Inspection on 20/12/05 for The Grove

This inspection was carried out on 20th December 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Grove 16/02/07

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 R McGorman Unannounced Inspection 20th December 2005 14:30 Grove, The DS0000018706.V263148.R01.S.doc Version 5.0 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.V263148.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 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.V263148.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Grove, The Address 8 Blakebrook Kidderminster Worcestershire DY11 6AP 01562 820728 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) 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.V263148.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home may accommodate one named resident who is over 65 years of age. 12th July 2005 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 work on the new conservatory is nearing completion. 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 home manager, and a senior support worker. 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.V263148.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this routine, unannounced inspection, was to check on any previous requirements and recommendations, and to monitor the care provision at the home, in relation to the stated aims and objectives. The inspection took approximately three hours, during which time was spent talking with staff and service users, to ascertain their views on living and working at The Grove. Several areas of the home were observed. The care records of service users were seen, and also the files of three members of staff. The records kept in respect of the maintenance of equipment, and safe working practices, including the fire log book, were also viewed during the course of the inspection. What the service does well: TRACS states that, ‘it is proud to be a caring service’, and evidence was provided that the staff and the company do care. The care planning process is thorough and detailed, with comprehensive documentation, and ongoing monitoring. The care provision is person centred, with service users being actively encouraged to be involved in making the decisions that affect their daily lives. Recruitment procedures are good, and training opportunities are provided for staff, who have demonstrated their ability to deal with complex issues. The administration of medication is undertaken to a very high standard. Grove, The DS0000018706.V263148.R01.S.doc Version 5.0 Page 6 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, The DS0000018706.V263148.R01.S.doc Version 5.0 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.V263148.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 Relevant documentation is in place to enable prospective service users to make an informed decision about their future care needs. The extensive assessment process ensures that both parties can confirm that the placement is appropriate for the service user. EVIDENCE: A Statement of Purpose and a Service Users Guide is provided, in the form of a ‘Clients Handbook’. These documents combined, contain the information required by this standard, and can be provided in different formats to aid communication, when required. A Service Level Agreement is established with each service user, and their relative, representative or advocate, if appropriate, and also the placing authority, prior to admission. A detailed assessment procedure is followed for a period of 3 months, and full support given to assist prospective service users in choosing where they wish to live. The information contains sufficient detail to confirm if the home would be able to meet the needs of the service user, and forms the basis of the initial plan of care, on admission. Grove, The DS0000018706.V263148.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 & 10 The service users plan of care is based on the initial and on-going assessment, which clearly records identified needs, and how these are to be met, and therefore ensures that staff are fully aware of the actions they need to take. The policy on Confidentiality reassures service users that information about them is handled appropriately. Grove, The DS0000018706.V263148.R01.S.doc Version 5.0 Page 10 EVIDENCE: A detailed plan of care is compiled for each service user, with their involvement, after admission to the home, and this is reviewed monthly with the key-worker and co-worker. The information contained in the care files was seen to be very extensive, and relates to the specific needs of each person, includes individual choice, and also records aspirations for the future. Service users confirmed that they are encouraged to take decisions about the many activities of daily living, and these details are then recorded in their individual plan of care. Individual risk assessments are included in each service user’s plan of care. A policy on confidentiality has been developed by the Company, and clear guidance provided, which relates to the sharing of information with other agencies. Details are included in the complaints procedure and the Client’s Charter, and service users and their family are also made aware of the process on admission. Staff are given training and information on all the issues relating to confidentiality. Grove, The DS0000018706.V263148.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,15 & 16 The choices available to service users in the daily routines of the house, and the opportunities provided for personal development, encourage their independence and also greater community involvement. The opportunities made available to service users, and their regular involvement with family and friends, enable them to live as fulfilling a life as possible. The manner in which support is provided by staff ensures that the rights of service users are respected and their best interests are protected. Grove, The DS0000018706.V263148.R01.S.doc Version 5.0 Page 12 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. There is a wide range of leisure activities in which service users are involved, both in the community and in the home, and the details are recorded in their care plans. The links with other agencies, and the opportunities available for service users, continues to expand gradually. The possibility of service users obtaining employment, or attending College is explored regularly. Proposals to improve computer facilities within the home for service users have been made previously, and consideration was being given to purchasing additional equipment, although this has not yet materialised. Contact with family and friends, or an advocate, is encouraged and individuals are enabled to maintain relationships as they wish, although concerns have been expressed about the availability of advocacy services in the area. In addition, service users have opportunities to meet people and develop friendships of their choice. Service users have individual choice and freedom of movement within their own bedroom and the communal areas of the home. The use of the kitchens in both units 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.V263148.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 & 20 Suitable arrangements are in place to ensure that the personal and health care needs of service users are met. Support and encouragement is provided to each person, in order to promote independence. The procedures in place for the safe administration of medication should be followed implicitly to ensure that the health of service users is promoted. Grove, The DS0000018706.V263148.R01.S.doc Version 5.0 Page 14 EVIDENCE: The personal and healthcare needs of service users are well documented, and there is evidence to show how staff understand and respond to them in an appropriate way. Service users are encouraged to be as independent as they are able. Additional specialist support and advice is sought from the primary health care team, and other health professionals, when necessary, and relevant details are recorded in the care plans. A recent visit from the Pharmacy Inspector found that the detailed procedures in place at the home are followed, and staff were commended on the overall control and handling of medication, which is maintained to a good standard. A few issues were identified and recommendations made as follows: • The date of receipt of medication must be recorded • The date a medication container is opened should be documented • Stock balances should be carried over when new MAR charts are used • Hand written entries on MAR charts should be signed by two staff • Refrigerator temperatures are to be recorded on a daily basis Grove, The DS0000018706.V263148.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not inspected on this occasion, having been met previously. Grove, The DS0000018706.V263148.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28 & 29 The premises are suitable for their purpose and are safe, comfortable, and clean, although failure of staff at the home to undertake weekly checks of the fire alarm system, potentially places staff and service users at risk. There is an ongoing programme of development in relation to the décor and facilities provided at the home, with the intention of continually responding to the changing needs of service users, and so improving their quality of life. The home provides a satisfactory standard of accommodation, with facilities provided to enable service users to maximise their independence. The location of the house is convenient to local services and amenities, and the layout provides adequate communal space for the needs of service users. Grove, The DS0000018706.V263148.R01.S.doc Version 5.0 Page 17 EVIDENCE: The Grove is a two storey, detached, Grade 2 listed building, situated in a pleasant residential area, within walking distance of the town centre of Kidderminster. The accommodation has been arranged on two floors, each providing facilities for six service users. The building is generally well maintained, and appears to be clean and homely, and comfortable and safe. 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 bathroom, shower and toilet facilities are suitably located around the home, and a review of these facilities on the ground floor has been undertaken by an occupational therapist. The communal areas of the house are maintained to a good standard, and carpeting has been replaced in some rooms. Handrails have been provided in the corridors on the ground floor, and new carpets are to be fitted in the New Year. Several dysfunctional items of equipment have been removed, and a new washing machine and tumble drier provided. Everything is now in good working order. The all weather conservatory is almost complete. There were no requirements made following a recent visit from the Environmental Health Officer. A contract is in place for the disposal of clinical waste, and for the servicing and maintenance of equipment. The Fire Safety Officer confirmed, during a visit earlier in the year, that the remedial work, identified previously, had been completed to a satisfactory standard. The Fire Log was inspected, and the records indicated several omissions, when the weekly fire alarm test had not been undertaken. Staff were reminded of the importance of these routine checks. Grove, The DS0000018706.V263148.R01.S.doc Version 5.0 Page 18 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): 31 & 33 The home is staffed by an adequate number of qualified and competent staff, who are able to meet the identified needs of service users. The ongoing programme of learning enables staff to undertake their work more effectively. The key-worker system ensures that each client has two support workers, who enable them to achieve their individual wishes and goals. Grove, The DS0000018706.V263148.R01.S.doc Version 5.0 Page 19 EVIDENCE: The rotas indicate that appropriate staffing levels are maintained to provide for the identified needs of service users, and although the staff group is diverse in their knowledge and experience, this is used in a positive way to assist service users in achieving their individual objectives. All new staff are given initial in-house training, followed by induction training, to ensure clarity and understanding of their role and responsibilities. A copy of the General Social Care Council’s code of conduct and practice is provided to each member of staff. Job descriptions are clearly defined. A key worker and co-worker provide on-going support to each service user, assist them to develop a weekly activity plan, and then enable the chosen activities to be undertaken. Grove, The DS0000018706.V263148.R01.S.doc Version 5.0 Page 20 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): 37,40,41 & 43 The management arrangements are satisfactory, and ensure that residents and staff benefit from positive leadership. The policies and procedures, and records maintained at the home, comply with legislative requirements and therefore help to safeguard the rights of service users. The high standards maintained in the management of the business help to ensure that it is effective and financially viable, with obvious benefits to service users and staff. Grove, The DS0000018706.V263148.R01.S.doc Version 5.0 Page 21 EVIDENCE: 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 returned from maternity leave recently. Agreement has been reached for her to work reduced hours, but over 5 days each week, with additional support from the experienced deputy manager. Ms Bashir has worked for TRACS for 6 years and has been manager at The Grove for the past 3 years. She has the Registered Managers Award, having previously gained a BSc Honours degree in Human Biology and Health Sciences. The extensive policy and procedure manual relating to The Grove, is detailed, available to staff and service users, and is also well used. These documents are regularly up dated following consultation and everyone is kept informed of any changes. The records are maintained to a satisfactory standard and are kept securely. Service users are made aware of their right to access their records. The organisation has experienced a change of directors quite recently, and a business and financial plan was made available to the Commission. There are clear lines of accountability within the home, to the regional office and also to head office. Service users are encouraged to be involved in the business and financial planning of the home. An appropriate level of insurance cover is in place to reflect loss or damage, and also for business interruption costs. Grove, The DS0000018706.V263148.R01.S.doc Version 5.0 Page 22 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X 3 X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 X X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 X 3 X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Grove, The Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 3 X X 3 3 X 3 DS0000018706.V263148.R01.S.doc Version 5.0 Page 23 YES 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 YA24 Regulation 23 Requirement The registered person must take adequate precautions against the risk of fire – The fire alarm must be tested each week and a record maintained Timescale for action 31/01/06 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 2 3 4 Refer to Standard YA12 YA15 YA20 YA28 Good Practice Recommendations Computer facilities for the use of service users at the home should be improved Further attempts to gain access to advocacy facilities should continue to be made The recommendations of the Pharmacy Inspector should be implemented The conservatory should be completed and commissioned Grove, The DS0000018706.V263148.R01.S.doc Version 5.0 Page 24 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: 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. 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