Inspection on 26/05/05 for The Grove

This inspection was carried out on 26th May 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 but made no statutory requirements on the home.

Other inspections for this house

The Grove 15/02/07

The Grove 13/10/05

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 S63 0SN Lead Inspector Jayne Barnett-Middleton Unannounced 26 May 2005 9:00 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 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 CS0000058045.V218870.R01.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Grove Address Thurnscoe Bridge Lane Thurnscoe Rotherham S63 0SN 01709 895424 None None Guardian Care Homes (UK) Limited Telephone number Fax number Email 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 PC Care Home Only 37 Category(ies) of OP Old Age (37) registration, with number of places The Grove CS0000058045.V218870.R01.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons accommodated shall be aged 60 years and above.2. The Manager will work supernumerary 3 days per week when the occupancy is in excess of 20 service users. At full occupancy the Manager will be totally supernumerary. Date of last inspection 20 January 2005 Brief Description of the Service: The Grove is a 37 bed home for older people, providing personal care. It is situated in the village of Thurnscoe eight miles from Barnsley town centre close to the A635 Barnsley to Doncaster Road, with easy access by bus and train. The home is within walking distance of all local amenities, which includes a variety of shops, supermarkets, chemist, post office, hairdressers, community centre, bowling green, pubs clubs and local village Churches and the health centre. The home stands in its own extensive gardens with mature trees and shrubs. The gardens are landscaped and well maintained providing ample sitting areas for service users and their families. Accommodation is on two floors, served by a passenger lift. It has twenty one single and eight double bedrooms, 26 of which are ensuite, three lounges and one dining room. Car parking is available at the side and front of the home. The Grove CS0000058045.V218870.R01.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out from 09.30 a.m to 3.30 p.m. Nine service users, eight staff, the manager and one relatives were spoken to. A sample of records was examined and a partial inspection of the building was carried out. Throughout the inspection positive and professional relationships were observed between staff and service users. The inspector wishes to thank the manager, staff and service users for their time and co-operation throughout the inspection process. What the service does well: The home had a relaxing and welcoming atmosphere. All service users spoke positively about the manager and staff team stating that they were “very good”, “perfect” and “like our daughters”. Service users said that their healthcare needs were met and confirmed that the manager and staff were “very good” in contacting their general practitioner and arranging healthcare appointments as they wished. The routines within the home were flexible. There was a good programme of activities available, which included shopping trips, cream teas and entertainment. A cinema afternoon had recently been introduced and was proving to be very popular. The home had an active “Friends of the Grove “ group who helped out with fund raising and organising outings. A resident newsletter had recently been introduced which informed service users of birthdays, planned events and a section for service users to contribute any news or comments that they may have. A good choice of menu was offered. Service users said that they enjoyed their meals and described the food as “very good”. The home was clean, tidy and pleasantly decorated which promoted a homely environment. Service users said that they liked living at the home and described it as “clean and comfortable”. A training and induction programme for staff was in place to enable them to meet the assessed and changing needs of service users. All service users spoke positively about the care provided and described living at the home as “good”, “highly satisfied” and “clean”, “comfortable” with “good food” and “good carers.” The Grove CS0000058045.V218870.R01.doc Version 1.30 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. The Grove CS0000058045.V218870.R01.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection The Grove CS0000058045.V218870.R01.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3. Service users were not admitted to the home without their needs being assessed. EVIDENCE: A full needs assessment was carried out for all residents prior to their admission. This confirmed that the service was appropriate for the service user, and provided staff with the information to formulate an individual plan of care. The home does not provide an intermediate care service. The Grove CS0000058045.V218870.R01.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 and 10. Service users individual needs were assessed and their changing needs were reflected in their plan of care. Service users had good access to health care services, which met their assessed needs. A policy and procedure to ensure that staff adhered to the safe administration of medication was in place. The procedure for recording stock medication required some improvements to ensure that medication administered could be monitored. Service users were treated with dignity and respect. EVIDENCE: Three Care plans set out in detail the action that was required by staff to ensure that all aspects of service users care needs were met. Since the last inspection care plans had been revised to ensure that the service user and their representative were invited to care plan reviews if they wished, to give them the opportunity to agree with staff the help that they needed to live as independently as possible. Service users preferred funeral arrangements were recorded, to ensure that their wishes following their death could be respected. Service users said that their healthcare needs were met and confirmed that the manager and staff were “very good” in contacting their general practitioner and arranging healthcare appointments as they wished. The Grove CS0000058045.V218870.R01.doc Version 1.30 Page 10 Service users were observed to be receiving personal care in a manner that respected their privacy and dignity and it was evident that service users who required help with washing and dressing had been assisted with this. There was a policy and procedure to ensure that staff adhered to safe practices regarding medication and the protection of service users. The recording and storage of medication was checked on a sample basis. Medication had been administered appropriately. Medication that was in stock had not been recorded on one medication administration sheet and it was difficult to track if medication signed for had been administered. Staff had received medication training, which promoted the safe administration of medication. The Grove CS0000058045.V218870.R01.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 and 15. The daily routines within the home were flexible and promoted resident choice. There was a good programme of leisure and social activities available. Service users were encouraged to maintain contact with their family, friends and the local community as they wished. A good choice of menu was offered and special dietary needs were catered for. EVIDENCE: The routines within the home were flexible. Service users were observed to be spending their day as they wished. Several service users were spending time in the lounge, whilst others had chosen to spend time in the privacy of their bedroom. Two service users said that they “preferred “ to spend their day in their bedroom and that “we can join in with activities, if we want to”. There was a good programme of activities available, which included shopping trips, cream teas and entertainment. A cinema afternoon had recently been introduced and was proving to be very popular. The home had an active “Friends of the Grove “ group who helped out with fund raising and organising outings. Service users were looking forward to a summer fete that was planned and one service user said, “ I have offered to help with a stall”. The Grove CS0000058045.V218870.R01.doc Version 1.30 Page 12 A resident newsletter had recently been introduced which informed service users of birthdays, planned events and a section for service users to contribute any news or comments that they may have. Service users were supported to maintain their religious beliefs and the local church visited the home on a regular basis to provide a service. A good choice of menu was offered and special dietary needs were catered for. Service users confirmed that they were offered a choice and that “we can have what we want”. Service users said that they enjoyed their meals and described the food as “very good”. The Grove CS0000058045.V218870.R01.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. The complaints procedure was clear and accessible. Complaints made by service users and their relatives were listened to and action was taken to deal with complaints promptly. There was an adult protection procedure and all staff had received adult protection training. EVIDENCE: The complaints procedure ensured that service users and their relatives were aware of how to make a complaint and who would deal with them. Service users stated that they were satisfied with the care provided. They confirmed that they had no complaints, however that the manager and staff were “nice”, “approachable” and that they felt “comfortable” in voicing any concerns that they may have. There was an adult protection policy and procedure that promoted the protection of service users from harm or abuse. A recent adult protection issue had been dealt with appropriately. The staff confirmed that they had recently attended refresher adult protection training, which enabled them to identify and report any allegations or incidents of abuse to service users. The Grove CS0000058045.V218870.R01.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,23,24 and 26. The home was clean, comfortable and in the main well maintained. Service users were provided with an environment that was safe, accessible and homely. EVIDENCE: The home was clean, tidy and pleasantly decorated which promoted a homely environment. Service users said that they liked living at the home and described it as “clean and comfortable”. A refurbishment programme is on going. The dining room, lounges, front entrance and corridor areas had all recently been redecorated to a very good standard. Two previous requirements to replace chairs in the lounge areas and to replace a bath on the ground floor had not been met. There were sufficient toilet, washing and bathing facilities, which were close to service users bedrooms and communal areas. The Grove CS0000058045.V218870.R01.doc Version 1.30 Page 15 Several bedrooms were checked and all were very clean and attractively decorated. All the rooms had been personalised by the service user with small items of furniture, photographs and mementoes, which encouraged service users to retain their own identity. Six bedrooms had recently been redecorated to a very good standard and new furniture had been provided. The manager confirmed that all service users were offered single accommodation. The Grove CS0000058045.V218870.R01.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30. Sufficient staff were provided to meet the individual needs of service users. A training and development programme was in place. Staff received regular training, which enabled them to meet the needs of service users. The home operated a recruitment procedure, which needed some amendments to promote the protection of service users. EVIDENCE: All service users spoke positively about the staff team and described them as “lovely”, “perfect” and “like our family”. One relative stated, “ I can’t praise the staff enough”. Staff rotas checked, demonstrated that the agreed staffing levels were being met to meet the individual needs of service users. There were proposals to reduce staffing levels, and the manager and area manager were in the process of reviewing the required hours by consulting with the C.S.C.I and calculating hours specified by `The Residential Forum Care Staffing in Care Homes for Older People`. The Grove CS0000058045.V218870.R01.doc Version 1.30 Page 17 Service users, staff and one relative expressed strong concerns about the proposed reduction in staffing levels. Service users said that their needs were met, however said that at times they felt there were “not enough staff”. The staff were concerned that less staff on duty would reduce the time that they had to provide the emotional care that service users deserved. One relative said that the home has always had an “excellent reputation” within the local community, and that she was concerned that a reduction in staff would effect the standards of care. A training and induction programme for staff was in place to enable them to meet the assessed and changing needs of service users. Staff confirmed that they had attended various training courses that included food hygiene, adult protection, moving and handling, infection control and first aid. The manager confirmed that eleven of the staff team held a level 2 or 3 National Vocational Qualification in Care, which developed the skills and competence of staff, to enable them to meet the changing needs of residents. A recruitment policy and procedure was in place that promoted the protection of service users. Two files checked did not contain two forms of identification or the full employment history of the employee. All staff employed had undertaken a Criminal Records Bureau Check at the enhanced level. The Grove CS0000058045.V218870.R01.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,35 and 38. Service users and staff benefited from the ethos, leadership and management approach. Service users financial interests were safeguarded by the procedures at the home. The homes policies and procedures promoted the health, safety and welfare of service users and staff. EVIDENCE: The manager is a qualified nurse and has many years experience within the caring profession. Staff, service users and relatives described the manager as “nice” and “approachable and fair”. The manager was in the process of undertaking a NVQ level four management qualification, which she had almost completed. All service users spoke positively about the care provided and described living at the home as “good”, “highly satisfied” and “clean and comfortable with good food and good carers.” The Grove CS0000058045.V218870.R01.doc Version 1.30 Page 19 Service users were encouraged to manage their own finances, which enabled them to maintain their independence. Arrangements were in place for service users who were unable to manage their monies due to their mental health. Monies were securely stored and records checked evidenced that service users were able to access their monies for hair care and personal items as they wished. The three records checked were well maintained and safeguarded the financial interests of service users. The kitchen was very clean and appeared very well organised. However, the kitchen units were worn and the doors and drawers were ill fitting. The hot plate door was loose and was in need of repair. The staff had received regular training, which promoted safe working practices and the health, safety and welfare of service users and their colleagues. The Grove CS0000058045.V218870.R01.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 2 2 x 3 3 x 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 3 x x 3 x x 2 The Grove CS0000058045.V218870.R01.doc Version 1.30 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP9. OP20 Regulation 13 23 Requirement Medication in stock must be accurately recorded. The lounge chairs which are worn must be replaced. (Timescale of 31st may 2005 not met) The defective bath in the ground floor bathroom must be replaced.(Timescale of 31st.May 2005 not met) Staff files must include proof of the persons identity, including a recent photograph. Staffs’ personal files must contain a record of the employee’s full employment history. Any gaps in employment must be accounted for and recorded. The identified kitchen units must be repaired or replaced. The hot plate door must be repaired. Timescale for action 30th June 2005. 31st July 2005. 31st July 2005. 30th June 2005. 30th June 2005. 3. OP21 23 4. 5. OP29 OP29 19 19 6. 7. OP38 OP38 16 16 1st August 2005. 30th June 2005. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. The Grove CS0000058045.V218870.R01.doc Version 1.30 Page 22 No. 1. 2. Refer to Standard OP31 OP28 Good Practice Recommendations The manager should attain the Managers Award by 2005. A minimum of 50 of care staff should attain NVQ Level 2/3 in care by 2005. The Grove CS0000058045.V218870.R01.doc Version 1.30 Page 23 Commission for Social Care Inspection Ground Floor, Unit 3 Waterside Court Bold Street Sheffield, S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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