Inspection on 04/08/05 for The Grove

This inspection was carried out on 4th August 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 30/12/05

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 2AG Lead Inspector Karen Thompson Announced 4 August 2005 th 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 E54_S4519_TheGrove_V237349_040805 - AI stage 04.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Grove Address 48 Lode Lane Solihull West Midlands B91 2AG 0121 705 3356 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) The Grove Residential Home Mrs Green Care Home 30 Category(ies) of Old Age (30) registration, with number of places The Grove E54_S4519_TheGrove_V237349_040805 - AI stage 04.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 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 E54_S4519_TheGrove_V237349_040805 - AI stage 04.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The report findings are based on an announced inspection. The two inspectors carried out the inspection over 8 hours. Information for the report was gathered from a number of sources: tour of the building, examination of records and documents, talking to staff, talking to service users, direct and indirect observation. What the service does well: What has improved since the last inspection? Redecoration and refurishment has meant a good standard of environment can be found in parts of the home. Further work is needed but the home is hoping to enhance the facilities in the future once funding is obtained. A number of outstanding health and safety issues have been addressed making the environment pleasant, comfortable and safe. Recording in residents notes has improved but further work is needed. Privacy and dignity for residents has improved but further work is required to meet service users expectations. The Grove E54_S4519_TheGrove_V237349_040805 - AI stage 04.doc Version 1.40 Page 6 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 E54_S4519_TheGrove_V237349_040805 - AI stage 04.doc Version 1.40 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 E54_S4519_TheGrove_V237349_040805 - AI stage 04.doc Version 1.40 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) 1, 3, 4 Information available ensures that prospective residents can make an informed choice about the home. Residents move into the home knowing their needs can be met after an assessment has been undertaken. EVIDENCE: The home admits residents for long-term care. The Service User Guide has recently been updated and was visible in resident’s bedrooms. The Registered Manager and deputy carried out the Pre admission assessments, which are detailed and comprehensive but these were not always signed or dated. One relative commented “I don’t think I could have found a better place”. 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 E54_S4519_TheGrove_V237349_040805 - AI stage 04.doc Version 1.40 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, 10, 11 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 ensuring that residents received appropriate support. Residents do not always feel their privacy and dignity is assured. 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 and they were also found to lacked 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 representative. Care plans were being reviewed regularly. Care plans did not contain a falls or nutritional assessment. Residents were however being weighed at regular intervals. 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. The Grove E54_S4519_TheGrove_V237349_040805 - AI stage 04.doc Version 1.40 Page 10 Residents files demonstrated that a variety of multi disciplinary teams members were visiting the home and referrals were being made. A relative commented “Since becoming a resident at the Grove, my mothers health and happiness has improved greatly.” The home offers yearly flu inoculations written consent needs to be obtained for these. All audits undertaken were correct in regards to tablets. Cream management was poor, prescription creams were observed in residents rooms but not recorded on the MAR chart. The staff interviewed had a thorough understanding of the residents clinical needs. The home has a good relationship with the community pharmacist and other health care professionals. 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. Feedback from residents indicated that sometimes their dignity was not always protected. Residents clothes were observed to be nicely laundered and the home has implemented a system to ensure service users hoistery does not get lost in the wash. Feedback from one resident suggested that they felt staff did not always dress appropriately for delivery of care, the may wish to consider introducing a dress code. Staff have received training with regards to care of the dying. Two benchs in the garden had been dedicated to a resident that had recently died The Grove E54_S4519_TheGrove_V237349_040805 - AI stage 04.doc Version 1.40 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, 15 A variety of leisure and recreation activities were available in the home, which residents are assisted to partake in. Meals offered both choice and variety which residents enjoyed. Resident’s choice however was not always being adhered to with regards to personal care thus a potential bad outcome for some service users. EVIDENCE: A variety of activities were available for residents ranging from bingo, shopping, gardening, visits to the local public house or attractions. As well as these one afternoon a week is set aside to take residents out with the allocation of staff to do this. One resident informed the inspector that they “ go on holiday every year and have been shopping to buy own clothes”. Visitors were observed around the home. One resident stated that they were able to “go to church (every week), people pick me up” The care plans were unable to demonstrate that stated choice was being delivered. One resident’s stated their choice was to have a bath, but they were receiving showers every week. Another resident h stated that they stayed up till 11pm, which was their choice. The menus seen were varied and offered choice, food stocks in the home were The Grove E54_S4519_TheGrove_V237349_040805 - AI stage 04.doc Version 1.40 Page 12 good with evidence of fresh fruit and vegetables being available. Residents comments with regards to meal ranged from “cook wonderful”, “food good choice” “get lots of tea”, “lovely food”, “choice of 2 main meals each day”. The Grove E54_S4519_TheGrove_V237349_040805 - AI stage 04.doc Version 1.40 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, 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 meets the standard. The home policy and procedure set out that it will inform the appropriate authorities. 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. The manager recently dealt with adult protection issue and liaised with all the relevant agencies. The home needs to review its restraint and handling of aggression policy and procedures. One care plan gave vague instructions in regards to dealing with aggression and the potential outcome could be poor for the resident. The Grove E54_S4519_TheGrove_V237349_040805 - AI stage 04.doc Version 1.40 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, 24, 25 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: A number of improvements have occurred in relation to the decoration and refurbishment of the building. The dining room has been repainted. One of the large lounge areas has been redecorated and refurished. A small visitors lounge is now available for use and is being enjoyed by residents as a quiet lounge. The Fire Officer reports requirements have been carried out by the home. The home is looking to extend and enhance the homes facilities. The plans with regards to this extension have been viewed by the Commission and have been submitted for planning permission. The proposed plans will enhance bathing and toileting facilities within the home. One bathroom that is part of this refurbishment was observed to have The Grove E54_S4519_TheGrove_V237349_040805 - AI stage 04.doc Version 1.40 Page 15 enamel missing from the baths surface. None of the resident’s bedrooms at present have ensuites facilities. Resident’s bedrooms were individualized and personalized. Residents are offered keys to their bedroom door. Residents have been offered net curtains for those bedrooms that are over looked since the previous inspection. Emergency lighting was observed throughout the home. The home was found to be warm and clean. Radiators have been fully guarded. Hot water outlets with the exception of baths and showers were being tested regularly to ensure they did not exceed 43c, testing needs to cover all areas. The sluice located in the laundry is not ideal sited, the home is advised to seek contact the Health Protection nurse who will carry out an environmental audit. The sluice is to be moved in the proposed plans for the building. The Grove E54_S4519_TheGrove_V237349_040805 - AI stage 04.doc Version 1.40 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, 30 Staffing levels were not always meeting the needs of Residents. Staff training is afforded a high priority ensuring that they are trained and competent to care for residents. EVIDENCE: Rotas supplied demonstrated that staffing levels dropped at the weekend. Feedback from relatives with regards to staffing “I feel at weekends there seem to be less staff on duty”, “not always sufficient staff on duty” “at weekends (staffing) seems to be thin on the ground”. The home employs auxiliary staff with regards to domestic, laundry and catering staff. Over fifty percent of staff were trained to either NVQ2 or 3 and several other staff were undertaking the qualification. Staff recruitment files sampled did not always have a POVA checks in place before starting working whilst awaiting for a CRB clearance, this means there is a weakness in their protection of vulnerable adult. There was a structured induction procedure for new staff. A impressive array of training was taking place but the home needs to audit how many staff had undertaken the required mandatory training, in regards to, manual handling, adult protection, health and safety and food hygiene. Other training topics covered areas such as sight awareness, care of the dying and dementia care. The Grove E54_S4519_TheGrove_V237349_040805 - AI stage 04.doc Version 1.40 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 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, 35, 36, 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. EVIDENCE: The manager evidenced during discussions her knowledge 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. Residents money is kept in individual wallets with a record sheet of transactions. Receipts need to be given to individuals depositing money in residents accounts held in the home. One resident item of jewellery was deposited in a brown envelope stored with resident’s money. There was no record of this deposit in any of the resident’s records. Staff were receiving supervision but not the required six sessions a year. The Grove E54_S4519_TheGrove_V237349_040805 - AI stage 04.doc Version 1.40 Page 18 The health and safety at the home was generally well maintained. Staff have specific roles in relation to carrying out health and safety checks within the home. Fire drills were taking place within the home but records are not being maintained. The Fire Risk Assessment needs to be updated along with the premises risk assessment which needs to include the grounds. There was evidence available to demonstrate servicing of equipment. The recent servicing of gas applances within the home indicate that the oven does not meet current requirements. The Grove E54_S4519_TheGrove_V237349_040805 - AI stage 04.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 x COMPLAINTS AND PROTECTION 3 x x x x x 2 2 STAFFING Standard No Score 27 2 28 3 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 2 3 x x x 2 2 x 2 The Grove E54_S4519_TheGrove_V237349_040805 - AI stage 04.doc Version 1.40 Page 20 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 7 Regulation 15(1) Requirement Timescale for action 30 Dec 05 2. 7 3. 8 4. 7 5. 8 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). 15(2)(b)(c 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) 12(1) The Registered Person must ensure that service users are assessed nutritionally and appropriate action taken.(Outstanding requirement 24 Jan 2005) 13(4)(b)(c The Registered Person must ) ensure manual handling assessments are linked into care plans. 12(2) The Registered Person must ensure that written consent is obtained from residents or their E54_S4519_TheGrove_V237349_040805 - AI stage 04.doc 30 Dec 05 30 Dec 05 30 Dec 05 30 Dec 05 The Grove Version 1.40 Page 21 6. 8 12(1) 7. 9 13(2) 8. 10 12(4)(a) 9. 10 12(4)(a) 10. 11. 14 18 12(3) 13(6) 12. 18 13(6) 13. 25 13(4) 14. 27 18(1)(a) representative prior to flu innoculation. The Registered Person must ensure that a falls risk assessment is carried out and appropriate action taken. 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 must consult with service users on a one to one consultation about how staff can maximize the privacy and dignity of service users. The Registered Person must review staff practice in relation to service users sitting in their night attire in the lounge. (Requirement carried forward from 24 Jan 2005 as not inspected on this visit.) The Registered Person must ensure that service users choice is adhered to. The Registered Person must on receipt of guidance from the local Social Service Authority up date their adult protectio procedure. The Registered Person must review its restraint policy and procedure. Staff must review training and guidance in managing aggressive behaviour. The Registered Person must ensure that all hot water outlets that service users have access to are tested and do not exceed 43c. The Registered Person must conduct a review of staffing at weekends and make changes to staffing levels or deployment if it is discovered these are 30 Dec 05 30 Nov 05 30 Dec 05 30 Dec 05 Within three month of receipt 30 Dec 05 30 Nov 05 30 Nov 05 The Grove E54_S4519_TheGrove_V237349_040805 - AI stage 04.doc Version 1.40 Page 22 needed. 15. 29 19(4) The Registered Person must ensure that satisfactory POVA checks are completed prior to commencement of employment. The Registered Person must carry out an audit of staff mandatory training and ensure that this training takes place. The Registered Person must ensure that any valuables given over to staff for safe keeping are have appropriatly recorded. The Registered Person must ensure that staff supervision takes place 6 times a year. The Registered Person must update the homes fire risk assessment. The Registered Person must ensure that fire drill records are maintained. The Registered Person must ensure that the oven meets requirements. The Registered Person must ensure that the premise risk assessment includes the grounds. The Registered Person must ensure that service users are offered a key to their bedroom and this is documented in their care plan. 30 Oct 05 16. 30 18(1)( c)(i) 16(2)(L) 17(2)Sch 4 9 (a)(b) 18(1) 13(4) 13(4) 13(4) 13(4) 30 Dec 05 17. 35 30 Oct 05 18. 19. 20. 21. 22. 36 38 38 38 38 30 Dec 05 30 Nov 05 30 Nov 05 30 Dec 05 30 Oct 05 23. 24 12(4)(a) 30 Nov 05 24. 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 9 Good Practice Recommendations Staff drug audits to confirm staff competence in medicine management should be undertaken on a regular basis. E54_S4519_TheGrove_V237349_040805 - AI stage 04.doc Version 1.40 Page 23 The Grove 2. 3. 4. 5. 9 9 10 26 Protocols for when required medication should be written. The medicine trolley should be kept in the locked medication room when not in use. The Registered Person consider introducing a dress code for staff. The Registered Person is recommended to contract the Health Protection Unit, Bartholemew House, 142 Hagley Road, Birmingham B16 9PA. Tel:- 0121 224 4670 The Grove E54_S4519_TheGrove_V237349_040805 - AI stage 04.doc Version 1.40 Page 24 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street B2 4UZ 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 The Grove E54_S4519_TheGrove_V237349_040805 - AI stage 04.doc Version 1.40 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!