Inspection on 12/01/07 for The Grove and The Courtyard

This inspection was carried out on 12th January 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Grove and The Courtyard 01/12/09

The Grove and The Courtyard 25/08/09

The Grove and The Courtyard 15/12/08

The Grove and The Courtyard 03/01/08

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE The Grove and The Courtyard 341 Marton Road Marton Middlesbrough TS4 2PH Lead Inspector Jackie Herring Key Unannounced Inspection 12th January 2007 09:30 X10029.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 and The Courtyard DS0000066271.V325744.R01.S.doc Version 5.2 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 and 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. The Grove and The Courtyard DS0000066271.V325744.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Grove and The Courtyard Address 341 Marton Road Marton Middlesbrough TS4 2PH 01642 819111 01642 819103 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) Grant Williamson Susan Gray-Smith Care Home 55 Category(ies) of Dementia - over 65 years of age (14), Mental registration, with number disorder, excluding learning disability or of places dementia (12), Old age, not falling within any other category (29) The Grove and The Courtyard DS0000066271.V325744.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One named individual who is under the age category can be accommodated in Grove Lodge DE(E) unit. One bed may be used to provide respite for service users aged 18 within the MD category of registration This is the first inspection. Date of last inspection Brief Description of the Service: The Grove and The Courtyard is a purpose built care home providing care for three different client groups, within three separate units. The Grove incorporates a 14 bedded unit for older people with dementia and 29 older people with personal care needs. All rooms within The Grove have ensuite facilities which include toilet and wash-hand basin. The Courtyard is a 12 bedded unit registered for younger adults with mental disorders of a neurological cause. All rooms within the Courtyard have ensuite facilities which include shower, toilet and wash-hand basin. The home is located centrally in Middlesbrough; it is on a busy main road, close to public transport, shops, public houses and churches. The weekly fees at The Grove and The Courtyard range from £338 - £500 . The weekly fees at The Courtyard is dependent upon individual packages of care. The Grove and The Courtyard DS0000066271.V325744.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place across two day, a total of 13 inspection hours. The inspection was to check that the home meets the key standards that the Commission for Social Care Inspection say are the most important for the people who use services, and that it does what the Care Standards regulations say it must. The registered manager, operations manager, two unit managers as well as care staff were involved in discussion; a number of records were examined including staff files; care files; policies and procedures and the complaint records. All three units were visited during the inspection. Seven residents were involved in informed discussions about their lives within the home, a further six residents had chats with the inspector. Three relatives also had some discussion with the inspector about the home and how their loved ones were being cared for. A pre inspection questionnaire had been completed as were a small number of relative and relative surveys. This was the first time the service had been fully inspected and was a good inspection. What the service does well: The Grove and The Courtyard provides a very homely, clean, spacious place for residents to live, which is tastefully decorated and offers a choice of communal areas. Resident said they felt safe in the home and made the following comments, “The care and support is excellent. All staff are always there hen needed. I could not wish for better care and attention”, “I know I am going to be very happy here. It is my home from home”. Relative also said, “Absolutely excellent in every way. My loved one could not be cared for any better than he/she is”. It was very clear that the staff team were enthusiastic about their individual roles and spoke knowledgably about the residents and their individual care needs. One staff member said, “It is a friendly warm atmosphere, where individuality its important”. Assessment of need and care plans within The Courtyard are very detailed and specific to the individual. The Grove and The Courtyard DS0000066271.V325744.R01.S.doc Version 5.2 Page 6 Medications systems are well managed and staff were very knowledgeable about the systems. What has improved since the last inspection? What they could do better: This is a new service and a number of the systems are in the process of being established. Through this inspection, a small number of areas have been identified as in need of further development. This includes, the care records within The Grove, in which more individual and personal details would be of benefit and would assist in developing more specific care plans. Activities within The Grove require some additional work, to ensure that residents are given good opportunities to meet their social and recreational needs. The complaint procedure and supporting records are in need of review and need to be recorded properly along with staff disciplinary records. All staff need to receive adult protection training. The mandatory staff training needs to be completed at regular intervals by all staff at the home as does staff supervision. The statutory induction of new staff needs to be developed and implemented. Staffing levels should also remain under review, particularly the evening shift to ensure that there are adequate number of staff on duty to meet resident’s need and to allow for choice and flexibility. The current review of the menu should also be completed. There is also the need to ensure that all health and safety checks are carried out regularly and are recorded. The Grove and The Courtyard DS0000066271.V325744.R01.S.doc Version 5.2 Page 7 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 summary of this inspection report can be made available in other formats on request. The Grove and The Courtyard DS0000066271.V325744.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) The Grove and The Courtyard DS0000066271.V325744.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s have their needs assessed before they are admitted to the home. EVIDENCE: Five resident’s records were examined during the inspection and each contained care management assessments as well as a pre-inspection completed by a key member of staff of the home. The Grove and The Courtyard DS0000066271.V325744.R01.S.doc Version 5.2 Page 10 In both The Grove and The Courtyard, the unit managers confirmed that pre admission assessments are conducted to ensure suitability of any potential admissions. Within The Courtyard, the admission process is slower with opportunities for prospective residents to spend some time in the unit to test if this is where they want to be and also for the staff to ensure that they are suitable for the unit and their needs can be met. The Grove and The Courtyard do not provide intermediate care. The Grove and The Courtyard DS0000066271.V325744.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good/adequate. This judgement has been made using available evidence including a visit to this service. The format for the assessment of need and care records are good and have been completed very well for those residents in The Courtyard, however the records within The Grove need to be build upon, with more detail. Effective systems are in place for medication management. Residents are treated with dignity and respect. EVIDENCE: The Grove and The Courtyard DS0000066271.V325744.R01.S.doc Version 5.2 Page 12 Five sets of resident’s records were examined, three from The Grove and two from The Courtyard and all had competed assessments and care plans. Four of the five residents were also involved in discussions about life in the home. The assessment records and care plans records differed in their style between The Grove and The Courtyard. Generally the care record format was good within both areas, with a clear information flow and appropriate assessment tools. The records completed within The Grove would benefit the residents if they were completed with more personal details to include lifestyle, like, dislikes and preferences. Some of the care plans needed more detail in terms of care to be given and there is the need to ensure that care plans are in place for the most significant needs and problems. For example, with a resident with mental health needs, the mental health assessment had not been fully recorded and there was no supportive care plan. In another assessment the moving and handling assessment was not detailed enough and there was no supporting care plan. In other instances, a number of residents had a large number of care plans, which were not all necessary and potentially deflected from what the main problems are. The records within The Courtyard were much more individual and more detailed and provided a good level of information for the care to be delivered to individual residents. In all of the records looked at there was evidence of GP, District Nurse, Community Psychiatry Nurses involvement as well as input for Occupation Therapist, Chiropodist and Opticians. The medication systems were looked at in all three of the units. They were found to be well organised with very good storage facilities and staff who were knowledgeable about the systems. Some minor good practice recommendations were made to build upon the systems already in place. During discussion, residents said, “I get well looked after, I just have to ask and they will help”, “I feel safe here and they pop in at night to check that I am alright”, “Staff are very good to me, they are helpful and polite and you are encouraged to ask for help”. The Grove and The Courtyard DS0000066271.V325744.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities are generally well managed for residents ensuring social, religious and recreational needs are provided for although some improvements could be made to increase opportunities for residents living in The Grove. Residents where possible are able to control aspects of their lives, their independence and make choices. Meals are generally provided to a good standard EVIDENCE: The Grove and The Courtyard DS0000066271.V325744.R01.S.doc Version 5.2 Page 14 During discussion with residents and staff it was identified that the area of social and recreational activities could be improved upon with The Grove. Whilst there is a programme of activity in place and staff confirmed that they do take place, it was identified that a dedicated activities co-ordinator would be of benefit within The Grove and that it would be good for the residents if there were more social events and entertainers. There was also the thought that the resident of The Grove had limited opportunities to go out of the home and this very much depended upon staff having time within their daily work. During discussion with the operations manager, it was confirmed that they would be recruiting an activities co-ordinator in the very near future. Activities with The Courtyard were extensive and there were both individual activities as well as some group activities. On the first inspection day, two residents were baking cakes, whilst a small group were enjoying board games and another was having a manicure. There is a dedicated craft room, which is said to be well used as well as a music and light room. Staff said, “There are different levels of activities, we have a flexible/moveable plan”. Through discussion, staff also talked about the importance of going out; to visit local shops and arrangements were being made to take residents swimming. It was confirmed through discussions with residents, relatives and staff that relatives and visitor were very welcome into the home and that people could visit when they wanted. During the inspection, visitors were involved in discussion about the home. Spiritual needs were said to be met for those residents who wanted this, staff said that a small number of resident did go to church, whilst there was also visits from the local clergy. There were some mixed thoughts about the meals and menu. Whilst some resident were very satisfied, there were others who thought the meals could be improved, particularly the tea meal, where some residents said this was repetitive with too many sandwiches. On the two inspection days there was a clear choice on the menu. There was also some discussion about different dietary preferences between the different units, it was however confirmed that the home manager and cook, with a view to offering alternative menu’s where necessary, were reviewing the menu. Residents and staff said that life throughout the home was fairly relaxed with no set routines. There was said to be some level of routine however this was flexible depending upon residents needs at any given time. One resident said, “It is good here, the staff motivate you, get you to join in, they sit and talk to you, they are very approachable even when they are busy, they stop and talk to you”. The Grove and The Courtyard DS0000066271.V325744.R01.S.doc Version 5.2 Page 15 One staff member who works on The Courtyard said, “Resident are given choices on all aspects of life within the unit, there is no real routine and the unit is run for the good of the residents”. A staff member from The Grove said, “We encourage residents to make lifestyle decision, we talk to them, ask them, find out about likes and dislikes, they can have a lie in, stay up late or have an afternoon nap”. The Grove and The Courtyard DS0000066271.V325744.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints procedure is good, however the records of complaints and associated investigation need more detail. The systems for protection of vulnerable adults are in place however more staff training is required to ensure that residents are adequately protected. EVIDENCE: Systems are in place for managing complaints and the complaints procedure is on display within the main entrance of the home and contained most of the information needed. The complaints system was looked at during the inspection and found to be in need of further development and information. It was not clear that all complaints had been appropriately recorded or that the one complaint that had been recorded had been fully investigated. Residents said that they were not aware of the complaints procedure and could not confirm that they had received a copy or seen it. They did however say The Grove and The Courtyard DS0000066271.V325744.R01.S.doc Version 5.2 Page 17 that they were very confident that if they had any worries or concerns then they would speak to a staff member about it. Relatives spoken to also said that they had raised minor concerns and that these had been addressed. It was unclear how many of the current staff had received training in regard to protection of vulnerable and abuse. The pre inspection questionnaire stated that a policy and procedure was in place. During discussion with newly appointed staff, they had not received training on this topic and it had not been covered as part of the orientation and induction processes. The Grove and The Courtyard DS0000066271.V325744.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a homely, well-maintained environment to suit their needs and lifestyles, which is clean and well maintained. EVIDENCE: The Grove and The Courtyard DS0000066271.V325744.R01.S.doc Version 5.2 Page 19 The environment within both The Grove and The Courtyard is of a very good standard, which is spacious, clean and well decorated. There are a number of communal areas designated for different purposes. Within The Grove, the EMI unit has a large lounge and separate dining room with spacious corridors as well as a café area to be used by all residents and relative. This area is rather warm with very little ventilation. There is also a resident smoking room that is made available to the residents of all of the units. The Older Person’s unit offers a large lounge, a small quite lounge and a separate dining room and again a good amount of corridor space, giving a sense of space and openness. The Courtyard is operated as a separate unit with the use of central service such as catering and laundry. The Courtyard is particularly spacious with a small café type, quiet room, interview room, extremely spacious lounge/dining rooms/fully equipped kitchen, craft room and relaxation room. A number of bedrooms were visited and there was much evidence of resident own personal belongings, which reflected their own tastes and personalities. Within the some of the toilets and bathrooms, soap and paper towel dispensers were not in place. The manager showed evidence that these had been ordered for some time and they were waiting for them to be fitted. Within The Grove, it was confirmed through discussion with staff that there was sufficient equipment to meet the needs of the residents. It was however confirmed that should one resident become permanent then there was the need for the home to equip their ensuite to ensure their needs are met. This was agreed at point of registration when none of the ensuite had any disabled equipment and the proprietors said that this would be fitted on an individual assessed basis. One resident said, “It is just like home, nicely presented, really nice”. The Grove and The Courtyard DS0000066271.V325744.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The procedures for the recruitment of staff are robust offering protection to residents. Staff however need to receive appropriate training. Staff numbers are reasonable. EVIDENCE: Five sets of staff files were looked at, some staff that had been employed at time of registration staff and some new staff members. Of the files examined good recruitment procedures were evidenced. The files contained application forms, appropriate references, Criminal Record Bureau checks including protection of vulnerable adults checks, health questionnaires. The Grove and The Courtyard DS0000066271.V325744.R01.S.doc Version 5.2 Page 21 All records demonstrated that in the main the appropriate checks had been completed prior to commencement of employment. Where staff had commenced prior to CRB there was evidence that the individual staff members were being supervised. Staff who had commenced employment at the time of registration had completed an in-house induction. Staff who had commenced employment since had completed an orientation, however there was no evidence of formal induction in place and no evidence of Skills for Care 12 week induction. This was discussed with the manager and a copy of the Skills for Care induction and guidance notes was given to her. Mandatory training was discussed and again, whilst some staff completed this as part of the initial induction, other staff had not. An ongoing programme needs to be rolled out and there is the need to be records in place to support this. It is acknowledged that some of this training is now planned and there was evidence within the main office of The Grove. Work is also underway for staff to be involved in other training such as dementia care, etc with the local college. Matrix demonstrated that this was underway and that most of the staff would be commencing additional training in the near future. A good number of staff employed had achieved their National Vocational Qualification, 56 of the current care staff. The manager said that most of the remaining staff have now been signed up to commence this qualification, which is good. Staffing levels and shift patterns were discussed with staff. In the main, staff thought that the staffing levels were sufficient to meet the needs of the residents. There was some slight concern about the levels within the ground floor EMI unit, particularly when there was only one senior care worker on duty for both floors. The hours of work in terms of shift were also discussed as the late staff finishes at 8pm and the night staff commence at this time with less staff on duty for this twelve-hour period. Concern was raised about the potential impact upon choice and flexibility for residents, when there was reduced staffing. For example one resident’s care plan states that three staff are required for personal care needs, however on this particular unit, there are only two staff after 8pm. One of the unit managers said they were looking at the staffing levels and hours of work, with a view to having a more flexible spread of staff. One staff member said, “There is a good staff mix with good knowledge, skill and experience”. The Grove and The Courtyard DS0000066271.V325744.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The Grove and The Courtyard DS0000066271.V325744.R01.S.doc Version 5.2 Page 23 31, 33, 35, 36, 38 Quality in this outcome area is good/adequate. This judgement has been made using available evidence including a visit to this service. Whilst residents, relatives and staff are very satisfied with the home and care provided, a small number of systems need to be developed further to enhance the running of the home and to ensure ongoing health, safety and welfare of residents. EVIDENCE: The home has a registered manager who has a very good level of experience, knowledge and skill to run and manage The Grove and The Courtyard. Through discussion with staff it was confirmed that there had been some early teething problems however it was generally thought that the home was now settling down and that the processes and systems were beginning to become established. It was identified that a small number of management processes and systems were in need of further development and potentially some training. This related particularly to that of staff supervision and any required disciplinary action. One of the relatives said, “The unit is fantastic, it is a vast improvement from previous place. There are things going on, they go out, carers are really good and we have developed good relationships with the manager and carers”. One staff member said, “This is the best job I have had, we work together, there is a good attitude, good atmosphere and everything runs smoothly. The unit manager is good, approachable and listens to you”. Systems for the management of residents’ personal allowances are well managed with good records to support this. Quality assurance was discussed and it was confirmed that Regulation 26 visits take place and some quality assurance forms have been sent out to relatives and social workers. Work on quality assurance is ongoing. The Grove and The Courtyard DS0000066271.V325744.R01.S.doc Version 5.2 Page 24 There is the need to ensure that safety check take place as the required regular intervals. It was noted during the inspection that the weekly fire zone check was not always taking place and that the water temperature were not being properly recorded and there was the need to consider increasing these checks in respect of baths and showers. There is a system in place for staff supervision, however these are not taking place at the required intervals and there is also the need to ensure that staff who are responsible for conducting formal supervision are trained to do so. The Grove and The Courtyard DS0000066271.V325744.R01.S.doc Version 5.2 Page 25 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 X 2 X 3 3 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 ENVIRONMENT Standard No Score 19 3 20 3 21 3 22 X 23 3 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 2 37 X 38 2 The Grove and The Courtyard DS0000066271.V325744.R01.S.doc Version 5.2 Page 26 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP16 Regulation 22 Requirement The complaints procedure and complaints records must contain up to date information and must detail all complaints made and evidence of any associated investigation. All staff must receive training in respect of protection of vulnerable adults. All staff must complete a formal induction within the required timescales and this must be evidenced on their files. All staff must receive regular mandatory training and records must be in place to support this. Checks on water temperatures and fire equipment must be completed at the required intervals and recorded. Timescale for action 01/03/07 2. 3. OP18 OP30 13 18 01/03/07 01/03/07 4. OP38 13 01/03/07 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 and The Courtyard DS0000066271.V325744.R01.S.doc Version 5.2 Page 27 No. 1. 2. 3. 4. 5. Refer to Standard OP7 Good Practice Recommendations Care records within The Grove should be developed further and include lifestyle details. Appropriate and relevant care plans should be developed from the assessments of need. Consideration should be given to increasing more opportunities for social and recreational activities for those residents living in The Grove. The planned menu review should take place and should ensure that individual preferences are taken account of. Staffing levels should be kept under review to ensure they meet the needs of the residents and ensure choice and flexibility in terms of meeting individual care needs. Care staff should receive formal supervision at least six times a year. OP12 OP15 OP27 OP36 The Grove and The Courtyard DS0000066271.V325744.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 and The Courtyard DS0000066271.V325744.R01.S.doc Version 5.2 Page 29 - 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. 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