CARE HOME ADULTS 18-65
Greenway Park (13) 13 Greenway Park Chippenham Wiltshire SN15 1QG Lead Inspector
Tim Goadby Unannounced Inspection 10th January 2006 10:45 – 14:15 Greenway Park (13) DS0000028295.V269457.R01.S.doc Version 5.0 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 Greenway Park (13) DS0000028295.V269457.R01.S.doc Version 5.0 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 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. Greenway Park (13) DS0000028295.V269457.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Greenway Park (13) Address 13 Greenway Park Chippenham Wiltshire SN15 1QG 01249 443965 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) Mr Philip Taylor Mrs Rhianydd Taylor, Mr Gregory Stephen Tennant Mr Philip Taylor Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Greenway Park (13) DS0000028295.V269457.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 30th June 2005 Brief Description of the Service: 13 Greenway Park provides care and accommodation for eight adults with a learning disability. Service users receive support with a range of social and behavioural needs. The majority of the current group have lived in the home for over ten years. Respite care and short-term placements are not available. The service is one of a group of three care homes in Chippenham, which together are known as the Cocklebury Farmhouse Homes. This is a private organisation. The owner/managers founded the company in the late 1980s. They remain closely involved in all aspects of its daily operation. This includes regularly working in each of the services. The property is close to the centre of Chippenham. The town offers various amenities, including shops, bars, restaurants, parks, a leisure centre with swimming pool, and a cinema. Rail and road links to Bath and Bristol are available. Service users regularly access a wide range of local amenities. This is a key feature of the programme within this organisations homes. The home is a detached and well maintained property. It stands in its own grounds, opposite a public park. There is a large garden to the rear, and a car parking area at the front. The accommodation is on two floors. There are six single bedrooms. One room is shared by two service users. Greenway Park (13) DS0000028295.V269457.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place in January 2006. A total of 3.5 hours was spent in the home. Another of the organisation’s services was inspected on the same day, and, where applicable, findings have been applied to both homes. The following inspection methods have been used in the production of this report: indirect observation; pre-inspection questionnaire, completed by the provider; sampling of records; sampling a meal; discussions with service users, staff and management; survey of service users and relatives. What the service does well:
Greenway Park is a well established service with a clear approach to promoting quality of life for its users. Everyone living at the home receives regular input to ensure that they access a wide range of opportunities. The home has succeeded in this approach with people who had previously proved difficult to support in other settings. Service users benefit from effective support which meets their needs and aspirations. Individual plans and associated documentation set out the needs of each person. The ways in which to support them, and the reasons for these, are clearly shown. If any restrictions are needed, these are fully explained. The consent of relevant parties is also shown. Service users benefit from a well run home. The organisation has a strong pool of senior staff, including the registered owner/managers themselves. They bring a wealth of qualifications and experience. Greenway Park, along with other homes in the organisation, benefits from having a regular direct presence of members of this senior team. This ensures effective direction and leadership. It also means that support is readily available to all staff when needed. Arrangements for the protection of service users uphold their rights, welfare and safety. The organisation has suitable procedures, and also works effectively within the local multi-agency framework for the protection of vulnerable adults. Greenway Park supports people who may present with significant behavioural needs. The home has devised clear and effective approaches for the management of these. The service has a good history of compliance with regulations and standards. Recent inspection reports have identified very few requirements or recommendations. On this occasion, one requirement has been set, along with four recommendations for good practice. Service history also indicates that the organisation takes effective measures to address any issues which are
Greenway Park (13) DS0000028295.V269457.R01.S.doc Version 5.0 Page 6 raised. Service users can be confident that the home strives to uphold best practice at all times, to the benefit of the people living there. Comment cards were received from four service users. All these responses indicate that people living in the home like doing so, and feel well cared for and safe. In addition, comment cards were completed by six relatives of service users. These also give positive feedback about the service provided by Greenway Park. Comments include: “I have never had any doubt that the staff have the interests of their charges at heart”; “This is an excellent home”; “We are extremely pleased with the care given”. What has improved since the last inspection? What they could do better:
The home needs to demonstrate effective practice in all aspects of recruitment and selection of staff, to ensure the protection of service users. One requirement and two recommendations were identified around this topic. If new workers take up their posts before the completion of a full criminal record check, there must be evidence that their deployment is in line with the criteria set out in care homes regulations.
Greenway Park (13) DS0000028295.V269457.R01.S.doc Version 5.0 Page 7 The service should consider amending its recruitment checklist, as on this occasion the system failed to identify that a criminal record check remained outstanding for several months. If specific issues arising during a selection process need to be addressed with the applicant, and taken into account as part of the final decision, the individual’s personnel record should reflect this. One further separate recommendation was made, relating to risk assessments. Practice is generally good, but some improvements could be made, to further enhance the protection of service users’ welfare. Firstly, documentation should show who has contributed to a risk management decision, particularly if restrictions have been imposed. Secondly, it would be helpful to show when an approach is next due to be reviewed, especially as frequencies may need to vary, depending upon the individual issues. 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. Greenway Park (13) DS0000028295.V269457.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Greenway Park (13) DS0000028295.V269457.R01.S.doc Version 5.0 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Standards relating to admissions to the home were not applicable at this inspection. Service users have their needs and aspirations met by the home. EVIDENCE: There have been no recent admissions. Most of the service user group have lived at Greenway Park since the home opened. One person transferred from another of the organisation’s services around two years ago. The home meets the needs of its residents well. There is a good level of support provided by the organisation’s own team. Specialist support is also available to individuals, when required. For instance, input is provided from professionals within the local Community Team for People with a Learning Disability. Service users come from various parts of the country. Often they are people who have experienced difficulties in other settings. The home has a good success record in providing stability for such individuals. This then enables them to access a wider range of opportunities than they have previously experienced. Greenway Park (13) DS0000028295.V269457.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 Service users are supported to take positive risks and access new opportunities, as part of an independent lifestyle. The approach to risk management would be enhanced by some improvements in the documenting of judgements, to ensure service users benefit from wide consultation and regular review. EVIDENCE: There is a detailed approach to risk assessment. Documents address a wide range of significant areas. The topics assessed may be generally applicable, or specific to individuals. Information sets out the possible risks; the factors influencing these; preventive measures; and management strategies, with reasons for the approach chosen. There is a proactive approach to ensuring that all identified risks are followed up thoroughly. Risk taking is promoted, where it will benefit service users. The input of the individual is shown, where appropriate. Other relevant agencies are consulted for their views. But documents do not always show who has been involved in a risk management decision. This is particularly important if a new restriction has been imposed.
Greenway Park (13) DS0000028295.V269457.R01.S.doc Version 5.0 Page 11 Although risk assessments are dated, they do not always show when they are due for review. Frequency may need to vary, depending on the particular issue, and it is useful to show this within the initial document. Greenway Park (13) DS0000028295.V269457.R01.S.doc Version 5.0 Page 12 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Service users are provided with full and active lifestyles, offering them full engagement with their local community. Service users are supported to maintain and develop relationships. Service users’ rights and responsibilities are upheld, balanced with appropriate steps to safeguard their welfare. Service users are offered healthy, nutritious and enjoyable meals, in keeping with their individual preferences. Greenway Park (13) DS0000028295.V269457.R01.S.doc Version 5.0 Page 13 EVIDENCE: A programme of day activities is arranged with each service user, and organised from within the home. Weekday mornings include participation in various sessions, including art, literacy, domestic skills, and cooking. Some of this work takes place in the form of projects. Service users can choose a topic of particular interest to them. Displays of some of the work produced can be found in bedrooms, and in communal areas. At the time of this inspection, the project in progress was focusing on the Chinese New Year. In addition, all users take part in different community activities. These involve interaction and communication with others. There are some well established group social events that take place each week. Various parties also took place over the recent Christmas and New Year period. Service users’ social needs are regularly assessed, as part of the care planning arrangements. Many activities take place during the daytime, when most staff are on duty. Social events will also be provided in the evenings. Rotas ensure that staff are available, to enable these to happen. Service users make frequent trips into Chippenham, and elsewhere. These may be for shopping, or in connection with other household matters. Many of the activities attended by service users are within walking distance of the home. Greenway Park also has its own minibus for outings, and public transport is readily accessible. Outings will usually be undertaken with two or three service users, supported by one or two staff. There are larger groups for some activities, which can also involve linking up with the organisation’s other homes. People in receipt of mobility allowance contribute a weekly sum towards transport costs. Additional charges may be made for longer journeys, according to the mileage. Service users also have the opportunity to go on an annual holiday. Familiar destinations are returned to regularly, reflecting the preferences of service users. During this inspection, various individuals mentioned the holidays they have had previously, and are hoping to repeat in future. Photographs from these trips are displayed in the home. Greenway Park (13) DS0000028295.V269457.R01.S.doc Version 5.0 Page 14 Some service users attend college courses, or local educational and occupational facilities for people with learning disabilities. Sessions undertaken include art and crafts, pottery, and independent living skills. A pictorial timetable of service users’ weekly activities is on display in the dining room. Many service users at Greenway Park do not have regular family contact. In a number of cases, their relatives live in other parts of the country, and are also now quite elderly. But the home ensures that people keep in touch to an appropriate degree. This includes help with correspondence, and with taking people to visit families. Service users may also have other friendships and relationships. They are able to maintain these as well. For instance, one person has a befriender who visits once a week. Service users take varying degrees of responsibility in their day to day activities and routines. Each person has a key to their own room, but not to the front door. The reasons for this are documented in care plans. Details about peoples’ responsibility for housekeeping tasks have also been recorded. In practice, service users have limited involvement in housekeeping and domestic duties. Service users can move freely throughout communal areas of the home. Peoples’ privacy within their own rooms is respected. Some individuals have their own satellite television channels in their room, so that they can watch their preferred programmes without detracting from the choice of others. People also use their own rooms as a space in which to pursue hobbies, such as photography, collecting model cars, or building a model railway. There is a wide range of information available about the home generally, and about individual service users. This addresses the issues of independence, choice, and restrictions very clearly. Routines of the home are set out. But there is flexibility within these for people to exercise choice. Where restrictions may be put in place, this is always linked to assessed needs of the service users concerned. There is a clear process for keeping these under regular review. All relevant persons are consulted about them. This includes accessing the service user’s own view, to the best possible degree. Greenway Park (13) DS0000028295.V269457.R01.S.doc Version 5.0 Page 15 Arrangements for food are well organised. There are seasonal menus, drawn up over a four week cycle. Fresh ingredients are used. The menu reflects an effort to promote a balanced diet. The choices of service users are also respected. Menus are regularly discussed with them. There are no particular dietary issues amongst the current resident group. But a list is kept of people’s known likes and dislikes. Greenway Park employs a cook, who works on weekday mornings. She prepares the main cooked meal, which is eaten at lunchtime. On the day of the inspection, this was shepherd’s pie, followed by fruit and yogurt. Service users and staff dine together. When the cook is not present, care staff prepare meals. Users may also help out, but levels of participation vary. Some people are independent with certain tasks, such as making hot drinks. Greenway Park (13) DS0000028295.V269457.R01.S.doc Version 5.0 Page 16 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Service users are supported to address their personal and health care needs effectively. Service users are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Greenway Park (13) DS0000028295.V269457.R01.S.doc Version 5.0 Page 17 At Greenway Park most service users have abilities in the area of personal care. They receive any necessary prompting from staff. Some people may need supervision, due to particular needs arising from health or behaviour, and this is made clear within individual records. The home has one female service user, and this person always has support from female staff for personal care. A range of health checks are carried out for all service users at regular intervals. Information about the various needs amongst the group forms part of their individual care plans. Issues present amongst the group include epilepsy, and impairments in sight and hearing. The care of service users is overseen by visits from a consultant specialising in learning disability. The previous postholder has recently retired, and there is to be a short interval before the replacement takes up their duties. Community nurses also give support as required. For instance, they can offer training for staff on specific issues relevant to the home’s service user group. Service users who are prescribed medication have this administered by staff. Policies and procedures set out the home’s approach. Arrangements for storage, recording and administration are appropriate. Only senior staff administer medication. They receive relevant training from the pharmacist that the home uses. Training has also been given to other carers, to promote their understanding of the topic. Some medication is prescribed to be given ‘as required’. This means that a prescribing decision has to be taken by the person administering. There are arrangements in place to support staff in doing so. Records show that this is usually an infrequent occurrence. Individual guidelines for the relevant service users set out how to judge when medication may be needed. In response to a recommendation of the previous inspection, there is also information about how to decide which dose to give, when a prescription allows for more than one possibility. Greenway Park (13) DS0000028295.V269457.R01.S.doc Version 5.0 Page 18 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Service users are safeguarded by the home’s policies and procedures for protection. Service users benefit from an effective and appropriate approach to the management of behavioural needs. EVIDENCE: Procedures relating to abuse and adult protection are in place. This includes information about the multi-agency processes within Wiltshire. Staff have received training on this topic. There is also a procedure relating to how staff may raise any concerns they have about practice. This is usually referred to as whistle blowing. It includes information about other agencies concerns might be disclosed to, if people feel the need to make use of them. Since the previous inspection an allegation about practices at the home was made to the CSCI. This concerned events said to have occurred two years previously. The allegations were investigated under the local adult protection procedures. The registered persons gave full co-operation to the process when they were made aware of the investigation. The concerns raised were not upheld. It remains the opinion of the Commission that practice at the home is appropriate to uphold the welfare and safety of service users. Greenway Park (13) DS0000028295.V269457.R01.S.doc Version 5.0 Page 19 The nature of the service user group at Greenway Park means that physical interventions may be needed on occasions. There is detailed information available about how this is practised. There are clear expectations for staff about how to manage any incidents. The approach set out for the use of physical interventions upholds all the recognised best practice principles. The various alternative strategies to be tried are also described. Staff who will be expected to practise physical interventions attend an initial five day residential course. There are then refresher courses, every two years. Generally only male staff receive this training. But the female deputy manager has also done so. Other female staff are not expected to participate in any holding or restraint. But there have been isolated occasions when they have been on the receiving end of assaults. They are provided with training in breakaway techniques, which should equip them to extricate themselves from such situations as speedily and safely as possible. Until new staff have attended such training, they may need additional support from colleagues. A recommendation from previous inspections concerns guidance on the use of physical interventions for individual service users. Although this is detailed, the Commission considered that it could usefully be developed further, to include clear definitions of the exact types of physical intervention that may or may not be used for each person. This can vary, depending on the characteristics of their behaviour, and other features, such as their build and state of physical health. Because use of physical interventions is always a potentially sensitive issue, it is best to have as much detail as possible in relevant documentation. Work has been undertaken to address this recommendation. The home has consulted with all relevant parties. Written descriptions of the techniques in use have been produced. Individual service user plans are now being updated to reflect which of the techniques may be applied to a particular person. Greenway Park (13) DS0000028295.V269457.R01.S.doc Version 5.0 Page 20 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Service users live in a comfortable, clean and safe environment, suitable to their needs. EVIDENCE: Greenway Park presents as good quality accommodation. It is clean and well maintained. Décor is comfortable and homely. Upkeep and redecoration is attended to as and when required. Service user bedrooms are situated on both floors. There are three rooms on the ground floor, and four upstairs, including one shared room. This has an en-suite bathroom. The shared bedroom has been occupied by the same two service users since the home first opened. They appear content with the arrangement. The actual layout of the room allows for it to be divided into distinct areas, giving them maximum privacy. Apart from the en-suite bathroom, there is another bathroom for general use, which is also upstairs. Downstairs, there is another separate WC. Greenway Park (13) DS0000028295.V269457.R01.S.doc Version 5.0 Page 21 Communal space is situated on the ground floor. There is a large lounge at the front of the home. Towards the rear, adjacent to the kitchen, is a dining room. This is big enough to get two dining tables in, and enables the whole household to eat together, if wished. Laundry facilities are in an outbuilding in the back garden. There are large areas of garden to both the front and back of the property. These are well maintained, and provide another attractive resource for people to make use of. A staff office and sleep-in room is situated on the first floor. The home was clean and hygienic in all areas seen at this unannounced inspection visit. Greenway Park employs a cleaner for weekday mornings. Care staff are responsible for cleaning at other times. Service users may participate to some degree, but this is fairly limited in this home. Greenway Park (13) DS0000028295.V269457.R01.S.doc Version 5.0 Page 22 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34 & 36 Service users are supported by suitable numbers of staff. Service users are put at risk by some failings in practices for the recruitment and deployment of new staff. Staff are supported and supervised effectively, enabling them to deliver a service that meets its users’ needs. Greenway Park (13) DS0000028295.V269457.R01.S.doc Version 5.0 Page 23 EVIDENCE: Staff are on duty at all times. This includes one person sleeping in overnight. They have access to on-call support, if required. However, this is rarely necessary. Daytime shifts are covered by managers, senior carers, and other care staff. A minimum of two staff are present during the day and evening. More staff are allocated to work at specific times, to support the various activities that service users undertake. So during the days there will be four or five staff working with them. These numbers are slightly lower at weekends, when there is a more relaxed approach. The home also employs a cook, and a cleaner, who work weekday mornings. Care staff carry out these tasks at other times. There are three seniors and four carers specifically allocated to Greenway Park. The staff team is mostly female. But there is a male presence amongst senior staff. The staffing situation at the home has been stable over recent months, with no changes to the team since the previous inspection. The organisation will tend to employ suitable applicants, even if this means going slightly over usual staff establishment levels for a time. People may then be deployed wherever their abilities are felt to be of most use. So staff may be based in one home for a time, but then go on to work in another. This means that some people can be available as relief cover, who already have a knowledge of the service and its users. Employees who are new to the organisation often begin at Greenway Park. If they are then felt suitable, they may move on to one of the other establishments that the group operates. There have also been examples of carers from those other homes returning to Greenway Park when successfully being promoted to a more senior level. The team structure includes managers, deputy and assistant managers, senior carers, and carers. The arrangements promote effective teamwork. Senior staff take on areas of additional responsibility. These include involvement with medication; service users’ money; administration and paperwork; and leading of shifts in the absence of other managers. Records were checked for two staff members appointed during 2005. Most of the required information is in place to demonstrate that appropriate recruitment and selection practices are observed. But there were a couple of points arising. Greenway Park (13) DS0000028295.V269457.R01.S.doc Version 5.0 Page 24 One employee had begun working at the home after receiving satisfactory clearance from a POVA First check, which establishes that the person’s name does not appear on the national list of those deemed unsuitable to work with vulnerable adults. The person had not yet received their full criminal record disclosure. Care homes regulations permit an employee to work in such circumstances, but there are strict criteria laid down for this. The home was not recognising these in its deployment of the individual concerned. It was agreed at the inspection that a risk assessment would be completed to support the appropriate use of this worker, and the protection of service users. This document was produced to the Commission immediately after the inspection. The delay in receipt of the criminal record check had been overlooked. Although the home has a system for checking progress on the various stages of recruitment, it had not picked up this particular issue. Another employee had been recruited although one of the references taken up indicated some apparent concerns. These issues had been discussed with the individual, and the decision was taken to proceed with the appointment. This was now felt to have been justified by the person’s satisfactory performance in post. But no record had been placed on the employee’s file about the context of the recruitment decision, or the arrangements for monitoring their progress. All staff have individual supervision meetings with a senior colleague. These sessions are recorded. Records are also kept of any other input to staff, such as issues of conduct and discipline. Greenway Park (13) DS0000028295.V269457.R01.S.doc Version 5.0 Page 25 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 42 Service users benefit from a well run home, with clear leadership and involvement from senior figures. Service users’ health and safety are protected by the systems in place. EVIDENCE: The organisation’s registered managers are Mr Greg Tennant, and Mr Phil Taylor. They were originally registered under previous care homes legislation. They have operated and managed services since establishing their company in 1988. Both continue to work in their homes. So they have regular direct contact with service users and staff. Mr Tennant and Mr Taylor are supported by a deputy manager, Mrs Carol Pearson; and an assistant manager, Mr Simon Willis. Greenway Park (13) DS0000028295.V269457.R01.S.doc Version 5.0 Page 26 The service benefits from a strong presence of managers and senior carers at all times. There are usually two people from within these groups present during the days. On-call arrangements also ensure that a senior person can attend quickly, if the need arises. Mr Tennant, Mr Taylor and Mrs Pearson have all completed the new Registered Managers Award (RMA) qualification. Mr Taylor has also achieved the National Vocational Qualification (NVQ) Level 4 award in care. Mr Willis has also obtained the NVQ 4, and will shortly be starting the RMA. Mrs Pearson is working towards the NVQ 4. Risk assessments clearly address any health and safety concerns. This is done for general topics, and for individual service user issues. The measures put in place to minimise risks are set out. The home’s fire log book shows that all required checks, practices and instruction relating to fire safety at the prescribed frequencies. A fire risk assessment is also in place, along with evacuation procedures. Greenway Park (13) DS0000028295.V269457.R01.S.doc Version 5.0 Page 27 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X N/A 3 N/A X Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 4 14 4 15 4 16 3 17 Standard No 31 32 33 34 35 36 Score X X 3 2 X 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Greenway Park (13) Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 4 X X X X 3 X DS0000028295.V269457.R01.S.doc Version 5.0 Page 28 N/A Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA34 Regulation 12-1 194,9,10,11 Requirement There must be documented evidence to support the appropriate deployment of any staff still awaiting full CRB clearance. COMMENT: This requirement was addressed immediately after the inspection. Timescale for action 10/01/06 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 2 Refer to Standard YA9 YA23 Good Practice Recommendations Risk assessments should show who has been involved in their production, and the date when they are due for review. Guidance on the possible application of physical interventions to individual service users should be developed, to include more detail about the techniques that are appropriate with each person. COMMENT: Work is ongoing to address this recommendation.
Greenway Park (13) DS0000028295.V269457.R01.S.doc Version 5.0 Page 29 3 4 YA34 YA34 The recruitment process checklist should be reviewed, to minimise the risk that uncompleted checks are overlooked. Staff files should include documented reasons for selection decisions if particular factors have had to be considered. Greenway Park (13) DS0000028295.V269457.R01.S.doc Version 5.0 Page 30 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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