961.V311649.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally service users and their relatives are confident their complaints will be listened to and acted upon. However, the organisation should take action to ensure all service users and their relatives are aware of the home’s complaints procedure. Service users are protected from abuse. EVIDENCE: The home has a policy and procedure in place for raising concerns and making complaints. This procedure is displayed in the home. In addition prospective service users are sent information of how to make a complaint. The home has received five complaints that have been investigated by the manager and acted upon. The service uses spoken to during this visit said they would feel confident to express any concerns or make a complaint. Four service users who responded to the survey said they knew how to make a complaint. Four relatives that responded to the survey said they were not aware of the home’s complaints procedure. The training records looked at showed the majority of the home’s staff has received training for the protection of vulnerable adults. This training should continue for all staff. Ings Grove House DS0000067961.V311649.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users live in a safe and well-maintained environment that is clean and comfortable. EVIDENCE: This is a new service that was opened in June 2006. A relative who responded to the survey said the layout of the home is excellent. The service users spoken with during this visit and all those who responded to the survey said the home is fresh and clean. During this visit the home was noted to be clean and odour free. Some service users bedrooms were seen. The service users spoken with said they were satisfied with the standard of accommodation offered at the home. Laundry facilities provided at the home were clean and well organised. Ings Grove House DS0000067961.V311649.R01.S.doc Version 5.2 Page 15 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 are employed in sufficient numbers and receive induction and ongoing training. Service users are supported and protected by the home’s recruitment policy. EVIDENCE: The home has a staff rota that shows there are sufficient numbers of care staff employed to meet the needs of the service users. The service users that responded to the survey said they receive the care and support they need. There were some positive comments made about the staff and one relative commented that the staff have shown nothing but kindness and care. A service user spoken with during this visit said the staff are “fantastic”, Three staff files were audited. The records looked at held the information required to ensure service users are protected by the homes recruitment procedures. Ings Grove House DS0000067961.V311649.R01.S.doc Version 5.2 Page 16 The information received by the Commission for Social Care Inspection (CSCI) shows there are 82 of the care staff working in the home has achieved NVQ (National Vocational Qualification) level 2 or above. The staff spoken with said they had received induction training and some ongoing training at Ings Grove House. However, there were no records available of the detail covered as part of the home’s induction training. The home is staffed from an existing staff team that has worked in other services within the organisation. The staff training records kept by the home were difficult to follow. This was discussed with the manager and it is a recommendation of this report that accurate, and up to date training records are kept in the home. Where there is no evidence to indicate that the staff has attended training, this training should be undertaken and the appropriate records kept. Ings Grove House DS0000067961.V311649.R01.S.doc Version 5.2 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users live in a home run by a manager who is fit to be in charge. The home is run in the best interests of the service users. The financial interests of the service users are generally safeguarded. Generally the health, safety and welfare of the service users is promoted and protected. EVIDENCE: Ms Rita Neil was registered as the manager of Ings Grove House in September 2006. The staff spoken with during this visit said the manager is approachable and supports the staff and service users. Ings Grove House DS0000067961.V311649.R01.S.doc Version 5.2 Page 18 Although the service has only been operational since June 2006 the manager has worked well to ensure there is a quality monitoring system that seeks the views of service users. One member of staff commented that the manager works hard monitoring the quality of the service and making adjustments accordingly. The manager said that service users are asked for comments about the service they receive during their stay and are asked to complete a questionnaire when they return home. In addition, the home holds service users meetings and there are regular quality visits carried out by the organisation. The financial records for three service users were audited. Two financial records were correct and one record had a minor discrepancy. This was discussed with the manager. Service users are supported to manage their own finances should they wish to do so and are provide with lockable facilities for this purpose. The information received by the Commission for Social Care Inspection shows that the equipment used in the home is new and in good working order. The fire records were looked at. The home has a fire risk assessment in place and there is weekly testing of the homes fire alarm system and emergency lighting. Staff should make it clear what they have checked when carrying out fire testing and this was discussed with the manager. The majority of staff has undertaken fire safety training and training is planned to ensure all staff receive fire training. Ings Grove House DS0000067961.V311649.R01.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME 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 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 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 X 3 X 3 X X 3 Ings Grove House DS0000067961.V311649.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? NA 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 OP9 Regulation 13 Timescale for action The registered person shall make 27/11/06 arrangements for the safe handling of medication received into the care home. Where a service user has chosen to self medicate the home must complete a risk assessment for this activity. The home must develop a robust policy and procedure for the staff to monitor this activity. Requirement 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 OP7 OP8 Good Practice Recommendations The care records kept for individual service users should be completed in full, dated and signed. The service users weight should be recorded as soon as possible following admission. This information should also be recorded in the relevant records such as nutritional and movement and handling risk assessments. Movement and handling assessments should be detailed. DS0000067961.V311649.R01.S.doc Version 5.2 Page 21 3. OP8 Ings Grove House 4. 5. 6. OP16 OP18 OP30 7. 8. 9. OP33 OP35 OP38 And give the carer all the required information in order to meet individual manual handling needs. The organisation should take action to ensure all service users and their relatives are aware of the home’s complaints procedure. Adult protection training should continue until all staff has received such training. Accurate and up to date training records for all the training undertaken by the staff team should be kept in the care home. Where there is no evidence to indicate that staff has attended training, the training should be undertaken and the appropriate records kept. The home should continue to develop quality assurance and quality monitoring systems. Greater care needs to be taken to ensure the financial interests of service users are fully protected. Fire training should continue until all the staff working at the home has received such training. Ings Grove House DS0000067961.V311649.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Brighouse Area Office St Pauls House 23 Park Square (South) Leeds LS1 2ND 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 Ings Grove House DS0000067961.V311649.R01.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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