Inspection on 03/01/08 for The Grove and The Courtyard

This inspection was carried out on 3rd January 2008.

CSCI found this care home to be providing an Adequate service.

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 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 12/01/07

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 Unannounced Inspection 09:30 3 January 2008 rd 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.V354552.R02.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.V354552.R02.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 Vacant 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.V354552.R02.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 12th January 2007 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 £380.00 (which includes a £10 top up) to £550.00 plus additional cost for individual packages of care. The Grove and The Courtyard DS0000066271.V354552.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection was an unannounced Key Inspection. All of the key standards related to older people were looked at. This was to check that the home meets the standards that the Commission for Social Care Inspection say are the most important for the people who use the services, and that it does what the Care Standards regulations say it must. The visit to the home was conducted in two and a half inspection days, all announced. During the visit to the home, a number of records were looked at, including records of people who use the service, along with medication records, staff records, training records and maintenance information. Time was spent talking to people who use the service, a relative and staff. Time was also spent walking around the home, observing interactions and generally finding out what The Grove and The Courtyard was like for residents and staff. Discussion also took place with the manager and there was brief discussion with the provider. A number of resident and relative surveys were sent to the home for completion. The manager has completed the Annual Quality Assurance Assessment (AQAA), the services self-assessment of how well they think they are meeting standards. This was received prior to the inspection and it was then used as part of the inspection process. Some of information has been reflected within the report to support the judgements made. Discussion took place with the Operations Director and Regional Manager who both acknowledged there was the need for improvement and further development at The Grove and The Courtyard. It was however clear that the organisation were totally committed to making these improvements. A new manager had recently been appointed who was very open and very clear about the work ahead. What the service does well: The Grove and The Courtyard provides a warm, friendly and caring environment for people to live. People who live there spoke of being happy and were very positive about the staff who provided their care. People said, “I am happy, there is nice staff, they are always wanting to please you and always willing to do so”. “We believe we get the care we need, staff visit us in our rooms and check that everything is fine”, “The girls help when I need them to”. The Grove and The Courtyard DS0000066271.V354552.R02.S.doc Version 5.2 Page 6 The environment is good, clean, tastefully decorated and homely and there is a good amount of communal space available for people. Bedrooms are personalised with people’s own belongings such as ornaments and photographs. People who use the service said, “It is comfortable here”. “The home is clean, there are no odours and the cleaners are always cleaning and tidying up”. There is a new manager in post who is very clear about what needs to be achieved and who is very enthusiastic and there is a commitment to further staff training and development. There is a very good practice in place for internally promoting staff. Staff have a range of qualifications from NVQ Level 2 and a number of staff with Level 3 and on with Level 4. One of the people who use the service said, “I am really pleased I came here, I am comfortable and really settled, I am full of praise for the staff”. What has improved since the last inspection? What they could do better: A number of areas have been identified as in need of further improvement, some of which relates to health and safety. There is the need to ensure the hot water to baths and showers is tested and recorded more frequently. There is also the need to ensure that the water to baths and showers is not too cold. The manager is continuing to work with the local fire authority to address some recommendations made by them. One of the bathrooms needs some adjustment so that the hoist can be used. The system for managing the people’s personal allowance needs to be improved, with more detail and supporting receipts. The way in which the amenities fund also needs to be looked at. Care records need to contain more detail with clearer interventions within the care plans. The system for reporting and recording incidents needs to continue to be monitored to ensure that all incidents are being properly recorded and investigated. Additional advice is needed in respect of the administration of medicines to people with specialist medical needs. The Grove and The Courtyard DS0000066271.V354552.R02.S.doc Version 5.2 Page 7 There needs to be more opportunities for people who use the service to be involved in social and recreational activities. The review of the menu should continue. Staff recruitment needs to be strengthened in line with the company’s own policies and procedures. The training plan that is being developed needs to be implemented. 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.V354552.R02.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.V354552.R02.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): Standards assessed 1 and 3 were looked at during this inspection. People who use this service experience good quality outcomes in this area. People have their needs fully assessed prior to being admitted to the service, ensuring their needs are met. People also have good information about the home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Three sets of records of people who use the service were looked at during the inspection all of which contained a copy of a pre admission assessment. The manager said that since being in post she has looked at the pre admission process for people and outlined a very good system. She said that additional comments are going to be made to the pre admission assessment, which will detail that individual people’s needs could be met and that this would be confirmed in writing. The manager confirmed that people had the opportunity The Grove and The Courtyard DS0000066271.V354552.R02.S.doc Version 5.2 Page 10 to visit the home at different times and could stay for dinner, tea or just spend some time in the home. Statement of Purpose has been updated following the change to the home manager. The Grove and The Courtyard DS0000066271.V354552.R02.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): Standards: 7, 8, 9 & 10 were looked at during this inspection. People who use the service experience adequate quality outcomes in this area. People receiving the service are happy with the way in which care is delivered by staff. However records detailing how personal care is to be delivered need more detail and information. Medication systems and records are good and only staff who have received the appropriate training have any involvement with medication. Some additional information is needed which will strengthen this further. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The Grove and The Courtyard DS0000066271.V354552.R02.S.doc Version 5.2 Page 12 The same three sets of records were looked at in more detail. They contain care assessment information, risk assessment and a range of care plans that are being evaluated on a regular basis. It was identified that the actual format for assessments and developing care plans was good. However, there is the need to include further detail and information, which will then develop more comprehensive care plans with detailed person specific interventions. In care plans of people who use the service who have more complex needs the care plans need to be developed further with clear needs statements and more thoughtful interventions. There is the need to detail the action taken following any challenging behaviour incidents and to update the assessment and care plans detailing the effectiveness of the actions taken. These type of incidents need to be recorded within the home’s incident reporting system. The manager said that this procedure has been updated and that incidents will now be properly recorded and investigated. A number of examples of this were shared during the inspection. Through discussion with the manager it was confirmed that she is in the process improving this area further and that expanding the level of detail of assessments and care plans was high on her list of priorities. The daily record of care needs to be looked at as they did not contain value based, person centred information about the person’s day and how they have been supported to have their care needs met. It was difficult to differentiate one person’s daily records from another persons. Examples included, “safe environment maintained, hard to understand, small diet and fluid, assisted with toilet and pad changed regularly, spent day in lounge”. The care files detailed the involvement by Doctors, district nurses and other health care professionals as needed. This was also confirmed through discussion with people. The medication system was looked at and found to be a good system. Medication Administration Records were well written and there were no gaps. It was confirmed through discussion with staff that only Senior Care staff administer medication and they have been trained and are qualified to do this. The system for managing controlled drugs was also looked at and found to be in order. There had been some previous concerns about the medication systems particularly about items going out of stock. The new manager has implemented a very thorough audit system, which is completed on a frequent basis. Further advice is needed in regard to staff administering medication via people’s PEG site. This is to ensure that this is appropriate for care staff to be involved in this tasks, that they have been trained by an appropriately qualified person and had their competencies assessed and that they are covered by the organisation’s insurance to do so. The Grove and The Courtyard DS0000066271.V354552.R02.S.doc Version 5.2 Page 13 A kind and helpful staff team were meeting the care needs of people who use the service. People who use the service said, “I am happy, there is nice staff, they are always wanting to please you and always willing to do so”. “We believe we get the care we need, staff visit us in our rooms and check that everything is fine”, “The girls help when I need them to”. The Grove and The Courtyard DS0000066271.V354552.R02.S.doc Version 5.2 Page 14 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): Standards: 12, 13, 14, 15 were looked at during this inspection. People who use the service experience adequate quality outcomes in this area. People who use the service have some opportunity to take part in activities. They are supported to live in a flexible environment where there is choice of routines and independence. The food provided is of a satisfactory quality and meets the dietary and cultural needs of the people who use the service. We have made this judgement using a range of evidence, including a visit to this service. The Grove and The Courtyard DS0000066271.V354552.R02.S.doc Version 5.2 Page 15 EVIDENCE: A number of relative surveys were returned prior to the inspection and detailed that there was a limited amount of entertainment, activities and social events for people who use the service to be involved in. Key people within the organisation recognise that this remains an area in need of further development. Recruitment for a dedicated activities person is underway. Relatives and friends are free to visit when they want to and were observed during the site visit. The way in which activities are recorded within The Courtyard needs to be looked at and improved upon. This was discussed with the unit manager and full details given. Whilst each resident has an individual daily plan, the activities undertaken do not always correspond to the plan and the activity record is not completed every day, a number of blanks were seen. It was recommended that when a resident does not want to be involved in their activity then this should also be recorded. Through discussion with staff, it was confirmed that arrangements are in place to meet people’s spiritual needs. They said that clergy visit the home and conduct a service and give Holy Communion. The residents generally enjoy meals although one or two said they could be more variety particularly at teatime. The menu was looked at which was a four-week rolling menu serving traditional British food. There was choice available as detailed on the menu and staff said that a member of staff speak to people who use the service the previous day to discuss their choice. There were some similarities on consecutive days within the menu, however it was confirmed that the menu is currently being reviewed and updated and work it being carried out to ensure that individual choices and preferences would be taken account of. The Grove and The Courtyard DS0000066271.V354552.R02.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): Standards assessed 16 and 18 were looked at during this inspection. People who use this service experience good quality outcomes in this area. People were generally confident their complaints would be listened to, taken seriously and acted upon. People who use the service are protected from abuse by the home’s policies and procedures. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The complaints log was looked at and fully detailed complaints that had been received. There was clear evidence of an investigation process and supporting information was documented to support this. Outcomes were detailed. The AQAA detailed that there has been five complaints in the past twelve months, this have all been resolved. On day one of the inspection a further complaint had been received. This had been investigated and resolved by the second inspection day to the satisfaction of the complainant. Staff during discussion confirmed they were aware of the action to take in the event of a potential protection of vulnerable adults situation. A number of staff confirmed they had received the training needed however it was acknowledged that newer staff still needed to have this training. The home had identified some potential protection of vulnerable adults incidents. The correct procedure was followed and appropriate action was taken. The Grove and The Courtyard DS0000066271.V354552.R02.S.doc Version 5.2 Page 17 It is clear from discussion with the new manager that all issues of concern are treated seriously and action will be taken to correct any shortfalls. A comment made within a relative survey stated, “I did complain about certain things in the home which were not resolved to my satisfaction. However after a change in senior staff things have improved”. The Grove and The Courtyard DS0000066271.V354552.R02.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): Standards: 19, 22 & 26 were looked at during this inspection. People who use the service experience good quality outcomes in this area. People live in a safe and very well maintained home, which is clean, well decorated and extremely homely. There is a generally a good range of equipment in place to support residents with mobility needs. Some alteration to a bathroom and shower would enhance this further. We have made this judgement using a range of evidence, including a visit to this service. The Grove and The Courtyard DS0000066271.V354552.R02.S.doc Version 5.2 Page 19 EVIDENCE: The environment was looked at during the second day of the inspection. The environment within both The Grove and The Courtyard continues to be of a very good standard, which is spacious, clean and well decorated. There are a number of communal areas designated for different purposes and people who use the service have opportunities to move around the home and access different areas. People who use the service said, “It is comfortable here”. “The home is clean, there are no odours and the cleaners are always cleaning and tidying up”. 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. A hairdressing salon is also available for use. 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. In the main, the bathrooms and shower rooms offer pleasing environments for the people who use the service and again are nicely decorated. Improvement could be made to one of the shower rooms, which is quite a large room, with no shower curtain in place. This would increase the level of privacy and reduce the potential vulnerability for people who use the service. Dining chairs were observed in bathrooms and shower rooms and one of the bathroom layouts needs to be looked at, as the hoist within the assisted bath would be difficult to use if needed. There was some discussion that residents who would use this bathroom have to go to another unit to have their baths. The Grove and The Courtyard DS0000066271.V354552.R02.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): Standards: 27, 28, 29 & 30 were looked at during this inspection. People who use the service experience adequate quality outcomes in this area. People are very satisfied with the care they receive. There is some shortfall in the recruitment procedures and this does not fully ensure that people are protected. The manager recognises the need to ensure all staff are well trained and there is the need further development to ensure that staff have the required training to meet the needs of the people who use the service. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Five sets of staff records were looked at during the inspection. Three members of staff had commenced employment prior to their Criminal Records Bureau checks being returned, but with a POVA First in place. Two of these staff members only had one written reference in place and due to the nature of their job roles, would be difficult to ensure that they were working fully The Grove and The Courtyard DS0000066271.V354552.R02.S.doc Version 5.2 Page 21 supervised at all times. The manager agreed with the comments made and said that her aim was to ensure that the CRB was back prior to any new staff commencing employment and that she would endeavour to do this. During discussion with people who use the service they said that there were sufficient staff to meet their needs. 40 of staff are trained to NVQ Level 2 and a number of staff have also achieved NVQ Level 3. Other staff are underway with both their Level 2 and Level 3 qualifications and a further staff have achieved NVQ Level 4 and a member of staff is doing the Registered Managers Award. Housekeeping and Catering staff are also in the process of doing a relevant National Vocational Qualification. Some really good practice was demonstrated when promoting staff internally, with a good level of supporting information in place. A training matrix was in place as was a rolling mandatory training programme which detailed, moving and handling, fire and infection control. A number of staff who spoke to the inspector detailed a range training they had received, including the mandatory training as well as Protection of Vulnerable Adults, Dementia Care and Palliative Care. The manager said that since being in post she had identified the need for staff to have more dementia care training. She has arranged for twenty of the care staff to commence Dementia Care Level 2 at Stockton Riverside College. Plans are also underway to access more service specific training for staff. The need for this was discussed with staff during the inspection and they clearly believed that further training would be advantageous to them and the residents. This training includes further management of challenging behaviour, Huntingdon’s, diabetes care and other training relevant to the three different client groups. It was identified during the inspection that some staff were involved in more complex care task, that of PEG feeding. Staff need to be trained by a suitably qualified and competent person such as district nurse and staff trained to undertake these tasks need to have the competencies updated. The Grove and The Courtyard DS0000066271.V354552.R02.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.V354552.R02.S.doc Version 5.2 Page 23 Standards: 31, 33, 35, 36 & 38 were looked at during this inspection. People who use the service experience adequate quality outcomes in this area. The manager has the required qualification and experience to manage The Grove and The Courtyard although is not registered for this post with CSCI. A number of areas require further development to strengthen the management systems and that protection, health and safety is fully promoted. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There has been a change in manager since the last inspection; the current manager has only been in post since September 2007. She has previously been registered with CSCI as manager of a care home within the same organisation. The manager was very open and was clear about the improvements that were needed at The Grove and The Courtyard. She has a clear plan for development, which is being implemented in order of priority. The Operations Director discussed the situation at The Grove and The Courtyard and it was acknowledged that there had been some difficulties. She was very positive about the headway that was being made and was clearly committed to making a number of improvements. One of the people who use the service said, “I am really pleased I came here, I am comfortable and really settled, I am full of praise for the staff”. People’s personal allowances were looked at and there was the need to improve the recording of some of the expenditure such as hairdressing. There was also some concern about the use of the people who use the service amenities fund, which is money raised by the home through fundraising activities. It has been used on a number of occasions to take people to the doctors or the hospital. This was discussed with the operations manager who agreed that this was not appropriate and would reviewed. The frequency for staff supervision needs to be increased, as staff are not having their formal supervision regularly enough. Whilst water temperatures were being recorded these were not being tested and recorded at regularly enough. An example being that very few baths/showers were tested in December and so far none in January. It is essential that the recommendation made by the Health and Safety Executive is followed. It was agreed that baths and shower temperatures would be recorded on a weekly basis. It was also identified that the water temperatures in some of these areas were too cold e.g. 32 degrees centigrade and would not be provide for a warm and comfortable bath or shower. Although accidents The Grove and The Courtyard DS0000066271.V354552.R02.S.doc Version 5.2 Page 24 are being recorded and there is an audit in place, this needs to be developed further to give more information and allow for the identification of increased risk areas, people or times. The AQAA detailed that equipment such as fire system and gas are serviced and maintained on a regular basis. The manager confirmed that she was working with the local fire authority to update the home’s fire risk assessment and to complete the other recommendations made during a fire inspection. The Grove and The Courtyard DS0000066271.V354552.R02.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 3 2 X 3 3 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 3 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 X 21 2 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No Score 31 2 32 X 33 3 34 X 35 2 36 2 37 X 38 2 The Grove and The Courtyard DS0000066271.V354552.R02.S.doc Version 5.2 Page 26 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 OP9 Regulation 13 Requirement Further advice must be taken regarding the administration of medication via people’s PEG site. If appropriate then staff need to be trained by a person who is suitably qualified to do so and their competencies need to be assessed. Action must be taken in respect of one of the bathrooms as due to the position of the bath the hoist is unable to be used. People who use this service need to have safe access to this facility to maintain their dignity. New staff must not commence employment until all of the employment checks have been completed as specified within Schedule 2. These records must be available within the care home. This will ensure protection to people who use the service. The management arrangements must be formalised and the manager must registered with CSCI. Timescale for action 14/01/08 2. OP21 23 31/03/08 3. OP29 19(1) 14/01/08 4. OP31 8(1) 31/03/08 The Grove and The Courtyard DS0000066271.V354552.R02.S.doc Version 5.2 Page 27 5. OP38 13 Bath and shower water temperatures must be checked and recorded in line with the Health and Safety Executives recommendations ensuring more safety in these areas for people who use the service. The previous timescale of 01/03/07 was not met. 14/01/08 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 OP7 Good Practice Recommendations The work that has commenced on updating the care needs assessments and care plans should continue. Residents care plans should be developed further to ensure that appropriate assessments and care plans are in place and meet the needs of more complex and challenging people. The daily record of care also needs to be reviewed to ensure that it details the care and support provided and contains information about the person’s day. The system for reporting and investigation incidents should be monitored to ensure they are being correctly recorded and investigated. 2. OP12 The activities programme should continue to be developed and there should be increased opportunities to be involved in a range of social activities which meet their individual as well as collective needs. The planned menu review should take place and should ensure that individual preferences are taken account of. There should be a system in place to ensure that all new staff receive training in respect of protection of vulnerable adults. Consideration should be given to increasing level of privacy DS0000066271.V354552.R02.S.doc Version 5.2 Page 28 3. 4. OP15 OP18 5. OP21 The Grove and The Courtyard 6. OP30 to one of the shower rooms. Where staff are involved in more invasive, complex care/medical tasks, a person who is suitably qualified to do so should train them and their competencies need to be assessed. This will ensure that the staff have the appropriate knowledge and skill to safely meet people’s needs. Work should continue to ensure that 50 of staff are trained to NVQ Level 2. The system for managing people’s personal allowances must have some more detail and the way in which the amenities fund is used must be looked at. This will provide additional protection for people. Care staff should receive formal supervision at least six times a year. The system for analysing accidents needs to be developed further to increase the information for which potential risks can be identified. 7. OP35 8. 9. OP36 OP38 The Grove and The Courtyard DS0000066271.V354552.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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.V354552.R02.S.doc Version 5.2 Page 30 - 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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