Inspection on 16/02/07 for The Grove

This inspection was carried out on 16th February 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 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 20/12/05

The Grove 12/07/05

The Grove 08/02/05

The Grove 01/09/04

The Grove 11/03/04

Similar services:

Aston Court Nursing Home

Breme

Ravenhurst

Westmead

Ashcroft Hollow Nursing Home

Bricklehampton Hall Nursing Home

Briar Hill House

Radbrook Nursing Home

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

CARE HOME ADULTS 18-65 Grove, The 8 Blakebrook Kidderminster Worcestershire DY11 6AP Lead Inspector Dawn Taylor Unannounced Inspection 16 February 2007 11:00 th Grove, The DS0000018706.V316310.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, The DS0000018706.V316310.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, The DS0000018706.V316310.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grove, The Address 8 Blakebrook Kidderminster Worcestershire DY11 6AP 01562 820728 F/P 01562 820728 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) suehullin@tracscare.co.uk TRACS Nazia Bashir Care Home 12 Category(ies) of Learning disability (12), Mental disorder, registration, with number excluding learning disability or dementia (12), of places Physical disability (12) Grove, The DS0000018706.V316310.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home may accommodate one named resident who is over 65 years of age. Date of last inspection Brief Description of the Service: The Grove is registered to provide residential care for up to 12 adults, who may have an acquired brain injury, who may have a learning disability or who may have physical disabilities.Registration has also been granted for one named service user who is over the age of 65 years. The Grove is a large, detached, Grade 2 listed building, situated in a pleasant residential area of Kidderminster and within walking distance of the town centre. There are 12 single bedrooms on two floors, and each floor is provided with lounge, dining room, kitchen, bathroom and toilet facilities. The house has a pleasant garden and there are plans for a conservatory. The company operating as TRACS Ltd., was established in 1983, and several homes in Wales and the West Midlands now provide care, training and rehabilitation for service users. The organisation has declared the intention in its mission statement, to provide the highest quality comprehensive care in the United Kingdom.The management structure at The Grove includes a Divisional Director and a Service Director who work from a regional office. The day-to-day running of the home is the responsibility of the Care Manager who is supported by a deputy, an assistant manager and two senior support workers. The stated aim of The Grove is to provide a high quality service, which offers holistic support, enabling service users to achieve a full and satisfactory life. Grove, The DS0000018706.V316310.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over a half day. This was a key inspection and twenty-two standards were assessed on this occasion. The inspector had discussions with service users and staff members on duty. Staff interaction with service users was also observed. The registered manager was met and provided the majority of the documentary records examined. What the service does well: What has improved since the last inspection? What they could do better: A more pro-active approach to accessing advocacy services is needed. Grove, The DS0000018706.V316310.R01.S.doc Version 5.2 Page 6 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, The DS0000018706.V316310.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, The DS0000018706.V316310.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): Standard 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about the home is available to enable prospective service users to make an informed decision about their future care needs. The assessment and admission procedures ensure that suitable placements are made for any prospective service users. EVIDENCE: There is a ‘Clients Handbook’ and a ‘Statement of Purpose’ in place. This material is available in print form and can be provided in different formats to aid communication, when required. All admissions are planned and based on assessment. Discussions with the manager indicated a planned admissions process was in place for all new service users. Staff would expect to work closely with the service user, social worker, parent or carer and any other key staff from the previous placement. Grove, The DS0000018706.V316310.R01.S.doc Version 5.2 Page 9 A Service Level Agreement is established with each service user. A full assessment is undertaken in the first three months and an initial review meeting takes place after thirteen weeks. Care Plans were in place for all service users. These plans stated clearly any medical, rehabilitation or therapeutic needs and how they were being met. TRACS employ a Clinical Support Nurse who is involved throughout a service users initial assessment and supports the development of Care Plans and risk assessments. Grove, The DS0000018706.V316310.R01.S.doc Version 5.2 Page 10 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): Standard 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users plan of care is based on the initial assessment, which identifies their assessed needs, and how these will be met. The individual care plans represent the day-to-day care practice of the home. Safety issues and the assessment of risk are considered and do not unnecessarily hamper the principles of providing quality care. EVIDENCE: An individual plan of care is produced for each service user, based on the initial assessment undertaken during the admission process. The plans detail the specific needs of service users and how these are to be met. There was good evidence that the individual plans are being monitored through the annual reviews, staff meetings and by keyworkers. Each service user has an allocated keyworker. Grove, The DS0000018706.V316310.R01.S.doc Version 5.2 Page 11 Individual risk assessments are included in each service users plan of care. Risk assessments are interrelated to service users care, activities based in the home and also within the community at a wider level. Service users confirmed that they are encouraged to take decisions about their day-to-day care and important life decisions through keyworker meetings and regular Client Meetings. Staff, services users and relatives also have the opportunity to feedback to TRACS through annual Quality Questionnaires. Feedback is collated and an Action Plan developed to address comments made. The service users are active members of their local community and colleges. Records related to the financial management of service user’s accounts follow the home’s policy and procedure. The provider ensures a detailed record of financial transactions of service user’s accounts is maintained. Grove, The DS0000018706.V316310.R01.S.doc Version 5.2 Page 12 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): Standards 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The opportunities made available to service users enable them to live as fulfilling a life as possible. The involvement of each individual in planning their activities, both within and outside the home, means that they are able to choose what they wish to do. The involvement of family and friends is encouraged, and enables supportive relationships to be maintained. The provider demonstrates a positive attitude to diversity, particularly in relation to disability. EVIDENCE: Part of the stated philosophy of the organisation is to provide care interventions, which positively encourage independent living and self care skills. Developmental work is undertaken with service users, as indicated by assessment, in relation to all the activities of daily living. Grove, The DS0000018706.V316310.R01.S.doc Version 5.2 Page 13 There is a wide range of leisure activities in which service users are involved, both in the community and in the home, and details are recorded in their Care Plans. In addition there are good links with local people and this includes using the local shops, pubs, cinema, restaurants and colleges. The manager continues to explore the availability of advocacy services in the area. The contact arrangements with relatives are set out at the initial assessment. Relatives are welcome to visit the home. Also contact is maintained by phone and emails. Service users are encouraged to retain involvement with their family. The daily routines in the household are based on shared group living. There was evidence of service users being involved with cooking and domestic household tasks. Service users have individual choice and freedom of movement within their own bedroom and the communal areas of the home. The use of the kitchen areas is subject to risk assessment, but a member of staff will support a service user who may wish to make a drink or snack. Grove, The DS0000018706.V316310.R01.S.doc Version 5.2 Page 14 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): Standard 18,19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Support and encouragement is provided to each service user, in order to promote independence in respect of their personal and healthcare needs. Procedures are in place for managing the ageing process and possible illness and death of service users, to ensure that dignity and respect is maintained. The arrangements in place for the safe management and control of medications are good. EVIDENCE: The personal and healthcare needs of service users are closely monitored, and additional specialist support and advice is sought from the primary health care team and other health professionals, when necessary. Grove, The DS0000018706.V316310.R01.S.doc Version 5.2 Page 15 All of the service users are registered with the local health centre and dentistry practice. Records are maintained on the service user’s case file related to the outcomes of these visits. The home has the Boots chemist MAR medication system to manage all medications. This system ensures medication errors are kept to a minimum. The storage of medication is appropriate and records indicated no gaps with staff signatures. All staff have completed in house training in the safe control and administration of medication. In addition staff are completing correspondence course in Handling Medication in Social Care Settings this is an accredited course. The registered manager keeps staff competency under review. Grove, The DS0000018706.V316310.R01.S.doc Version 5.2 Page 16 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): Standard 22 & 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A complaints procedure is followed at the home, and service users are encouraged and enabled to express their views and opinions. The understanding by the manager and staff of the issues relating to the abuse of vulnerable adults, should ensure the protection of service users. EVIDENCE: A complaints procedure is in place and in a suitable format for service users. A record is maintained, which includes comments and compliments. During this visit no complaints about the service, or have any comments or compliments had been recorded. Policies and procedures for the protection of service users are in place. Training on the Protection of Vulnerable Adults is given to all staff. Grove, The DS0000018706.V316310.R01.S.doc Version 5.2 Page 17 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): Standards 24 & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The premises are suitable for their purpose. They are well maintained, nicely furnished, clean, and ensure as far as possible that the safety and wellbeing of service users is promoted. EVIDENCE: The Grove is a large two storey, detached Grade 2 listed house, which is maintained to a good standard, and is suitable for its purpose. The communal areas of the home are nicely decorated and comfortably furnished. It is situated in a pleasant residential area, within walking distance of the town centre of Kidderminster. Grove, The DS0000018706.V316310.R01.S.doc Version 5.2 Page 18 The accommodation has been arranged on two floors, each providing facilities for six service users. The bedrooms within the home are all single occupancy, and comply with the National Minimum Standards with regard to size and space. They are furnished to a high standard and there is evidence that service users personalise them as they wish. Appropriate locks are fitted to the bedroom doors. The provision of toilets, bathing and showering facilities are good. The communal areas of the house are maintained to a good standard. An all weather conservatory has now been built to the back of the house over looking the garden area. Grove, The DS0000018706.V316310.R01.S.doc Version 5.2 Page 19 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): Standards 32,34 & 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The registered person operates a robust recruitment procedure. The training arrangements of the home are meeting the professional needs of staff. EVIDENCE: There are twenty-one members staff of employed at the home. The number of staff on duty depends upon the needs of each service user. Two night waking staff and one sleeping in member of staff provide nighttime cover. There is a clear staffing structure that is known to staff and service users. Systems of communication and accountability are well understood and contact with senior members of staff is available over twenty-four hours a day. Grove, The DS0000018706.V316310.R01.S.doc Version 5.2 Page 20 Records of the recruitment process for staff for the home indicate that a systematic procedure is in place. The requirement that all staff having contact with service users have clear Criminal Records Bureau (CRB) checks is well established. All staff are given initial in-house training, followed by induction training to ensure clarity and understanding of their role and responsibilities. Staff have relevant experience and receive on-going training including adult protection, first aid and health and safety training. All staff are encouraged to attend relevant external courses. Eight of the staff are qualified to NVQ level 2 in Health and Social. All staff receive monthly supervision and annual appraisals. Grove, The DS0000018706.V316310.R01.S.doc Version 5.2 Page 21 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): Standards 37,39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management arrangements at the home are good, and staff and service users benefit from the positive leadership they receive. The policies, procedures and records maintained at the home, comply with legislative requirements and therefore help to safeguard the rights of service users. EVIDENCE: Grove, The DS0000018706.V316310.R01.S.doc Version 5.2 Page 22 The management structure for The Grove includes a Service Director and a Divisional Director who are located regionally, and who provide regular support to staff at the home. The Registered Manager , Ms Naz Bashir has worked for TRACS for seven years and has been manager at The Grove for the past four years. She has the Registered Managers Award, having previously gained a BSc Honours degree in Human Biology and Health Sciences. The homes ethos and culture is based on an open atmosphere by creating an environment that is relaxing to live in while, ensuring service users are fully protected. There are quality assurance and quality monitoring systems in place that involve service users, family members and staff in the process. Annual Quality Questionnaires are sent out, feedback is collated and an Action Plan is produced. The financial viability of the business is sound. The provider has appropriate insurance arrangements in place and certificates are available. All of the domestic installation checks are within the annual timescales. The records connected to fire safety checks were examined. A clear structure was in place for checking equipment and there were organised practice evacuation drills. Grove, The DS0000018706.V316310.R01.S.doc Version 5.2 Page 23 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 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Grove, The DS0000018706.V316310.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action 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. Refer to Standard YA15 Good Practice Recommendations Further attempts to gain access to advocacy facilities should continue to be made Grove, The DS0000018706.V316310.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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, The DS0000018706.V316310.R01.S.doc Version 5.2 Page 26 - 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. 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