Inspection on 30/12/05 for The Grove

This inspection was carried out on 30th December 2005.

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 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 11/07/07

The Grove 20/07/06

The Grove 04/08/05

The Grove 24/01/05

The Grove 27/09/04

The Grove 02/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Grove 48 Lode Lane Solihull West Midlands B91 2AE Lead Inspector Karen Thompson Unannounced Inspection 30th December 2005 10.45 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Grove DS0000004519.V275429.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 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 DS0000004519.V275429.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Grove Address 48 Lode Lane Solihull West Midlands B91 2AE 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) 0121 705 3356 0121 713 2110 grovesolihull@yahoo.co.uk The Grove Residential Home (Solihull) Mrs Lyndon Green Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places The Grove DS0000004519.V275429.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th August 2005 Brief Description of the Service: The Grove is a mid Victorian building with an extension added. It consists of three storeys and is located on the main route to the Coventry Road from Solihull. Solihull town centre is easily accessible from the home. The home is near places of worship and is on a main bus route. There are two main lounges, a small visitors room and a dining room. The home caters for 30 older adults and all bedrooms are of single occupancy. Access for wheelchairs is available with ramps at the front and rear of the building. The homes garden is accessed by a ramp from one of the main lounges. The Grove DS0000004519.V275429.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The report findings are based on an unannounced inspection, which incorporated one anonymous complaint investigation. Areas of concern identified with this complaint were in relation to staff practice and attitude during meal times. This has been looked at under standard 15 of meals and mealtimes to which it specifically relates. Information was gathered from a number of sources: a tour of the building, examination of records and documents, talking to staff members, managerial staff residents and relatives, direct and indirect observation. This report needs to be read in conjunction with the previous inspection report of August 2005. What the service does well: What has improved since the last inspection? What they could do better: Some of the recruitment practice is not adequate enough to protect residents. Some training which is compulsory has not been provided for all staff which might put residents’ safety at risk. Staff supervision is not taking place six The Grove DS0000004519.V275429.R01.S.doc Version 5.1 Page 6 times a year and this needs to increase so that staff are fully aware of the how to meet residents needs. The formal record of providers’ visits needs to be forwarded to the Commission on a monthly basis so the home can be monitored in between inspection visits. Assisting residents at meal times was mixed and minor amendments to staff practice are required. To ensure that residents dignity is protected. 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 DS0000004519.V275429.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection The Grove DS0000004519.V275429.R01.S.doc Version 5.1 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 the following standard(s): 3, 4 Residents move into the home knowing their needs can be met after an assessment has been undertaken. EVIDENCE: The Registered Manager and deputy carried out the pre admission assessments, which are detailed and comprehensive but these were not always signed or dated. Following admission, staff draw up a care plan which outlines the residents needs and the action required by staff to meet these needs. A review is undertaken at the end of the month. The Grove DS0000004519.V275429.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 9, 10 Residents health, personal and social care needs were not always set out in the individual care plan leading to potentially poor outcomes for some service users. Medication management is good with the exception of cream management. EVIDENCE: Care plan records were found to be orderly and included a number of the residents needs. Care plan documentation varied in quality. Records could be detailed but they were also found to lack clarity and detail on how to deliver care in some instances. Documentation was not always being signed or dated by staff and residents or their representatives. Care plans were being reviewed regularly. Care plans did not contain details of specific falls or skin integrity assessments. Manual handling assessments were taking place but the findings were not being linked back into the Care Planning process and or used to inform care practice. Discussions with the Registered Manager revealed that the management team intend to review care-planning implementation in January. A number of staff are due to attend a reporting and recording study day in the near future. The Grove DS0000004519.V275429.R01.S.doc Version 5.1 Page 10 Residents’ files demonstrated that a variety of multi-disciplinary team members were visiting the home and referrals were being made. One relative commented “Mrs Green………will talk to relatives about care and condition and always make time for you”. All audits undertaken were correct in relation to tablets. Prescribed cream management has improved, but creams were observed not always to be dated on opening. The Medication trolley is now being stored in the medication room. All staff have successfully completed accredited training in the safe handling of medicines. The inspector observed good interaction with staff and residents. Residents were spoken to in an appropriate manner by staff. The Registered Manager informed the inspector that all staff have been issued with uniforms and that a dress code is to be implemented in January 2006. The Grove DS0000004519.V275429.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 14, 15 A variety of leisure and recreation activities were available in the home, which residents are assisted to partake in. Assistance with meals was not always appropriate and staff practice needs to be reviewed to ensure that residents’ comfort and dignity is maintained. Residents’ choice was not always recorded but staff and residents were able to demonstrate choice was taking place. EVIDENCE: A variety of activities were available for residents ranging from bingo, shopping, gardening, visits to the local public house or attractions. The Registered Manager has started a celebrations book, which is a permanent record of activities and events that have taken place within or outside the home. Visitors were observed around the home. The care plans were unable to demonstrate that stated choices were being delivered. Discussions with staff, relatives and residents however did show that choices were taking place. During the inspection the inspector observed good and bad practice around the assisting of meals. Carers did not always sit down when assisting to feed a resident and main eye contact. The Grove DS0000004519.V275429.R01.S.doc Version 5.1 Page 12 Carers’ attitude towards assisting residents around lunchtime was the main focus of the complaint. As a general rule the home discourages visiting at meal times and a relative confirmed this. However they also stated that if you arrived when a meal was being served you would be offered food. The complainant stated that they visit at lunch times due to concerns about staff attitude during the serving of meals. During the inspection good interaction between staff and residents was observed. The visitors book was checked for the previous month and the complainant had either not signed in or had not been visiting at meal times during this period as very few people visited during this period and those that did, did so to take their relative out. The outcome of the complaint was unproven. The Commission has received a similar complaint in regards to staff attitudes at the beginning of this year and the situation will be monitored. The reasons for these anonymous complaints were discussed with the Registered Manager. The Grove DS0000004519.V275429.R01.S.doc Version 5.1 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 the following standard(s): 16, 18 Systems are in place to ensure that Residents are protected and concerns are listened to and acted on in a sensitive and professional manner. EVIDENCE: The complaints procedure meet the standard at the previous inspection and was not reviewed at this visit. The home policy and procedure set out that it would inform the appropriate authorities in relation to Adult Protection issues. Guidance from the Local Social Service Authority in relation to Adult Protection is required and the home is awaiting this to ensure that they know who the appropriate authorities are. A variety of staff have been nominated to receive training at the beginning of the new year to enhance their understanding of how to deal with challenging behaviour, violence and aggression and care of the vulnerable adult. The home needs to review its restraint and handling of aggression policy and procedures following this course to ensure that they are in line with best practice. The Grove DS0000004519.V275429.R01.S.doc Version 5.1 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 the following standard(s): 22, 25, 26 The standard of environment provides residents with an attractive, safe and comfortable and homely place to live. Residents private accommodation is suited to their needs and personalised according to their tastes and preferences EVIDENCE: The home is looking to extend and enhance the homes’ facilities. The plans for this extension have been viewed by the Commission and have been submitted for planning permission. The Registered Manager informed the inspector they were hoping first to enhance the ground floor with a conservatory. Residents’ bedrooms were individualized and personalized and buzzers were observed to be accessible for residents remaining in their bedrooms. The home was found to be warm and clean. All hot water outlets were being tested regularly. The Grove DS0000004519.V275429.R01.S.doc Version 5.1 Page 15 One shower hot water outlet was observed to be in excess of 43 degrees centigrade an immediate requirement was made to ensure that this was rectified. The inspector was informed a few days following the inspection that the shower was now at the correct temperature. Staff were observed wearing the correct protective clothing for the tasks they were performing. The Grove DS0000004519.V275429.R01.S.doc Version 5.1 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29, 30 Residents’ needs are being met by a variety of staff. The recruitment procedure is not as robust as it could be to ensure the safety and wellbeing of residents’. EVIDENCE: Rotas supplied demonstrated that staffing levels were evenly spread thought out the week and were sufficient to meet the needs of residents’. The home employs auxiliary staff with regards to domestic, laundry and catering staff. The home has a number of vacancies at present, but the permanent work group are doing extra shifts to cover these. One resident commented, “Can’t speak too highly of staff”. Staff recruitment files sampled did not always have POVA checks in place before starting working whilst waiting for a CRB clearance; this means there is a weakness in their protection of vulnerable adult. An impressive array of training was taking place but the home needs to ensure the required mandatory training, in manual handling and fire safety is completed by all staff. The Grove DS0000004519.V275429.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37, 38 The home is well managed and run for the benefit of the residents. The health, safety and welfare of residents and staff are promoted and protected. The scheme for depositing valuables is not robust and could lead to potentially poor outcomes for residents. Formal reporting to the Commission needs to improve so that the home can be monitored between inspections. EVIDENCE: During discussions her knowledge the manager demonstrate of the needs of the residents in her care. She had been in post for many years and was appropriately qualified to run the home. Formal written reports in relation to Regulation 26 are not being carried out monthly. This was discussed with the Registered Manager and feedback postinspection indicated that these would be recommencing soon. The Grove DS0000004519.V275429.R01.S.doc Version 5.1 Page 18 The home has a quality assurance system in place consisting of internal audits, regular resident and staff meetings and questionnaires being sent out to residents. The feedback from the questionnaires was mainly positive. Receipts need to be given to individuals depositing money in residents accounts held in the home. Staff were receiving supervision but not the required six sessions a year Policies and procedures were not looked at in detail but the Registered Manager is hoping to place these documents on computer to establish a regular review process. The health and safety at the home was generally well maintained at the previous inspection and so was not looked at in detail at this visit. Staff have specific roles in relation to carrying out health and safety checks within the home. Fire drills were taking place within the home and records are being maintained. The premises and grounds have been risk assessed and identified risks have been reduced. This needs to be formally recorded in a risk assessment. The Grove DS0000004519.V275429.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X X X 3 X X 2 3 STAFFING Standard No Score 27 3 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 3 X 2 2 X 2 The Grove DS0000004519.V275429.R01.S.doc Version 5.1 Page 20 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. Standard OP7 Regulation 15(1) Requirement The Registered Person must ensure that all service users care plans are based on comprehensive assessments and cover all aspects relation to health, personal and social care. (Outstanding requirement 24 Jan 2005). The Registered Person must ensure that care plans are reviewed and updated frequently to reflect changing needs and current objectives for health and personal care. This process must involve consultation with the service users and or representative. (Outstanding requirement 24 Jan 2005) The Registered Person must ensure manual handling assessments are linked into care plans. (Outstanding requirement 4 Aug 2005) The Registered Person must ensure that a falls risk assessment is carried out and appropriate action taken. DS0000004519.V275429.R01.S.doc Timescale for action 30/03/06 2. OP7 15(2)(b,c) 30/03/06 3 OP7 13(4)(b,c) 30/03/06 4. OP8 12(1) 30/03/06 The Grove Version 5.1 Page 21 (Outstanding requirement 4 Aug 2005) The Registered Person must also ensure that an assessment is carried out in regards to skin integrity for all residents. 5. OP9 13(2) The Registered Person must ensure that all prescribed creams are dated on opening and discard after 28 days of opening. (Outstanding requirement 24 Jan 2005) The Registered Person ensures that staff are familiar with good practice in relation to assisting residents with feeding. The Registered Person must ensure that service users choice is adhered to. (Outstanding requirement 4 Aug 2005) The Registered Person must on receipt of guidance from the local Social Service Authority up date their adult protection procedure. (Outstanding requirement 4 Aug 2005) The Registered Person must review its restraint policy and procedure. Staff must review training and guidance in managing aggressive behaviour. (Outstanding requirement 4 Aug 2005) The Registered Person must ensure that satisfactory POVA checks are completed prior to commencement of employment. (Outstanding requirement 4 Aug 2005) The Registered Individual must ensure that regulation 26 visits are carried out and that a written report of this is given to the Manager and a copy is forwarded DS0000004519.V275429.R01.S.doc 30/03/06 6 OP15 12(2) 28/02/06 7. OP14 12(3) 30/03/06 8. OP18 13(6) 31/01/06 9 OP18 13(6) 30/03/06 10. OP29 19(4) 31/01/06 11 OP32 26 30/03/06 The Grove Version 5.1 Page 22 12. OP30 18(1)(c,i) 13. OP35 16(2) 17(2) Sch4 9a,b 14. OP36 18(1) 15. OP38 13(4) to the Commission. The Registered Person must ensure all staff receives mandatory training, such as fire and manual handling. (Outstanding requirement 4 Aug 2005) The Registered Person must ensure that any valuables given over to staff for safe keeping are have appropriately recorded. (Outstanding requirement 4 Aug 2005) The Registered Person must ensure that staff supervision takes place 6 times a year. (Outstanding requirement 4 Aug 2005) The Registered Person must ensure that the premise risk assessment includes the grounds. (Outstanding requirement 4 Aug 2005) 30/03/06 30/03/06 30/03/06 30/03/06 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. Refer to Standard OP9 OP10 Good Practice Recommendations Protocols for when required medication should be written. The Registered Person consider introducing a dress code for staff. 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