Inspection on 15/02/07 for The Grove

This inspection was carried out on 15th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 13/10/05

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 Andrea Leverett Key Unannounced Inspection 15th February 2007 10:30 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 The Grove DS0000058045.V294752.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. The Grove DS0000058045.V294752.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Grove Address Thurnscoe Bridge Lane Thurnscoe Rotherham South Yorkshire S63 0SN 01709 895424 01709 897948 none None Guardian Care Homes (UK) Limited 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 Irene West Care Home 28 Category(ies) of Dementia - over 65 years of age (13), Old age, registration, with number not falling within any other category (15) of places The Grove DS0000058045.V294752.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons accommodated shall be aged 60 years and above. The manager will work 40 hours per week supernumerary. Date of last inspection 13th October 2005 Brief Description of the Service: The Grove is a 28-bed Home providing 13 beds for older people with dementia and 15 beds for older people needing 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 beds, 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 homes current scale of charges is £327.50 to £356.50 The Grove DS0000058045.V294752.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key visit, which took place on the 15th February. The visit was spent talking directly with residents privately and collectively; 3 relatives, 4 staff members and the manager. Some judgements about quality of life and choices were taken from direct conversation with residents and their relatives, observation and evidencing records held at the home. A tour of the premises was undertaken. The judgements made in this report take into account any incidents, accidents and other significant events that have been reported to the commission, in line with good practice, since the last key inspection. Information taken from the reports of the organisations own unannounced monitoring visits undertaken since the last inspection have also been reflected in this report. The inspector found that the Home continues to provide a high standard of care in a well-maintained environment. Feedback from residents and their relatives was overwhelmingly positive about the care provided and observation on the day of the site visit and records seen supported their opinions. Although the Home has improved staffing levels since the last inspection, some staff and relatives still thought that the Home was short staffed at times. Some typical responses from residents included: “ I have been to two other homes and this is the best that I have been to. Very good. People are friendly and you can have a laugh and a joke. I am helped to go to my room whenever I like. I can have a bath whenever I like. On average this is about three times a week. Good meat and fresh vegetables and they do lovely fish and chips on Fridays. You have a choice of hot breakfast every day.” “ I like it here this is the nicest Home I’ve been in and I like the food” Some typical responses from Relatives included: “ I can’t complain of the care it is absolutely fantastic, most people seem to enjoy the food, I could eat it.” “ I go to relatives meetings every month and find them useful. I feel confident to raise any concerns and at any time” “ Absolutely brilliant, best one I have come across, hand on heart I can’t find a fault with it. I have visited at different times of the day and never once come and not been happy, excellent care, they are so caring, nothing is too much trouble. I can stay over night if I have any concerns and I have done in the past when mom was very ill.” The Grove DS0000058045.V294752.R01.S.doc Version 5.2 Page 6 “They seem to be looking after mom alright but look short staffed sometimes. Food seems nice and activities are good. They go out to panto’s and have singers and entertainers come into the Home. The staff are caring and kind.” What the service does well: What has improved since the last inspection? Residents now benefit from a new service user contract, which reflects the fact that the Home is under new ownership. Residents have benefited to improvements to the quality of their environment. Under the homes new registration all rooms are single occupancy and work has been undertaken and is on going to improve the decoration and furniture and fittings of communal areas and bedrooms. A programme of routine cleaning for the kitchen and other areas of the Home are now in place and cleaning schedules showed that on the whole these are being followed. Staffing levels have improved since the last inspection. The Home now has two staff on each floor and three staff in total on the nighttime shift. Although some staff and a relative thought that more staff were needed at times there is no evidence to suggest that residents needs are not being met. The Grove DS0000058045.V294752.R01.S.doc Version 5.2 Page 7 Improvements have been made to the homes medication records. A record of the purpose of medication for each resident is now kept and the Home has a copy of the Royal Pharmaceutical guidelines, which staff has access to. 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. The Grove DS0000058045.V294752.R01.S.doc Version 5.2 Page 8 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.V294752.R01.S.doc Version 5.2 Page 9 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): 2,3 Quality in this outcome area is good. Residents benefit from having current up to date contracts, which includes a statement of the terms and conditions of the Home. Prospective service users benefit from having their needs fully assessed before moving into the Home and know that their needs will be met. This judgement has been made using available evidence including a visit to this service. The Grove DS0000058045.V294752.R01.S.doc Version 5.2 Page 10 EVIDENCE: The Grove has recently come under new ownership and a sample inspection of resident’s contracts showed that these have been up dated to reflect this. Care records of three of the most recently admitted service users showed that Care manager assessments were in place. In addition to this the Home undertakes its own assessments, which include health and social care needs, risk assessments, life histories and likes and dislikes. The information from these assessments are reflected in the service user care plans. Observation on the day of the site visit showed that staff have a good understanding of residents needs and likes and dislikes and that meeting them was given a high priority. The Grove DS0000058045.V294752.R01.S.doc Version 5.2 Page 11 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 excellent. Resident’s benefit from having care plans, which show how their health, personal and social care needs, will be fully met. Residents know that their medication will be administered safely and appropriately. Residents feel they are treated with respect and their right to privacy is upheld. This judgement has been made using available evidence including a visit to this service. The Grove DS0000058045.V294752.R01.S.doc Version 5.2 Page 12 EVIDENCE: The inspector case tracked three service users records, which showed that care plans were in place. The plans reflected the service users assessed needs and showed how service users health, personal and social care needs would be met. Information given by residents their families and observation of and discussion with staff evidenced that the Home has a good understanding of residents needs and that ongoing support is provided to meet these needs. It was evident from records seen and discussion with residents that access to health professionals to promote their health and well-being is given a high priority at the Grove. Residents spoken to and relatives confirmed that access to GP’s, community nurses; chiropody and other specialist health services such as incontinence, nutritional and mental health services are available as needed. The Home has also developed links with the “ Memory Team” at Kendray hospital and several senior staff has spent time there developing their skills and knowledge in order to promote good practice in the care of its residents with dementia. An inspection of Medication Administration Records, medication storage and direct observation of medication being administered showed that good practice is being followed for the benefit and safety of residents. The Home has a secure medication trolley and medication is stored tidily. Only senior staff that are trained to do so administer medication and staff spoken to confirm that they are in the process of having their medication training updated at the Sheffield College. Observation on the day and discussion and feedback from residents and their relatives showed that residents are treated with the up most respect. Interaction between staff and residents was seen to be high and staff support was given sensitively and discreetly. Residents and their relatives spoke highly of the staff team and strongly commended the staff on their caring. The Grove DS0000058045.V294752.R01.S.doc Version 5.2 Page 13 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): 12,13,14,15 Quality in this outcome area is excellent. Residents find the lifestyle experienced in the Home matches their preferences and expectations, and satisfies their social, cultural and recreational interests and needs. Residents and their relatives know that the Home will encourage family contact and liaise with relatives in the best interests of residents. Residents are encouraged to access the community in line with their wishes. Residents are offered a varied and nutritious diet and know that their preferences will be taken into consideration when planning meals. This judgement has been made using available evidence including a visit to this service. The Grove DS0000058045.V294752.R01.S.doc Version 5.2 Page 14 EVIDENCE: A choice of communal spaces means that privacy and quiet time can be sort by residents, without having to return to their own room. Relatives can find quiet congenial spaces in which to visit residents and lively group activities can simultaneously be accommodated. This greatly enhances the lifestyle options and quality of life for residents. In addition to this the Home has a dedicated activities coordinator who provides a range of activities both in and outside the home. Activities included regular visits out to the theatre, entertainment brought into the Home such as Singers and dance groups, Dominoes, Manicures, Pamper Sessions, Video film shows, Crafts and Cream Teas. On the day of the unannounced site visit residents were seen enjoying a film show and were offered a range of refreshments including a choice of alcoholic drinks. Residents who are supported with dementia are situated on the first floor and have to access the garden area and open spaces via a lift to the ground floor. Regular opportunity to access open spaces would be better evidenced if the Home kept a record of when this was offered and how often residents went outside. A recommendation has been made regarding this. Residents and their relatives told the inspector that visitors are made welcome in the Home at any reasonable time. Family and friends of residents are encouraged to come and go as they wish without prior arrangement and are encouraged to get involved in the life of the home. The Grove has regular residents and relatives meetings and Friends of the Grove fund raising committee. There is a real sense of life in the Home with effort given to ensuring that cultural, seasonal and individual events are celebrated. Relatives spoken to say that they were confident that the staff would communicate with them appropriately in the best interests of residents. Residents confirmed that they are consulted about menus and their feedback is sort on food provided. An inspection of the kitchen, food stores and menu’s was also undertaken. It was evident that a range of fresh healthy homemade food was provided. Choices are offered and the chef keeps records of resident’s likes, dislikes and dietary needs. For example residents have the choice of cream, full, semi skimmed or skimmed milk to meet individual choice and nutritional needs. The Grove DS0000058045.V294752.R01.S.doc Version 5.2 Page 15 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): 16,18 Quality in this outcome area is good. Residents and their relatives know that their concerns and complaints will be listened to and acted upon. Residents are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussions with residents, their relatives and staff evidenced that concerns and complaints are taken seriously and acted upon. Residents and relatives felt that most concerns are dealt with promptly and informally and the homes complaints book confirmed that even the smallest of concerns are documented and records kept of action taken to resolve them. The Home also has a formal complaints procedure, which meets good practice standards. All staff have received up to date training in adult protection and discussion with staff evidenced that they have a good understanding of the issues that could indicate abuse and knew what procedures to follow. The Home has an Adult protection Procedure and Whistle Blowing Policy. The Grove DS0000058045.V294752.R01.S.doc Version 5.2 Page 16 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): 19,22,26 Quality in this outcome area is good. On the whole residents live in a well designed, safe, nicely decorated and maintained home that is clean, pleasant and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A choice of communal spaces means that privacy and quiet time can be sort by residents, without having to return to their own room. This greatly enhances the lifestyle options and quality of life for residents. Residents have benefited to improvements to the quality of their environment. Under the homes new registration all rooms are single occupancy and work has been undertaken and is on going to improve the decoration and furniture and fittings of communal areas and bedrooms. A programme of routine cleaning for The Grove DS0000058045.V294752.R01.S.doc Version 5.2 Page 17 the kitchen and other areas of the Home are now in place and cleaning schedules showed that on the whole these are being followed. Information taken from the homes pre inspection questionnaire evidenced that equipment and facilities in the Home are well maintained. A tour of the premises on the whole supported this but two mobile hoists did not have up to date service stickers. The manager stated that one of these is not currently in use. A requirement has been made that the homes mobile hoists are serviced regularly. A tour of the premises and feedback from relatives evidenced that the Home is kept clean, hygienic and free from offensive odours throughout. A programme of routine cleaning is now in place and improvements have been made to ensure the safe and hygienic disposal of incontinence wear. Gloves and aprons are provided to ensure infection control. The Grove DS0000058045.V294752.R01.S.doc Version 5.2 Page 18 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): 27,28,29,30 Quality in this outcome area is good. Resident’s resident’s needs are met by appropriate numbers and skill mix of staff. Generally staff are trained and competent to do their job but improvements are needed in some areas. Residents are protected by the homes recruitment policy and procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels have improved since the last inspection. The Home now has two staff on each floor and three staff in total on the nighttime shift. Although some staff and a relative thought that more staff were needed at times there is no evidence to suggest that residents needs are not being met. Staffing levels on the day of this unannounced inspection and staff rota’s inspected showed that sufficient staff are on duty to meet residents needs. Good and consistent standards of personal care and high activity levels also supported this judgement. However given the high levels of needs and the introduction of the new dementia care unit a recommendation has been made The Grove DS0000058045.V294752.R01.S.doc Version 5.2 Page 19 that the Home continue to consult with residents and relatives regarding staffing levels and keep them under review. Training records seen and staff spoken to confirmed that a range of mandatory and service specific training was undertaken by staff and over 50 of staff have NVQ 2 or above. It is acknowledged that the Home has made a good start towards training its staff to better understand the needs of its residents with dementia, but more could be done to ensure that residents benefit from all staff having access to this training and a recommendation has been made regarding this. It is also recommended all staff involved in preparing and cooking food have Food Hygiene refresher training in line with good practice guidelines. A sample of staff files inspected contained all relevant information required to demonstrate safe recruitment practises. Files included application form, passport and birth certificates, 2 written references, Job descriptions and evidence of Criminal Record Bureau checks. The Grove DS0000058045.V294752.R01.S.doc Version 5.2 Page 20 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): 31,33,35,38 Quality in this outcome area is excellent. Resident’s benefit from living in a Home that is managed by a person who is well trained and competent. Residents personal preferences, support and care needs are provided through the managers open leadership and the promotion of a safe home and working environment. Resident’s benefit from a staff team that is appropriately supervised and supported. Robust financial systems to safe guard residents from financial abuse are in place. This judgement has been made using available evidence including a visit to this service. The Grove DS0000058045.V294752.R01.S.doc Version 5.2 Page 21 EVIDENCE: The manager is a trained nurse and has worked with this service user group for a number of years. Residents, relatives and staff expressed a high regard for the management approach to the home. Residents and relatives felt the manager was approachable and staff said they felt well supported. The manager demonstrated, a very clear understanding the needs of residents and a proactive approach to addressing them. Monitoring health and safety in the home is to a good standard and risk assessments are completed for individuals and the environment. The inspection process has evidenced consistently high standards of care and improvements in training, record keeping and quality assurance systems. The Grove DS0000058045.V294752.R01.S.doc Version 5.2 Page 22 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 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 X X 2 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 4 X 4 X 3 X X 3 The Grove DS0000058045.V294752.R01.S.doc Version 5.2 Page 23 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 OP22 Regulation 23.2(c) Requirement The Home must ensure that mobile hoists are serviced regularly. Timescale for action 19/03/07 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 OP30 OP30 Good Practice Recommendations It is recommended that all staff benefit from training in Dementia. It is also recommended all staff involved in preparing and cooking food have Food Hygiene refresher training in line with good practice guidelines. The Grove DS0000058045.V294752.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 The Grove DS0000058045.V294752.R01.S.doc Version 5.2 Page 25 - 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. 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