Inspection on 13/10/05 for The Grove

This inspection was carried out on 13th October 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

The Grove 15/02/07

The Grove 26/05/05

The Grove 01/02/05

The Grove 27/07/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE The Grove Thurnscoe Bridge Lane Thurnscoe Rotherham South Yorkshire S63 0SN Lead Inspector Mrs Sue Stephens Unannounced Inspection 12th October 2005 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 The Grove DS0000058045.V254845.R01.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. The Grove DS0000058045.V254845.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Grove Address Thurnscoe Bridge Lane Thurnscoe Rotherham South Yorkshire S63 0SN 01709 895424 01709 897948 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) Guardian Care Homes (UK) Limited Mrs Irene West Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places The Grove DS0000058045.V254845.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons accommodated shall be aged 60 years and above. The Manager will work supernumerary 3 days per week when the occupancy is in excess of 20 service users. At full occupancy the Manager will be totally supernumerary. 26th May 2005 Date of last inspection Brief Description of the Service: The Grove is a 37-bed home for older people, providing personal care. It is situated in the village of Thurnscoe, eight miles from Barnsley town centre close to the A635 Barnsley to Doncaster Road, with easy access by bus and train. The home is within walking distance of all local amenities, which includes a variety of shops, supermarkets, chemist, post office, hairdressers, community centre, bowling green, pubs clubs and local village Churches and the health centre. The home stands in its own extensive gardens with mature trees and shrubs. The gardens are landscaped and well maintained providing ample sitting areas for service users and their families. Accommodation is on two floors, served by a passenger lift. It has twenty-one single and eight double bedrooms, 26 of which are en-suite, three lounges and one dining room. Car parking is available at the side and front of the home. The Grove DS0000058045.V254845.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 5 ¾ hours between 9:15 am and 15:00pm. The visit included an inspection of the premises, observations of care and practices, and consultation with residents, visitors, staff and the administrator. Samples of the homes records, including one care plan, were checked. Residents were consulted, either individually or in small groups; lunchtime was observed and residents who chose to spend time in their own rooms were visited and consulted. The manager and area manager were consulted the following day to clarify some details about the home. The residents, visitors, staff and administrator are thanked for the welcome they gave to the inspector and for their assistance during this inspection. What the service does well: Residents and family members consulted said they were very pleased with the care provided by the home. Staff were friendly and caring and the managers were approachable and supportive. Care plans were informative, gave clear information on residents’ needs and the action staff were to take. Residents said they felt their health needs were well met and had access to health care services. Good medication administration practices were observed and residents were spoken to with respect and courtesy. Residents and relatives said the leisure and activity opportunities at the home were good, fun and enjoyable. These included themed events and outings. Mealtimes were relaxed and residents said the meals were good and tasty. Choice of food was available and drinks were encouraged and offered regularly. Residents were satisfied that their concerns were listened to and acted upon. The environment was in the main clean; it was warm and comfortable and decorated in a well-maintained and homely manner. Residents said they were pleased with the home and their rooms; and that they were comfortable and had the equipment they needed to meet their needs. The Grove DS0000058045.V254845.R01.S.doc Version 5.0 Page 6 Staff had access to National Vocational Training and the home was well managed. 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 Grove DS0000058045.V254845.R01.S.doc Version 5.0 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 The Grove DS0000058045.V254845.R01.S.doc Version 5.0 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): 2 and 4 and 6. Resident’s were satisfied that their needs were well met by the home. EVIDENCE: Residents were issued with contracts however these were existing contracts from the previous owner; following the inspection the area manager confirmed that Guardian Care would be issuing new contracts to all residents. Residents consulted said they were happy with the care they received, they said staff were helpful and attentive and they felt well cared for. Two relatives were consulted; both confirmed that the home meets the needs of their family member well. They said they were satisfied that the home provided good care. The Grove was suitable to accommodate residents requiring intermediate care, however there were no intermediate care residents to consult with at the time of inspection. The Grove DS0000058045.V254845.R01.S.doc Version 5.0 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 and 10 Care plans were informative, covered care needs and were accessible to residents and their close family. Medications systems were good, however some records could be improved to better safeguard residents welfare. EVIDENCE: A new care plan system had been introduced. One plan was checked; the plan included comprehensive risk assessments, it identified the resident’s needs and the action staff were to take. Daily records were made including outcomes of visiting specialists, for example district nurse and optician. Health care issues and accidents were recorded and good information about the resident’s past history had been sought. The plans could be improved by including a section that asked the resident their likes, dislikes and preferences for each area. For example if the resident preferred not to get up too early in the morning, or had other preferred routines or wishes. One relative confirmed they were kept informed about their close relatives plan of care and had sat and discussed it with the manager. The Grove DS0000058045.V254845.R01.S.doc Version 5.0 Page 10 Residents said they had access to G.P and other health support professionals for example district nurse, optician, dentist and chiropody. Both relatives confirmed the home keeps them informed about their family member’s health and welfare. Residents and the family members consulted said staff treated residents and their visitors respectfully. Medication systems and records were checked. The staff member observed demonstrated good practices including asking residents about their welfare, encouraging independence to take medication in their own time, and administering medicines with a dignified approach. Storage was clean and orderly and records were in the main well maintained. The date of receipt of medication had not been recorded, a record of staff signatures for identity could not be found and staff did not have access to pharmaceutical guidelines for care homes. A record of the purpose of medication for individual residents, and its affects was not available for staff to refer to. The Grove DS0000058045.V254845.R01.S.doc Version 5.0 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 and 15 Residents were offered a good variety of leisure time and activities, providing enjoyment and stimulation. Mealtimes were relaxed and pleasant and arranged to suit resident’s needs and preferences. Meals were tasty, nutritious and plentiful. EVIDENCE: Residents and two relatives confirmed that good leisure and recreational activities were provided; these included open days and garden fetes, and seasonal parties and outings, for example seaside and shopping trips. The administrator coordinated activities in the afternoon including crafts, cream teas and manicures. The relatives confirmed they were welcomed at the home and invited to all events; one relative discussed how a group of relatives had formed an organisation (Friends and Relatives of the Grove) with the help and support of the administrator and manager, as a result the themed garden fete had been a good success. Photos of events were kept available for residents to refer to. Residents said they were pleased with the meals, they could choose different from the main menu if they wished, and found meals tasty and satisfying. The Grove DS0000058045.V254845.R01.S.doc Version 5.0 Page 12 Lunchtime was observed; it was relaxed and pleasant, residents were helped to the dining area and it was noted that staff ensured residents were seated comfortably. Staff encouraged residents to have drinks and they were offered a good selection with regular top-ups; and fruit was offered in addition to puddings. Residents needing assistance were helped in a dignified manner and residents who wished to eat alone were able to do so. The cook understood individual’s dietary needs and preferences well, however there was insufficient records held in the kitchen on resident’s dietary needs. See standard 38 for information about the kitchen. The Grove DS0000058045.V254845.R01.S.doc Version 5.0 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. Standard 17 was checked and met on the last inspection. Residents and family could raise concerns and their views were listened to. EVIDENCE: Residents and families consulted said they were aware of the complaints procedure; they could raise concerns if they wished and staff and the manager would listen and take action. One family member stated they could raise minor concerns which prevented them developing into complaints. Residents who had raised concerns had been taken seriously and action had been taken. The Grove DS0000058045.V254845.R01.S.doc Version 5.0 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): 19,20,21,22,23,24,25 and 26 The home was comfortable and clean and met the needs and preferences of the residents. EVIDENCE: The home was warm, comfortable and well maintained. A staff member employed at the home carried out a programme of routine maintenance including décor and day-to-day repairs. Residents’ rooms were clean and personalised and residents said they were comfortable, warm and had everything they needed in their rooms. The gardens were tidy and accessible. A derelict structure was within very close proximity to the home, locked doors prevented access to the structure however the structure was unsightly and had not been risk assessed. Following the inspection the area manager confirmed that the organisation was looking at removing the debris and making the area sound. The Grove DS0000058045.V254845.R01.S.doc Version 5.0 Page 15 The lounges and dining areas were spacious and sufficient to accommodate wheelchair users. Bathrooms, showers and toilets were easily accessible, and each bedroom had an en-suite with toilet and washbasin. These were maintained and clean. One bathroom was out of order, this had been changed to a storage area; however there were sufficient alternative bathrooms for the number of residents living at the home. Aids and appliances included walking aids, wheelchairs, cushions and bed equipment; two hoists were available and rails were provided in corridors. Residents consulted said they were satisfied with the equipment provided. It was noted that wheelchairs were clean and clearly labelled to identify individual’s equipment. One hoist had not been kept clean around the base; this was however cleaned on the day. Residents said they could use the call alarm and staff were attentive when called. The laundry was clean and organised, and residents clothing was clean and presentable. Continence wear was not safely disposed of in one bedroom checked. The Grove DS0000058045.V254845.R01.S.doc Version 5.0 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 and 29 Lower staffing levels had raised concerns with some residents and family members. Good employment checks were, in the main, carried out, however some improvement is needed to ensure residents remain in safe hands. EVIDENCE: Staffing levels had been altered to reflect the homes changed registration from nursing to residential care and to reflect the lower numbers of residents accommodated in the home. Some residents commented that although staff were attentive and did see to their needs they were concerned that at times not enough staff were available. This concern was reflected by family members, who also said they worried about the night times. The administrator confirmed two night staff were provided, however this was to cover two floors. Staff were training towards National Vocational level 2 or above; the number of staff training would to raise levels to above the 50 target when completed. Two staff records were checked these contained appropriate staff recruitment checks and procedures; however in one file full recruitment history had not been obtained and the reason why the employee had left the last employment (working with children or vulnerable adults) had not been verified. The Grove DS0000058045.V254845.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 and 38 The home was well run and residents were satisfied with the services and care they received. The cleanliness of the kitchen and some health and safety maintenance checks need to be improved to ensure residents health and welfare continues to be safeguarded. EVIDENCE: Quality assurance systems were in place, these included visits from the organisation, reports to the commission, relative and resident group, manager checks and development plans for the home. The manager was reviewing the homes audit system. The manager, following inspection discussed new recording and management systems being introduced to further improve the quality standards of the home. The Grove DS0000058045.V254845.R01.S.doc Version 5.0 Page 18 Standard 38 was checked in part. Fire equipment checks and electrical checks were out of date; these were arranged by the administrator on the day to be serviced in the near future. The kitchen area was checked; the general cleanliness of the kitchen was not sufficient, this included dirt between tiles, food spills and crumbs in a fridge, unlabeled food and frozen food not kept orderly to ensure stock rotation. Some fire doors had been propped open in secluded areas of the home. The Grove DS0000058045.V254845.R01.S.doc Version 5.0 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 2 X X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 3 3 3 3 3 3 2 STAFFING Standard No Score 27 2 28 2 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X 2 The Grove DS0000058045.V254845.R01.S.doc Version 5.0 Page 20 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 2 Standard OP2 OP9 Regulation 5 13 Requirement All residents must receive a revised contract from the provider. The date of receipt of medication must be recorded. A record of staff signatures for identity must be kept available. Staff administering medication must have access to the Royal pharmaceutical guidelines for care homes. A record of the purpose of medication for each individual must be maintained. A record of residents’ dietary needs and preferences must be maintained and available to the cooks. The derelict structure must be risk assessed and an action plan put in place to secure present and future safety. A programme of routine cleaning must be put in place for hoists. All staff must be informed about The Grove DS0000058045.V254845.R01.S.doc Version 5.0 Page 21 Timescale for action 31/01/06 30/11/05 3 OP15 13 30/11/05 4 OP19 23 30/11/05 5 OP26 13 30/11/05 6 OP27 12 and 13 7 OP29 19 the importance of safe and hygienic disposal of continence wear. Residents and relatives must be 31/01/06 consulted about their opinions on staffing levels. Outcomes and any agreed action must be fed back to the residents, relatives and the commission. Full employment history must be 30/11/05 checked for all new staff. Where new staff have left previous employment, where they have worked with children or vulnerable adults, their reason for leaving must be verified. A system must be put in place to 30/11/05 identify when safety maintenance checks are due. Staff must be informed about ensuring fire doors are not left propped open. A programme of routine cleaning, including daily and weekly tasks must put in place. Thorough cleaning of the kitchen must take place daily, and as per cleaning schedules. Audits must be carried out regularly to check that the cleanliness of the kitchen is maintained. Foods must not be stored unlabeled, and stock rotation must be closely monitored. 8 OP38 13 The Grove DS0000058045.V254845.R01.S.doc Version 5.0 Page 22 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 OP28 Good Practice Recommendations The plans should include a section in each area which details residents stated likes, dislikes and preferences. A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) should be achieved by 2005, excluding the registered manager. The Grove DS0000058045.V254845.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 The Grove DS0000058045.V254845.R01.S.doc Version 5.0 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!