Care Home: Blue Grove House

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What the care home does well There are many strengths to the service. The physical standards are good with an attractive and welcoming home provided for residents. The home is purpose built and there has been recent redecoration which has been carried out to a very good standard. Staff are friendly and helpful and provide residents with careful attention. Residents are happy and expressed lots of positive comments about the care received. For example, one resident said, “I’ve been very happy here. The staff do a great job and they really look after you”. Other residents made similarly positive comments such as, “my room is lovely”, “I like the food”, and, “if I need something they (the staff) get it”. Staffing levels are generous which allow staff the time to spend with residents. Care is not rushed. There has been planning in how care is arranged so that tasks are delegated amongst the senior staff and the manager and deputy manager are able to spend time monitoring care provision and assisting staff where needed. For example, on completing care plans and reviews. Activities are varied and well considered. There is an activities coordinator who has been able to arrange a range of activities and to plan for suitable and varied sessions such as reminiscence. The new manager has successfully boosted communication and openness within the home. There are good relations between staff and residents and there are systems in place which can monitor care provision and address matters as they arise. There are positive links with relatives which have enabled funds to be raised to buy equipment at the homeBlue Grove HouseDS0000052129.V378792.R01.S.docVersion 5.2 What has improved since the last inspection? The redecoration of the building has been carried out to a high standard with very good attention to detail. Residents have a high quality of physical standards. The manager and staff have worked hard with developing the home’s care plans. Senior staff monitor the care plans regularly and also assist staff to complete care plans. The care plans in use are very detailed and comprehensive. Improvements have also been made to the staff training records. These are now clearly recorded with records showing what training has been provided, who has done the training and what training is planned for the future. This work is helpful in terms of planning for the future. Such data had not been easily available before. There is a clear focus on what the service is aiming to do. This comes from the management team at the home. Each senior person is involved in some way as tasks, such as responsibility for training or medication, are delegated to them. In return, staff are assisted more in their day-to-day care work and senior staff can pinpoint an issue, such as care planning, and assist staff on this where needed. In addition, the increased level of communication and focus on providing a caring, open service has lead to the good relations between staff and residents. The home’s Annual Quality Assurance Assessment sets out plans for the future and this document can be used to track future progress. What the care home could do better: The service is already performing well. There are plans for future developments and plans for providing evidence that these improvements are being made. So, to do better, the service needs to keep on doing what it is doing. The manager has a clear idea of how the service is to develop and he is assisted by a dedicated staff team, a very good building, a well resourced service and by the wider Anchor organisation. This inspection has identified that progress could be made in the following two areas. They are both wider Anchor issues rather than specifically related to this home. One, the staff training records are all paper based. The addition of computer records, possibly using a dedicated training package, could assist in a more detailed analysis of training data as well as make it easier to retrieve. Second, the care planning system is comprehensive but can involve a lot of time for staff to make sure that it is all completed fully and accurately. Consideration should be given to reviewing the care planning documentation with the aim of making it easier to use whilst retaining its effectiveness.Blue Grove HouseDS0000052129.V378792.R01.S.doc Version 5.2 Key inspection report CARE HOMES FOR OLDER PEOPLE Blue Grove House 325 Southwark Park Road London SE16 2JN Lead Inspector Duncan Paterson Key Unannounced Inspection 21st December 2009 9:00 DS0000052129.V378792.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Blue Grove House DS0000052129.V378792.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Blue Grove House DS0000052129.V378792.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Blue Grove House Address 325 Southwark Park Road London SE16 2JN 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) 020 7394 2300 020 7231 4284 jean.adams@anchor.org.uk www.anchor.org.uk Anchor Trust Manager Post Vacant Care Home 48 Category(ies) of Dementia (48), Old age, not falling within any registration, with number other category (48) of places Blue Grove House DS0000052129.V378792.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP (maximum number of places: 48) 2. Dementia - Code DE (maximum number of places: 48) The maximum number of service users who can be accommodated is: 48 25th March 2009 Date of last inspection Brief Description of the Service: Blue Grove House is a purpose built residential care home registered for 48 older people. It is owned and run by Anchor Trust which also runs other care homes in the local area. The home was opened in October 2003 to replace an ex-local authority home. There are three floors, each with a group living unit comprising 16 bedrooms all with en-suite facilities, a kitchen, a dining area and lounge. There is a secure, rear garden for use by residents. Blue Grove House is situated on bus routes and is close to a local shopping area and a range of leisure facilities. There has been a change of manager at Blue Grove with the current manager having been in post for nine months. He is to apply to us for registration as the manager. The fees charged are in the range between £531 and £624. The home’s statement of purpose as well as previous inspection reports are on display in the foyer. Blue Grove House DS0000052129.V378792.R01.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 2 star. This means the people who use this service experience good quality outcomes. This key inspection took place on 21 December 2009. The inspection involved discussing care arrangements with residents, the manager, deputy manager and area manager as well as with a sample of staff. Where possible visiting professionals, such as a health care worker, and relatives were spoken with. Care records were inspected as were a sample of the home’s records, procedures, policies and forms. The Annual Quality Assurance Assessment (AQAA) returned to us by the home, was taken into consideration. What the service does well: There are many strengths to the service. The physical standards are good with an attractive and welcoming home provided for residents. The home is purpose built and there has been recent redecoration which has been carried out to a very good standard. Staff are friendly and helpful and provide residents with careful attention. Residents are happy and expressed lots of positive comments about the care received. For example, one resident said, “I’ve been very happy here. The staff do a great job and they really look after you”. Other residents made similarly positive comments such as, “my room is lovely”, “I like the food”, and, “if I need something they (the staff) get it”. Staffing levels are generous which allow staff the time to spend with residents. Care is not rushed. There has been planning in how care is arranged so that tasks are delegated amongst the senior staff and the manager and deputy manager are able to spend time monitoring care provision and assisting staff where needed. For example, on completing care plans and reviews. Activities are varied and well considered. There is an activities coordinator who has been able to arrange a range of activities and to plan for suitable and varied sessions such as reminiscence. The new manager has successfully boosted communication and openness within the home. There are good relations between staff and residents and there are systems in place which can monitor care provision and address matters as they arise. There are positive links with relatives which have enabled funds to be raised to buy equipment at the home Blue Grove House DS0000052129.V378792.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The service is already performing well. There are plans for future developments and plans for providing evidence that these improvements are being made. So, to do better, the service needs to keep on doing what it is doing. The manager has a clear idea of how the service is to develop and he is assisted by a dedicated staff team, a very good building, a well resourced service and by the wider Anchor organisation. This inspection has identified that progress could be made in the following two areas. They are both wider Anchor issues rather than specifically related to this home. One, the staff training records are all paper based. The addition of computer records, possibly using a dedicated training package, could assist in a more detailed analysis of training data as well as make it easier to retrieve. Second, the care planning system is comprehensive but can involve a lot of time for staff to make sure that it is all completed fully and accurately. Consideration should be given to reviewing the care planning documentation with the aim of making it easier to use whilst retaining its effectiveness. Blue Grove House DS0000052129.V378792.R01.S.doc Version 5.2 Page 7 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Blue Grove House DS0000052129.V378792.R01.S.doc Version 5.3 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Blue Grove House DS0000052129.V378792.R01.S.doc Version 5.3 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 13&4 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Information for people about the service is well presented and detailed. The service provided meets people’s needs and is well considered. EVIDENCE: The Statement of Purpose has recently been updated. It provides people with clear, easy to read details about the home, the services provided and the manager and staff. It is a useful guide for residents. The Statement of Purpose is on display in the foyer along with lots of other information and pictures about the home. The foyer is a pleasant, spacious area which welcomes and introduces people to the service. There was much positive feedback about the service from residents, many of whom were spoken with during the inspection. Typically, residents praised the Blue Grove House DS0000052129.V378792.R01.S.doc Version 5.3 Page 10 comfortable surroundings and staff. The following comments received were examples of this. “The staff here are very good. They look after you and see that you get what you need.” “It’s very clean and homely. I see the staff cleaning every day and they’ve made it nice.” There were good relations evident between staff and residents with many of the staff demonstrating a good knowledge of residents and their needs and individual characters. For example, staff were aware of how individuals may be affected by dementia or physical needs. A visiting health care worker said that she trusted staff to act on what she advised when it came to the care for a resident. Staff demonstrated commitment to provide residents with a good service. A sample of care plans and assessments were looked at. These contained details of residents’ needs and details of their assessment. There were ample details recorded about residents and how care should be provided. There was evidence from the home’s Annual Quality Assurance Assessment (AQAA) and from discussions with the manager and deputy manager, that there is an awareness of equality and diversity matters. There is also a willingness to develop the service through the involvement of residents as well as staff. The new manager has been successful in establishing an open culture at the home with each staff member aware of his / her role and where residents are valued. Intermediate care is not provided at this service. However, the top floor (Fox Unit) provides a service under contract to Southwark Council. The aim is to provide a short stay placement to allow people a period of recovery time before returning home. There is input from community health teams but the service falls short of intermediate care. This unit was visited during the inspection and residents spoken with. Again, there was positive feedback even from people who had stayed for a number of months, which is longer than planned. This was discussed with the manager and area manager who advised that sometimes residents stay longer in cases where changes need to be made to the resident’s home in the community. This service is reviewed with Southwark Council as it is part of the overall contract for the service. Blue Grove House DS0000052129.V378792.R01.S.doc Version 5.3 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 & 11 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. There has been investment in time and energy to develop the care plans and make them effective tools to guide care provision. The good relations between staff and residents assist to provide a caring, supportive environment as well as an approach to care that is able to address arising issues. EVIDENCE: A sample of care plans was inspected during. The sample covered residents who had recently moved to the home as well as people who had lived at the home for a longer time. Residents were spoken with in all three floors of the home and we were able to discuss the care arrangements. A sample of staff were also spoken with as well as observations made. Care plans are comprehensive and provide a range of useful information about each resident and their needs. There are lots of accompanying assessments and profiles such as pressure area care assessments, mobility assessments Blue Grove House DS0000052129.V378792.R01.S.doc Version 5.3 Page 12 and detailed profiles about end of life arrangements. There are also lots of details about health care needs and appointments with health care professionals. The manager and deputy manager said that there had been investment in developing the care plans in use. On the day of the inspection one of the senior staff was auditing care plans. The AQAA returned to us provided details of work to develop care plans. For example, there was an emphasis on helping staff get to grips with care plans so that the reviews were up to date. From the inspection of care plans there were gaps identified in the section of the care plans entitled, “Pre-review meeting records”. Some of the care plans were also a little difficult to look through because of the amount of papers and this could make using them difficult. It will be worth Anchor considering a review of the care planning documentation so that staff can easily complete plans and reviews. Medication arrangements were inspected for all three units. There has been a change to the storage arrangements since the last inspection. Medication is now stored for all three units in a ground floor locked room. The room is large enough for this purpose and also contains lockable facilities for controlled drugs. The Boots medication system of blister packs is used with additional storage arranged for bottles and creams if needed. One of the senior staff has been delegated to take a lead role for medication. There were good standards achieved overall in the recording. Only staff who have had medication training administer medicines and staff spoke with confirmed they had had this training. There are regular audits of the medication system. One matter was identified during the inspection. For one resident, who had been in hospital, medication was re-started in the wrong place in the blister pack. This was raised with the manager and deputy manager who responded proactively. He checked the system and agreed to remind staff about recordings. Staff were observed to work with residents in a kind, warm and respectful way. Residents expressed pleasure with the home and life there and it was clear that there were good relations all round. There were detailed records on the care plans seen about wishes in the event of death. It was clear from these records that time and effort had been invested into establishing residents’ wishes. Blue Grove House DS0000052129.V378792.R01.S.doc Version 5.3 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 & 15 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from having good quality activities resources as well a varied activities programme. The service has strong roots in the community with relatives involved and community groups visiting. Meals are comfortable, enjoyable occasions for residents and there has been thought and consideration put into how food is prepared and served. EVIDENCE: There is an activities officer at the home who was engaged in providing a number of activities during the inspection. A conversation was held with her and she was able to describe her role. She was able to demonstrate tools used in reminiscence sessions as well as describe the varied activities that took place. There had been a bingo session in the morning as well as a Christmas themed event with mince pies. She said that religious leaders attended regularly and that there were regular events in the garden. She also described how relatives had been involved in raising money at the home which had been used to buy equipment for activities. She also said that she was planning to develop the individual activities for residents. Blue Grove House DS0000052129.V378792.R01.S.doc Version 5.3 Page 14 Two relatives were spoken with during the inspection. Both said that they visited often and both said that they were welcomed. They provided positive comments about the home and had no cause for concern. The home is well established in the community with many of the residents having previously lived in the area. The serving of lunch was observed on all three units and the kitchen was visited. There has been a change since the last inspection in that the main meal of the day is now served in the evening rather than at lunchtime. The meal was served efficiently by staff. Each unit has a spacious dining room with a number of separate tables. Lunch was seen to be an enjoyable experience for residents with staff helping discretely. The majority of residents need no assistance with eating meals and they were sitting enjoying their meal with other residents. The catering staff had a good knowledge of residents’ diets and meal preferences. There is a varied menu and the kitchen was clean and well organised with ample space for storage. There had been a positive kitchen inspection from Southwark Council earlier in the year. Blue Grove House DS0000052129.V378792.R01.S.doc Version 5.3 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is a willingness to hear residents’ views, either positive or negative. Residents are encouraged to complain and if they do the issues are taken seriously. The overall staff approach to care for residents is one of dignity and staff are provided with relevant safeguarding training. EVIDENCE: There is a formal complaints system available at the home as well as informal means, such as residents meetings, where residents and others can raise complaints. The complaints records were inspected. These had details of 15 complaints which had been made since our last inspection of 25 March 2009. These are mostly of relatively minor matters which had been resolved quickly and easily. In each case the records were clear and cross referenced to a more detailed standard form. There was evidence that residents’ opinions were respected and where they raised concerns these were investigated. It was also evident from the complaints records that residents were encouraged and enabled to voice concerns they had. The manager, in discussion, and via the returned AQAA, set out the home’s approach to complaints which is to encourage feedback and complaints. Part of this was a record of compliments which we also inspected. There were Blue Grove House DS0000052129.V378792.R01.S.doc Version 5.3 Page 16 many examples contained in this file of positive comments about the home, the service and staff. Anchor has a safeguarding policy and procedure which informs practice. Staff on duty spoken with said that they had received a range of training including safeguarding. This was confirmed when the home’s training records were viewed. Additional safeguarding training as well as other training for staff is planned. There had been a recent safeguarding allegation at the home which had been responded to properly by the service and in line with the home’s policy. Blue Grove House DS0000052129.V378792.R01.S.doc Version 5.3 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 21 22 23 24 25 & 26 People who use this service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. The physical standards are excellent. The recent redecoration has been carried out to a high standard and residents have very good quality accommodation. EVIDENCE: Excellent facilities are provided. The majority of the interior of the home has recently been decorated and the quality of the décor and presentation is very high. The home was also very clean with a domestic worker available on each floor during the morning. Very comfortable, attractive living conditions are provided for residents. Many residents commented on the home’s physical standards. One person said, “I can’t believe how good they are”. Blue Grove House DS0000052129.V378792.R01.S.doc Version 5.3 Page 18 There has been careful attention to detail in the decoration and provision of furnishings and fabrics. There is a colour co-ordination scheme which carries son a colour theme even down to crockery on the dining room tables. This helps to provide a very pleasant environment in which to live and work. On a similar theme, there is a ground floor communal lounge where activities and other events are held. This was a comfortable room with modern equipment and attractive furnishings. This must help with the provision and take up of activities. Indeed, during the inspection there was a well attended morning activity session. There is a large garden which can be used for events in warmer weather. Pictures of events in the garden involving residents and staff were seen on display. The home is purpose built and there are modern facilities including, large corridors, en suite facilities in bedrooms and large communal bathrooms suitable for people with physical disabilities. Each unit has its own laundry facilities as well as dining area and lounge. Blue Grove House DS0000052129.V378792.R01.S.doc Version 5.3 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 & 30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The staffing levels are high resulting in staff having time to spend with residents. The management team support staff well through the system of delegating key tasks and monitoring the service regularly. Staff are recruited well and the home has a training plan so that future staff training needs can be met. EVIDENCE: The staffing provision on the day of the inspection was generous. There were three care staff available on each unit. Each unit has a maximum of 16 residents and, generally, residents do not have high level needs. In addition, there was a team leader on duty as well as the deputy manager and manager. Also available was the activities coordinator, catering, domestic, facilities and the home administrator. Staff were relaxed and were observed to work well with each other and residents. Staff spoken with were able to identify good things about the service such as teamwork and the support of the manager. There was openness as well in the way the staff went about their work. A sample of staff files were inspected to assess the recruitment arrangements. The files were well ordered and provided evidence that the required Blue Grove House DS0000052129.V378792.R01.S.doc Version 5.3 Page 20 information such as references and Criminal Record Bureau checks had been obtained. There were also records of induction for new staff. Staff with NVQ qualifications are well represented within the staff team. The manager, via the AQAA, has set out an ambitious plan to increase this to 90100 of staff. The training records were inspected. The deputy manager takes the lead role for this and has made a substantial difference to the recording and presentation of staff training records. There are records of courses attended as well as a training plan for future provision. The records allow an easy to view overview of staff training needs and where additional resources and input is needed. Individual records of staff training are kept on staff individual files. There were no computer systems available to record staff training and this is an area that may be considered by the home and Anchor. The manager advised that there are plans from the organisation to start using computer technology e-learning in order to extend training to staff. Blue Grove House DS0000052129.V378792.R01.S.doc Version 5.3 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 33 35 36 37 & 38 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is a clear aim and focus to the service. The management team have developed openness and communication within the home and have encouraged residents to be involved. There are clear plans for the future development of the service. There are effective means to make sure that the home is properly maintained and that staff are supervised regularly. EVIDENCE: One of the strengths of the home is the clarity of the aims and methods followed by the manager and staff to realise these aims. The new manager has been successful in developing a culture of openness and co-operation. Senior staff have been delegated areas of responsibility such as taking the lead for medication, care planning or training. Staff supervision responsibility is Blue Grove House DS0000052129.V378792.R01.S.doc Version 5.3 Page 22 similarly delegated throughout the home. This has lead to staff taking on greater responsibility for their day-to-day work as well as producing a greater level of communication in the home. The manager is to apply to us for registration. There are a number of quality assurance initiatives. These include a monthly quality indicators return, Regulation 26 reports as well as audits within the home which focus on health and safety as well as quarterly audits on care plans and infection control. There was an audit of care plans being carried out on the day of the inspection and there was a positive response when we asked about medication recordings. The deputy manager was able to look into the issue immediately. The home is well resourced and organised with senior staff who are able to monitor care provision and practice and address issues promptly. The arrangements for looking after residents money was checked with the home’s administrator. The system has recently been updated and follows the overall Anchor policy on money handling. Money is only looked after for a small number of residents and the policy is only to look after small amounts. If money builds up it is given to relatives or other representatives of residents for safekeeping. Local authorities are involved in the safekeeping of residents money as much as possible. A sample of staff supervision records was inspected. The responsibility for staff supervision has been delegated throughout the home. For example, each unit has a team leader who is responsible for supervising the staff on that unit. The records seen were detailed and there was evidence that supervision was being provided to staff on a regular basis. Staff spoken with during the inspection confirmed that they had supervision regularly. The home’s health and safety, maintenance and servicing records as well as fire and risk assessment records were inspected. These were comprehensive and provided evidence that the home’s equipment and installations were being maintained regularly and that there were regular checks of the fire safety systems as well as regular fire drills. Blue Grove House DS0000052129.V378792.R01.S.doc Version 5.3 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 4 4 4 4 4 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Blue Grove House DS0000052129.V378792.R01.S.doc Version 5.3 Page 24 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. Standard Regulation Requirement Timescale for action 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 Consideration should be given to reviewing the care plan documentation is use. This could serve to reduce the amount of time staff spend on care plan recordings. Consideration should be given to introducing a computer system for storing and analysing staff training details. This could save time on retrieving data as well as add extra quality to the analysis of training information. 2. OP30 Blue Grove House DS0000052129.V378792.R01.S.doc Version 5.3 Page 25 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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