Inspection on 19/01/06 for The Grove

This inspection was carried out on 19th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 01/03/07

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 Mr Roger Andrews Unannounced Inspection 19th January 2006 03:00 Grove Cheshire Home DS0000015641.V279751.R01.S.doc Version 5.1 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.V279751.R01.S.doc Version 5.1 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.V279751.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Grove Cheshire Home Address Scotts Hill East Carleton Norwich Norfolk NR14 8HP 01508 570279 01508 571057 grove@east.leonard-cheshire.org.uk 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) Leonard Cheshire Mrs. J Jane Noble Care Home 31 Category(ies) of Physical disability (31) registration, with number of places Grove Cheshire Home DS0000015641.V279751.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th August 2005 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.V279751.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced. On this occasion not all of the National Minimum Standards were inspected and the previous inspection report from August 2005 should also be looked at for more information. The Grove is a home that the Commission does not receive regular complaints about. The inspection was carried out by talking to the manager, a member of staff and three residents. Some records were also looked at as well as a look at some of the corridor and communal areas of the building. What the service does well: 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. Grove Cheshire Home DS0000015641.V279751.R01.S.doc Version 5.1 Page 6 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.V279751.R01.S.doc Version 5.1 Page 7 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion. EVIDENCE: Grove Cheshire Home DS0000015641.V279751.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7&8 Residents enjoy a high degree of autonomy in decision-making. EVIDENCE: Residents are able to manage their own finances. Some residents are assisted with looking after some of their money and with small purchases. Refer to comments under standard 40 in this report. The organisation does not act as appointee for any of the residents. Some of the residents also look after their own medication. The residents are very much encouraged to participate in decision making processes both in relation to their personal independence and in the way the home operates. Refer to comments under standard 39 in this report. Residents are kept up to date with all developments in The Grove. Currently displayed is a notice asking residents for their views on the future development of the home. The annual review is available in the main reception area, though both this document and the copy of the last inspection report are pinned up rather high for residents in wheelchairs to reach and could be located at a more convenient level. See recommendation. Residents also have regular Grove Cheshire Home DS0000015641.V279751.R01.S.doc Version 5.1 Page 9 meetings with the management of The Grove. The minutes of the recent ‘Heads Of Department’ meeting were also displayed for residents to read. The residents publish their own newsletter. Grove Cheshire Home DS0000015641.V279751.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 Residents can see friends and visitors at their convenience. EVIDENCE: Several residents were spoken to during the inspection. Examples were given of regular contact with friends and family. This includes visits to The Grove and visits by residents. One resident reported that she was now visiting her family every month. Another resident said his family had visited earlier in the day. There are no restrictions on visitors. Grove Cheshire Home DS0000015641.V279751.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Medication is properly stored, but errors in records must be identified and followed up. EVIDENCE: The medication records were looked at. The daily administration record had a few blank spaces where initials or a code letter had not been entered. A system should be in place to pick up these errors at an early opportunity, (e.g. the next person completing the record reporting blank spaces to the manager.) See requirement. Medication is properly stored in a secure fashion. Where required specific medications are kept in refrigerated conditions. Grove Cheshire Home DS0000015641.V279751.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion. EVIDENCE: Grove Cheshire Home DS0000015641.V279751.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Needed improvements to the dining room have been scheduled in the budget for the coming financial year. The Grove is clean and no safety hazards were identified. EVIDENCE: The Grove provides a range of communal areas for residents to use. The dining room is in need of redecoration and re-flooring. This was raised in the previous inspection report and it has been planned to refurbish this area within the budget allowance for the year 2006/07. During a walk around the premises no obvious hazards were noted and all areas were free from any unpleasant odours. Grove Cheshire Home DS0000015641.V279751.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 The training needs of the staff are monitored and The Grove is well on the road to ensuring all or the vast majority of staff have undertaken NVQ training. EVIDENCE: There are currently fifteen staff undertaking NVQ training. Twelve of these are at level two and three are at level 3. Four of the staff are undertaking the NVQ Assessors Award. One of the Care Supervisors is undertaking the ‘verifiers’ course. When this group complete their training nearly all of the staff will have an NVQ award. The above figures include two of the night staff who are undertaking NVQ training and one who holds an NVQ qualification. There is a part time training co-ordinator post. Separate training files are maintained on each member of staff and a selection of these were viewed at random. Examples of training undertaken included the protection of vulnerable adults, first aid, an induction and assessment record, moving and handling, foundation training and fire awareness. There is an ‘identified training needs’ sheet which is discussed with staff at supervision sessions. Grove Cheshire Home DS0000015641.V279751.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 40 & 42 The residents are kept informed of all developments and have full access to policies and procedures documents. Financial records of money looked after on behalf of some of the residents are of a good standard, but individual staff must not ‘lend’ money to residents. Grove Cheshire Home DS0000015641.V279751.R01.S.doc Version 5.1 Page 16 EVIDENCE: All of the policies and procedures are available to staff and residents to read and are located on a bookshelf outside of the manager’s office as well as at other locations. The fire records were checked. Weekly tests of the fire points are being carried out and documented. The Fire system was serviced in June 2005. The lift was serviced in July 2005. Servicing certificates were seen for other lifting equipment such as hoists. Some example financial records were viewed for some of the residents whose personal allowances are looked after by staff. These were in good order and copies have to be sent on a monthly basis to the organisation’s national accounting centre for audit. All purchases on behalf of residents are entered onto a specific form and have to be signed off by the manager. In one instance some funds have been loaned to a resident to allow the booking of a holiday via the personal finances of a member of staff. Such transactions should not take place and any urgent immediate need to loan a resident money should be from an agreed fund held by the organisation and not from the personal funds of staff members. See requirement. For standard 39 refer to comments in standard 8. Grove Cheshire Home DS0000015641.V279751.R01.S.doc Version 5.1 Page 17 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 X 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 X 23 X ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 4 X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X X X 3 3 X 2 X Grove Cheshire Home DS0000015641.V279751.R01.S.doc Version 5.1 Page 18 No 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. Where money is loaned to a resident for any reason this should be from an agreed fund and not from the personal money of an individual staff member. Timescale for action 01/02/06 2 YA42 13 01/02/06 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 YA24 Good Practice Recommendations The dining room would benefit from redecoration and attention to the floor tiles which are becoming unsightly. Grove Cheshire Home DS0000015641.V279751.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Grove Cheshire Home DS0000015641.V279751.R01.S.doc Version 5.1 Page 20 - 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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