Care Home: The Grove Residential Home

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What the care home does well There is a stable, consistent management team at the home. The management of the home have developed sound relationships with those who live at the home and were able to demonstrate a clear understanding of individual`s needs. Those living at the home have the opportunity to raise concerns and receive support from staff, which assists them with expressing their views. Staff members receive guidance and training that helps to protect those living at the home from harm. People living at The Grove benefit from staff members who understand their needs and undertake relevant training. There are recruitment procedures in place, which promote equal opportunities and help to protect those living at the home from being supported by unsuitable staff The home is well maintained and good quality furnishings are provided with homely touches to make the home more comfortable for the people who live there.The health and safety of those who live and work at the home are generally well promoted and protected. What has improved since the last inspection? The home has worked diligently in order to meet all of the requirements and recommendations that were made at the last inspection. Care plans are in place for all of those who live at the home, these are well written, sufficiently detailed in order that these direct and guide staff practice. These plans are available to those who live at the home upon request. Care plans are kept under review and recorded an excellent level of detailed information to ensure that people are fully supported in all aspects of their care. Care plans are dated to evidence when the care plan had been completed; this assists in the review and monitoring of these documents. To ensure a clear audit trail and accountability the home has improved upon the recording of stock held medication. Records of medication administered on a daily basis within the home have also improved. Manual handling risk assessments are dated this will assist with the review and monitoring of these assessments. Risks for those who live at the home are well written and incorporate a full evaluation of the risk factors identified for people. The assessments in place demonstrate how people will be supported to maintain their safety. Spot checks that are completed at the home to monitor staff practices are good. These spot checks included what the observation of practice was and what the outcomes of the observations were. These checks are well written. The home has informed the Commission of incidents, which have affected the wellbeing of those who live at the home. These notifications have demonstrated that the service has dealt with issues effectively and in the best interests of those who live at the home. What the care home could do better: Prescribed medication that is administered by a health professional (who is not employed at the home) should have clear links within the homes medication administration records to demonstrate that it has been given. CARE HOMES FOR OLDER PEOPLE The Grove Residential Home 88 High Street Winterbourne South Glos BS36 1RB Lead Inspector Odette Coveney Unannounced Inspection 26th February 2009 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Grove Residential Home DS0000072118.V374443.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. 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 Residential Home DS0000072118.V374443.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Grove Residential Home Address 88 High Street Winterbourne South Glos BS36 1RB 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) 01454 778569 01454 775367 Grove Care Ltd Mrs Fiona Angela Jarman Care Home 36 Category(ies) of Dementia (36), Old age, not falling within any registration, with number other category (36) of places The Grove Residential Home DS0000072118.V374443.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category (Code OP) 2. Dementia (Code DE) The maximum number of service users who can be accommodated is 36 13th November 2008 Date of last inspection Brief Description of the Service: The Grove is set back on the main road into Winterbourne. There is a garage with a small supermarket incorporated next door. Also within a short walking distance there are a range of local amenities such as a post office, bakers, optician, chemist, a church and public houses. The Home is a large detached Victorian house, which has been extended to accommodate 36 people who have Dementia. The Home is spacious and the extension undertaken in 2008 for additional bedrooms is well designed and does not detract from the original building. The grounds are small and the most used outside area is the inner courtyard, which is attractively set out. There is an aviary at one end of this area. The Home is on a bus route to Bristol City Centre that passes through smaller suburbs that have full shopping facilities. Fees at the home range from £425 - £550 per week, this is dependent upon individuals’ assessed needs. The Grove Residential Home DS0000072118.V374443.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 stars. This means the people who use this service experience Good quality outcomes. This was an unannounced inspection that took place over eight hours to review the requirements made at the last inspection that had been completed in November 2008. The purpose of this visit was also to review care practices at The Grove to ensure that they are in line with the legislation and that current good practice is followed at the home. At the last inspection, seven requirements and four recommendations were made in relation to different areas of service provision at the home. It was pleasing to note that the home had made considerable effort to ensure all the requirements and the recommendations had been met. We met with the home manager Mrs Fiona Jarman and spoke informally with two relatives who were visiting at the time of our visit. We also had an opportunity to speak with two staff members and with five residents relaxing at home. What the service does well: There is a stable, consistent management team at the home. The management of the home have developed sound relationships with those who live at the home and were able to demonstrate a clear understanding of individual’s needs. Those living at the home have the opportunity to raise concerns and receive support from staff, which assists them with expressing their views. Staff members receive guidance and training that helps to protect those living at the home from harm. People living at The Grove benefit from staff members who understand their needs and undertake relevant training. There are recruitment procedures in place, which promote equal opportunities and help to protect those living at the home from being supported by unsuitable staff The home is well maintained and good quality furnishings are provided with homely touches to make the home more comfortable for the people who live there. The Grove Residential Home DS0000072118.V374443.R01.S.doc Version 5.2 Page 6 The health and safety of those who live and work at the home are generally well promoted and protected. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by The Grove Residential Home DS0000072118.V374443.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Grove Residential Home DS0000072118.V374443.R01.S.doc Version 5.2 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 The Grove Residential Home DS0000072118.V374443.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is clear information to demonstrate that individual’s aspirations have been assessed in order to ensure that the home is able to meet their needs. EVIDENCE: The Grove is a care home registered with the Commission for Social Care Inspection (CSCI) to provide personal care and accommodation for up to 36 older people who have a diagnosis of dementia. The home was successful in their application to The Commission in 2008 to register and extend the home with an additional two further bedrooms, increasing the numbers able to be accommodated at the home from 34 to 36. Grove Care Ltd owns the Grove. It is a family run company; the company was set up in 2004. The home is one of two homes operated by Grove Care Ltd; the other home is ‘Oriel Lodge’ located in Bath. The Grove Residential Home DS0000072118.V374443.R01.S.doc Version 5.2 Page 10 During our last key visit to the home on 13th November 2008 we reviewed the homes statement of purpose and we recorded; “ Within the home’s statement of purpose there is comprehensive and clear information for people living at the home and their relatives about the services and facilities provided at the home”. The statement of purpose contained information about the staff and the management arrangements at the home. There is also information about the rights of residents; rights to privacy, to be treated with dignity and supported to maintain their independence. Information also included how individuals are supported with their admission into the home, the services and facilities provided by the home and other agencies as well as information about how to make a complaint and how individuals needs would be assessed and met. The home’s admission processes were not reviewed at this site visit, it was not felt that this was appropriate as there have not been any new admissions to the home since our last visit to the home in November 2008. The home has demonstrated at previous inspections that they only admit people into the home following a full assessment of needs, ensuring that the home is able to meet these. Records in place showed that people were originally admitted to the home following a full care management assessment these ensured that all aspects of care provision were assessed with information in place to direct staff as to how these would be met. Contracts, or ‘terms and conditions’ of the placement were seen at our last visit to the service in November 2008 and as there have been no admissions into the home since our visit. At our last key visit to The Grove we saw that contracts in place showed the charges applicable, what was and was not included in the fees, the notice period, the room allocated to the individual, and the arrangements for receiving and handling complaints. Intermediate care is not provided at this home. The Grove Residential Home DS0000072118.V374443.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information recorded within care plans is excellent and contain detailed person centred information to direct staff. Those living at the home can be assured that health needs will be met and people are supported appropriately with their medication. EVIDENCE: During our last visit to the home we reported that care plans must contain full detailed information to ensure that people are fully supported in all aspects of their care. There are people living at The Grove who have complex needs and it is important that care plans and associated records contain full information in order to guide and direct staff practice. This will also ensure that people living at the home are fully supported in all aspects of their life in the home including, personal, health, emotional wellbeing and the effective management of potential risks. Prior to this visit we had met with the manager and one of the responsible individuals for the home and they shared with us a new care planning format, which was in the process of being implemented at The Grove. The Grove Residential Home DS0000072118.V374443.R01.S.doc Version 5.2 Page 12 It was evident that there had been a significant level of work that had been undertaken by the home to make improvements in this area. This would have included a full audit and review of the information in place and an evaluation of each person’s support requirements in all aspects of their physical, social, emotional wellbeing. During this visit four care files were reviewed and they contained person centred plans, these reflected the changing and complex needs of people using the service. The care files also contained personal information to include next of kin and social and other health care support. Recording quality within the care plans we reviewed were of an excellent standard. The care records reviewed contained comprehensive information focused on the specific requirement of the individual. All care plans were now in a new format. This provided a “person-centred” assessment of a person’s areas of need. Monthly reviews highlighted changes, and the current priorities for care provision. The care plans also contained a range of information to include likes and dislikes, choices they make, how they communicate along with family and friends. Records seen by us, and talking to people and relatives of those who live at the home showed that staff were very responsive to indicators of possible deterioration in wellbeing. Doctors and district nursing services were accessed as appropriate. There were detailed records of doctors’ visits and appointments with various specialists, such as the falls prevention nurse, occupational therapists, and physiotherapist and community psychiatric nurses. The home maintains health records well. We saw that the home records individual’s weights, nutrition and primary health care support. All of those seen contained up to date, well detailed information. Staff were seen adding and referring to the care records during the inspection demonstrating that they are using the documents as a working tool as expected. Staff were also noted interacting with residents in a warm and friendly manner and one staff member spoken with told us of the importance of body language and facial expressions in order for staff to be able to obtain consent or disapproval from people living at the home who have communication difficulties. The staff member gave a number of examples and described to us a typical morning with a particular resident and how the resident is enabled to make choices. Staff used their professional skills and experience to attend to one resident with complex needs without undermining the residents’ independence. Staff were seen knocking at the doors and waiting for an answer before entering to attend to residents in their individual bedrooms. The Grove Residential Home DS0000072118.V374443.R01.S.doc Version 5.2 Page 13 Staff were noted interacting with people living in the home in an informal, sensitive and respectful manner. This is a demonstration of good practice. During our last visit to the service we were concerned about some of the systems of medication and recording within the home. Requirements were made that medication, which is held in stock at the home, must be better accounted for and records for these medications must be clear and accurate and also that medication administration records that are completed by staff must be correctly and consistently documented. These requirements had been met and there had been significant improvements in this area. We were informed that stock medication is now only ordered when needed and weekly internal audits of medication held at the home are undertaken. At the time of this visit none of the people living in the home look after their own medicines, staff look after and give all the medicines. Medications are administered through a monitored dosage system and the records of administration were used to check against the medications held within the dosage system. Correct use of codes and the absence of gaps in the recording of medications administration indicate that staff sign the records immediately after administering medications. We did note that one person has an injection that is given to them by a district nurse. We were told that the district nurses would not sign the homes medication administration records. We did see that the home maintains a record within the individuals care plan to show that this injection had been given. It is recommended that prescribed medication that is administered by a health professional (who is not employed at the home) should have clear links within the homes medication administration records to demonstrate that it has been given. Staff files reviewed showed that staff working at the home have completed a training update on medicine administration competency. The Grove Residential Home DS0000072118.V374443.R01.S.doc Version 5.2 Page 14 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. 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. The Grove has identified people’s social, religious and recreational needs, and arranges activities as an integral part of the care offered. People were encouraged to make choices and were able to keep in contact with family and friends. People had a choice of meals, served in a pleasant environment. EVIDENCE: There was evidence that residents have regular contact with families. Relatives told us that they are always made welcome at the home. One person told us “My relative is well looked after, staff are kind, caring and extremely patient, I am very happy with the quality of care given”. Service in the dining room was relaxed but efficient. Meals were served attractively on good quality crockery. There was comfortable dining furniture, with tables that seated up to four people and chairs designed for stability. People could take as long as they liked to eat. Where assistance or prompting was necessary to support someone to eat, this was provided discretely at table level. On the day of our visit those living at the home were seen to be enjoying The Grove Residential Home DS0000072118.V374443.R01.S.doc Version 5.2 Page 15 lunch; people had roast lamb with assorted vegetables, with a fruit flan provided for dessert. A member of staff told us about the individual food preferences and religious beliefs of people living at the home. They told us about the special dietary requirements for both health and cultural beliefs of people living at The Grove and gave examples to us of how this was respected. We were also informed that one persons relative had showed the cook how to prepare and cook special dishes to meet their relative’s religious requirements. This demonstrates a commitment from the home to ensure this important aspect of someones care is provided and respected. In the lounge we saw people who live at The Grove looking at a folder and taking great interest from this, upon investigation we saw a background information and hobbies folder. This contained photographs and information about local industries and employers in the area; information was in place about sports, wartime historical information and varying modes of historical transport. It was evident that a great deal of time and effort had been put into this folder and people living at the home appeared to benefit from the stimulation and discussion. During our visit an entertainer was at the home, people were seen singing and dancing and having fun. People who did not wish to participate were supported by a member of staff in a quiet area of the home and enjoyed afternoon tea and conversation. Regular activities are provided at the home and special social and fundraising events are celebrated. The home produces a newsletter this gives information and an update about life and events held at the home. Within the newsletter it gave details about a forthcoming event at the home to celebrate Harry Grindell Matthews who was an inventor and wireless pioneer who formally lived at The Grove. The Grove Residential Home DS0000072118.V374443.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is provision for receipt of and response to complaints. Staff and management understand and exercise responsibilities in respect of keeping residents safe. EVIDENCE: There was a complaints procedure that outlined the steps to take if there are any complaints. The Commission has received no complaints about the home since our last visit to the service. We reviewed the complaints logbook held at the home and saw that there were no recorded complaints. Safeguarding Adults policies and procedures that commit to protecting individuals from abuse are in place. Staff have attended Safeguarding Adults training to raise their awareness on their responsibilities towards protecting individuals from abuse. A member of staff consulted was clear about their responsibility to report poor practice, the principles of abuse and the actions to be taken for reporting alleged abuse. All new staff have Criminal Records Bureau (CRB) checks and are checked against the Protection of Vulnerable Adults (POVA) register. The Grove Residential Home DS0000072118.V374443.R01.S.doc Version 5.2 Page 17 The Grove Residential Home DS0000072118.V374443.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at The Grove live in a comfortable, safe and well-maintained environment, which meets their individual and collective needs. The home is kept clean and tidy and provides sufficient communal space together with bath, shower and toilet facilities. Those living at the home have personalised their bedrooms to varying degrees but to their individual wishes. EVIDENCE: The home is a large, comfortable, safe and well-maintained property and the maintenance for this is ongoing with redecoration and renewal of the fabric being undertaken as and when required. Within the entrance area of the home, on display is a copy of the homes emergency fire plan and the compliments and complaints procedure. The Grove Residential Home DS0000072118.V374443.R01.S.doc Version 5.2 Page 19 Bedrooms are suitably furnished and people living in the home can bring in limited items of personal possessions to make their bedrooms more homely. People living at the home can and have personalised their bedrooms to varying degrees but to their individual wishes. Each person had their name and photograph on their bedroom door in order to assist them in their direction around the house. During our visit we noted that one of the bedrooms was in the process of being refurbished, Fiona Jarman informed us that a new en suite facility was being installed in this area and that due to ongoing improvements at the home there were only four of the thirty six bedrooms at the home which do not have en suite facilities. We noted that since our last visit to the home signs had been fitted in key areas of the home. These are in place to support, guide and direct those people living at the home. We saw the pictorial signs for the dining room, managers office and toilet areas. People living at the home were seen making use of these signs and these appear to have assisted people in their orientation around the home. The Grove Residential Home DS0000072118.V374443.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 28, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have support from competent, trained staff who are provided in sufficient numbers. People are protected by sound recruitment practices that ensure nobody works at the home until checks on their background are complete. EVIDENCE: Recruitment and employment documentation was kept in the home and the records for two of the newer staff were looked at. They had Criminal Records Bureau (CRB) checks and were checked against the Protection of Vulnerable Adults (POVA) list. Two written references were obtained prior to employment, together with proof of identity. The manager monitored staff performance during their probationary period to review progress Evidence was available in the staff files to confirm that the newly appointed members of staff had received an induction training programme, which is normally completed within six weeks. On completion of this programme staff would be considered for NVQ 2 training as well as undertaking various mandatory training. A training matrix has been established by the home, which includes training undertaken and due to be completed by staff. The home continues to ensure that staff attend and update their knowledge through training and this was confirmed by some staff spoken to. The Grove Residential Home DS0000072118.V374443.R01.S.doc Version 5.2 Page 21 There are a range of mechanisms in place for the proprietors to both brief and receive feedback from staff in order to monitor the standard of care and services provided to the residents. These include regular staff meetings, daily handover meetings and both formal and informal staff supervision. Staff spoken to confirmed that they receive formal supervision and they are happy with the level of support available. During our visit we noted that staff were engaged with people who live in the home and there was a calm and organised atmosphere. The Grove Residential Home DS0000072118.V374443.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management team provides leadership and direction so people benefit from a well run home. Quality assurance systems include obtaining the views of service users and their supporters to monitor and improve the service. There are systems in place to identify and promote the health and safety needs of residents and staff, and to provide safekeeping of people’s monies where desired. EVIDENCE: The Grove is privately owned and is the second care home of The Grove Care Ltd who also own ‘Oriel Lodge’ which is located in Bath. Mrs Fiona Jarman took over as Registered Manager of the home in 2006. Mrs Jarman has completed The Grove Residential Home DS0000072118.V374443.R01.S.doc Version 5.2 Page 23 an NVQ at level 4 in care and the Registered Managers Award. The statement of purpose for the home states that Mrs Jarman has also completed training in areas such as first aid, protection of vulnerable adults, moving and handling, basic food hygiene. Basic health and safety, drugs administration, advanced care planning and dementia awareness During our last visit to the service a requirement was made that manual handling risk assessments and individual residents risk assessments must be dated in order to demonstrate when they were completed and to further assist in the review and monitoring of assessments. A review of these documents at this visit found that this requirement had been met. At this visit we saw that the home had conducted a quality assurance of the service, which is provided at The Grove. This had been undertaken earlier this year. The home sent questionnaires to relatives of individuals who live at the home. The questionnaires were developed to cover seven key areas of service provision, including health and personal care, daily life and social activities, complaints and protection, The executive summary reported that 100 of the respondents were either very satisfied or quite happy with the service. Comments seen by us within the returned questionnaires included: “With variable degrees of dementia each resident gets individual attention, which is excellent”, “The home has a good family atmosphere, and visitors are always made welcome”. During our last visit to the service we found that there had been incidents, which had not been reported to us. A requirement was made that the home must inform the Commission of incidents, which adversely affect the wellbeing of those who live at the home. The home has contacted us when required to do so and have demonstrated that incidents which have affected the wellbeing of people who live at the home had been dealt with appropriately ensuring that action had been taken to support people who live at the home. The home continues to complete health and safety checks and records show gas checks, hoists, passenger lifts and portable appliance testing by outside contractors are conducted and evidenced that the home promotes health and safety within the workplace. The Grove Residential Home DS0000072118.V374443.R01.S.doc Version 5.2 Page 24 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 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 X 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 3 3 3 X X 3 X 3 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 X 3 X 3 3 X 3 The Grove Residential Home DS0000072118.V374443.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP9 Good Practice Recommendations Prescribed medication that is administered by a health professional (who is not employed at the home) should have clear links within the homes medication administration records to demonstrate that it has been given. The Grove Residential Home DS0000072118.V374443.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 The Grove Residential Home DS0000072118.V374443.R01.S.doc Version 5.2 Page 27 © 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 Residential Home DS0000072118.V374443.R01.S.doc Version 5.2 Page 28 - 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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