Inspection on 01/03/07 for The Grove

This inspection was carried out on 1st March 2007.

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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Grove 17/01/08

The Grove 19/01/06

The Grove 18/08/05

The Grove 12/03/05

The Grove 24/01/05

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

CARE HOME ADULTS 18-65 Grove Cheshire Home Scotts Hill East Carleton Norwich Norfolk NR14 8HP Lead Inspector Mrs Marilyn Fellingham Unannounced Inspection 1st March 2007 09:30 Grove Cheshire Home DS0000015641.V331912.R01.S.doc Version 5.2 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 Grove Cheshire Home DS0000015641.V331912.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 Adults 18-65. 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. Grove Cheshire Home DS0000015641.V331912.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grove Cheshire Home Address Scotts Hill East Carleton Norwich Norfolk NR14 8HP 01508 570279 01508 571057 grove@lc-uk.org www.leonard-cheshire.org.uk Leonard Cheshire 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) Mrs. J Jane Noble Care Home 31 Category(ies) of Physical disability (31) registration, with number of places Grove Cheshire Home DS0000015641.V331912.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th January 2006 Brief Description of the Service: The Grove is a voluntary sector care home operated by the Leonard Cheshire Foundation. The premises comprise a carefully adapted period house to which purpose built extensions have been added. Accommodation is provided there for 31 people with physical disabilities. The Grove is situated within 54 acres of landscaped grounds on the edge of the village of East Carlton, to the south of Norwich. Grove Cheshire Home DS0000015641.V331912.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The care services of this home are judged against outcome groups, these assess how well the home delivers the outcomes for people using the service. This was an unannounced inspection and was carried out by talking to the manager, staff members, service users and relatives. Records were examined as well as a tour of the home. What the service does well: What has improved since the last inspection? Grove Cheshire Home DS0000015641.V331912.R01.S.doc Version 5.2 Page 6 New dining tables have been provided and these are adjusted to accommodate all wheelchair users. The home now has a system in place for loaning money to service users and staff no longer loan money to them. 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. Grove Cheshire Home DS0000015641.V331912.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Grove Cheshire Home DS0000015641.V331912.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service user’s individual aspirations and needs are assessed prior to admission to the home. EVIDENCE: Case tracking confirmed good practice, it also confirmed that the process for assessing the service user’s needs was done over a period of time and settling in period to ensure that the home is able to meet the needs of, at times most complex cases. The admission records indicated that the service user’s mental, physical and social health care needs were taken into consideration in order to formulate a plan of care. Contracts were seen for newly admitted service users who were informed by letter that their needs could be met. Grove Cheshire Home DS0000015641.V331912.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service, the inspection process and discussion with service users and staff. Service users are encouraged to lead independent lifestyles and take an active part in all aspects of life in the home. EVIDENCE: The Inspector examined four care plans; the assessment process had been used to formulate a plan of care that also included areas of activity, personal, therapeutic, social and physical interventions. It was noted that there had been continued evaluation of care and records of multidisciplinary intervention and review. There were very detailed daily notes with some of the data being entered onto care plans when appropriate. There was evidence of service user and relative’s involvement, where able, in the care planning process. Risk assessments were in place and service users are encouraged to take responsible risks in their daily activities. Grove Cheshire Home DS0000015641.V331912.R01.S.doc Version 5.2 Page 10 Those service users spoken to indicated that they were encouraged to take risks in their daily lives and towards more independence. Service users have regular meetings and the chairperson for this group said that after their meetings they then attend a managers meeting where any of their concerns can be aired and that these meetings were also used to share information about the home. The service users also participate in the selection of new staff. Grove Cheshire Home DS0000015641.V331912.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service, discussion with service users and relatives. Activities and meals are managed extremely well. The service users are encouraged to be in control of their own lives and enhance their personal development. EVIDENCE: Discussion with service users confirmed that opportunities were given to encourage them in their personal development and social needs; various notes in their care plans referred to involvement in learning opportunities and leisure activities. The inspector noted that a number of service users were in the activity room; some learning about IT another was booking tickets for a show in Norwich. One service user was listening to music in his room; his room had been arranged to accommodate all of his musical equipment. Two more service users were playing snakes and ladders, whilst another was running the home’s shop. Another resident was learning to play a keyboard and also had just been provided with a special large key-board to learn some basic IT skills and their Grove Cheshire Home DS0000015641.V331912.R01.S.doc Version 5.2 Page 12 relative who also spoke for him stated that he had achieved quite a lot since coming to the home. Many residents stated that they were given many opportunities to go on outings but ultimately they chose what they wanted to do. There are a number of access routes for wheelchair users and one resident was seen taking himself out into the wood by the lake; another resident was having tea with his relative who was going to take him for an outing round the grounds. One resident stated that they visit their father and that his father also visits any time he wants to. All of the service users spoken to spoke highly of the meals provided for them, making remarks like they are really delicious, good quality food, the kitchen knows what I like and the food is good with lots of choices. One stated that their favourite food was prawn cocktail and that they had just been given it for lunch because it was their birthday. Grove Cheshire Home DS0000015641.V331912.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service and discussion with staff, management and auditing of the medicines. Service users are well supported by staff. Arrangements for the administration of medication is not handled well. EVIDENCE: Discussion with the service users confirmed that they felt that they were well supported by staff at all levels and that they are encouraged to make decisions about their daily lives. Since the last inspection the management have held numerous meetings with the nurses to ensure that the administration of medication is managed well: however after auditing a number of medicines the Inspector found once more that there were gaps in the daily administration record where no initials or code letter had not been entered. The Inspector also noted that for two service users their daily record of Temazepam did not tally with the amount left. After careful examination of past records and records of the receipt of this medication into the home it was found that the anomaly had occurred because nurses had been not been using the individual tablets as prescribed, but using one lot as a pool. A requirement is made to ensure that only Grove Cheshire Home DS0000015641.V331912.R01.S.doc Version 5.2 Page 14 individual prescribed medicines are given to those persons as named on the prescribed tablets. It is also recommended that although Temazepam does not need to be recorded in the CD register it is considered good practice to do so and reduce mistakes being made and encourage a tighter auditing system. It is also recommended that more frequent auditing of medication take place. Discussion with the nurses would indicate that they do always have the time to complete these extra duties. The manager stated that she would address these issues immediately. Grove Cheshire Home DS0000015641.V331912.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service, available evidence, and discussion with staff, management and service users. Arrangements for dealing with complaints are satisfactory. EVIDENCE: The Inspector examined the records for complaints, these were detailed and contained notes on action taken. It was also noted that responses were made within 28 days according to the home’s policies and procedures for making a complaint. Service users and relatives spoken to were aware of how to air their concerns and also knew that the residents meetings could also be used as a forum for taking any concerns to the management. All the staff spoken to were aware of all issues relating to the protection of vulnerable adults and they confirmed that they had attended training sessions in relation to this; staff training records also verified this. Grove Cheshire Home DS0000015641.V331912.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service, observations made during a tour of the home, available evidence and discussion with the manager and service users. EVIDENCE: The home was found to be very clean and tidy and the service users whose rooms were inspected all said that they were satisfied with their accommodation. The rooms were suitable for the client group and the inspector noted that they contained equipment to maximise their independence. The manager explained that it is envisaged that the main dining room will be refurbished and made more homely and the floor tile replaced as they have become unsightly in the coming financial year; unfortunately it had been put on hold for year. It was noted that new dining tables had been purchased that specially accommodated wheelchair users. It is also anticipated that a new lift will be fitted too. Grove Cheshire Home DS0000015641.V331912.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service, and by examining records and discussion with staff and management. EVIDENCE: Discussion with staff members confirmed that they felt that they were clear about their roles and responsibilities; however it would appear that due to a lack of Registered Nurses on any given shift, (the compliment of Registered Nurses was reduced due to the reduction of service users, however the needs of the service users and numbers has since increased), they feel that they cannot always carry out their duties adequately. One example of this is that medicine audits should be carried out more frequently as this would reduce the problems of mismanagement of the medication. Records for newly appointed staff were examined and were seen to reflect a robust checking system before staff are employed. The staff records were also seen to contain appropriate proof of staff identity. The staff spoken to indicate that they felt that the provision of training opportunities in the home were good and the training records confirmed this. New staff members confirmed that they had been given an induction and records were seen for this. Grove Cheshire Home DS0000015641.V331912.R01.S.doc Version 5.2 Page 18 Formal supervision is in place and records were seen for this activity and the staff also stated that they had had supervision sessions. Grove Cheshire Home DS0000015641.V331912.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service, examining records and discussion with staff, management and service users. EVIDENCE: Discussion with staff, visitors and service users led the Inspector to believe that the home is well run. Service users and staff have definitely benefited from the ethos and leadership of the manager who constantly strives to ensure that the home meets the National Minimum Standards. The staff and service users feel that they are very well managed and supported. The policies and procedures are continually being updated to conform to current best practice and used as an information system for the staff to ensure Grove Cheshire Home DS0000015641.V331912.R01.S.doc Version 5.2 Page 20 that they are safeguarding the best interests of the service users and promoting their safety and welfare. Grove Cheshire Home DS0000015641.V331912.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 x 28 x 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 4 4 x LIFESTYLES Standard No Score 11 4 12 4 13 X 14 4 15 x 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 3 3 3 3 3 3 Grove Cheshire Home DS0000015641.V331912.R01.S.doc Version 5.2 Page 22 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 YA20 Regulation 13 Requirement Errors in the record of daily administration of medicines need to be identified and followed up at the earliest opportunity. This is a repeat requirement. The registered person must ensure that medication is only administered to those persons whose name is on the prescribed medication. Timescale for action 01/03/07 2. YA20 13 01/03/07 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 YA24 YA20 Good Practice Recommendations The dining room would benefit from redecoration and attention to the floor tiles, which are becoming unsightly. It is recommended for best practice that the home keep a record of Temazepam in the CD register. It is also recommended that regular audits of the medication take place. Grove Cheshire Home DS0000015641.V331912.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Grove Cheshire Home DS0000015641.V331912.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!