Inspection on 30/06/05 for 13 Greenway Park

This inspection was carried out on 30th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

13 Greenway Park 13/06/07

13 Greenway Park 10/01/06

13 Greenway Park 04/02/05

13 Greenway Park 30/09/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Greenway Park (13) 13 Greenway Park Chippenham Wiltshire SN15 1QG Lead Inspector Tim Goadby Unannounced 30th June 2005 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 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 Stationary 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) D51_D01_S28295_GREENWAYPK_197126_300605Stage4.doc Version 1.30 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 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 Mr Philip Taylor Care Home 8 Category(ies) of LD Learning Disability (8) registration, with number of places Greenway Park (13) D51_D01_S28295_GREENWAYPK_197126_300605Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th February 2005 Brief Description of the Service: 13 Greenway Park provides care and accommodation for 8 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 10 years. Respite care and short-term placements are not available. The service is one of a group of 3 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 organisation’s 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 2 floors. There are 6 single bedrooms. One room is shared by 2 service users. Greenway Park (13) D51_D01_S28295_GREENWAYPK_197126_300605Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in June 2005. A total of 6.25 hours was spent in the home. The following inspection methods have been used in the production of this report: indirect observation; sampling of records, including case tracking; sampling a meal; discussions with service users, staff and management; tour of the premises. What the service does well: What has improved since the last inspection? The service has consistently performed well over recent inspections, and there were very few areas for improvement identified at the February 2005 visit. One recommendation of that inspection has been addressed. The organisation’s quality assurance system has now resulted in the production of an annual development plan. This sets out various relevant targets for action, including some specific to Greenway Park. Greenway Park (13) D51_D01_S28295_GREENWAYPK_197126_300605Stage4.doc Version 1.30 Page 6 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 contacting your local CSCI office. Greenway Park (13) D51_D01_S28295_GREENWAYPK_197126_300605Stage4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection Greenway Park (13) D51_D01_S28295_GREENWAYPK_197126_300605Stage4.doc Version 1.30 Page 8 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 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 to the home. Most of the service user group have lived at Greenway Park since the home opened. One person transferred from another of the organisation’s homes around 2 years ago. The home appears to meet the needs of its residents well. There is a good level of support provided by the organisation’s own team. Specialist support has also been available to individuals, when required. For instance, there has been input 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) D51_D01_S28295_GREENWAYPK_197126_300605Stage4.doc Version 1.30 Page 9 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 standard(s) 6, 7 & 8 Service users have their needs reflected in their individual plans. Service users can make decisions and choices about their daily lives, and the conduct of the home. EVIDENCE: The home has devised its own care plan format, covering all relevant areas. Examples viewed during the inspection showed that these are being maintained to a good standard. They include information about people’s needs, the factors influencing these, and the support to be given by staff. There is regular review of needs. Reviews also take place in response to specific events, if required. Within the home, senior staff have lead responsibility for producing and updating plans. But all staff contribute to the process. Care plans also show to what extent service users and others have been involved in their development. Greenway Park (13) D51_D01_S28295_GREENWAYPK_197126_300605Stage4.doc Version 1.30 Page 10 There is clear information about any factors that may limit someone’s rights. Restrictions in place are linked to an individual’s assessed needs. The consent of the service user is recorded, where appropriate. Service users are able to make decisions and choices in their daily lives. Individuals can select from the range of activities offered. Personal preferences and interests are reflected in how people’s bedrooms have been furnished and decorated. Service users vary in their capacity to participate in the day to day running of the home. Review meetings provide the opportunity for individuals to express their views on a regular basis. Service users also meet together informally, at mealtimes, and as part of discussion groups. These are used as times to talk about matters of common interest, and to plan future activities. Information of interest to service users is displayed in the home’s dining room. This includes a weekly activities board, displays of project work, and a variety of notices. Greenway Park (13) D51_D01_S28295_GREENWAYPK_197126_300605Stage4.doc Version 1.30 Page 11 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 standard(s) 11, 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. EVIDENCE: Greenway Park (13) D51_D01_S28295_GREENWAYPK_197126_300605Stage4.doc Version 1.30 Page 12 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. 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. 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. But social events will also be provided in the evenings. Rotas are drawn up accordingly, to enable these. 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 2 or 3 service users, supported by 1 or 2 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. Some service users attend college courses, or local educational and occupational facilities for people with learning disability. Sessions undertaken include art and crafts, independent living, literacy, and yoga. 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. Greenway Park (13) D51_D01_S28295_GREENWAYPK_197126_300605Stage4.doc Version 1.30 Page 13 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 has 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. 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 affected service users. 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. Arrangements for food are well organised. There are seasonal menus, drawn up over a 4 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. 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) D51_D01_S28295_GREENWAYPK_197126_300605Stage4.doc Version 1.30 Page 14 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 standard(s) 20 Service users are protected by the home’s policies and procedures for dealing with medicines. Service users who are prescribed ‘as required’ medication would benefit from the home defining more precisely how this is used. EVIDENCE: One service user is supported to be self-medicating. This is underpinned by relevant risk assessments. All other service users who are prescribed medication have this administered by staff. Policies and procedures set out the home’s approach. Storage, recording and administration were seen to be 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 may be 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 showed that this is usually an infrequent occurrence. But there had been some recent use of such Greenway Park (13) D51_D01_S28295_GREENWAYPK_197126_300605Stage4.doc Version 1.30 Page 15 interventions. Individual guidelines for the relevant service users set out how to judge when medication may be needed. But there was no information about how to decide which dose to give, when the prescription allowed for more than one possibility. Greenway Park (13) D51_D01_S28295_GREENWAYPK_197126_300605Stage4.doc Version 1.30 Page 16 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 standard(s) 22 & 23 Service users are safeguarded by the home’s policies and procedures for complaints and protection. Service users would benefit from further clarity about how the home may apply physical interventions. EVIDENCE: The home’s complaints procedure is included as an insert in the Service User Guide. The procedure includes information about people who can be contacted if an individual is not happy about something. Service users have been given a copy of the procedure to keep in their own rooms. Information has also been provided for families on how to raise concerns. The organisation was in the process of reviewing the complaints procedure, to produce a more user friendly version. This would include greater use of photos and symbols, to promote understanding as much as possible. 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 the external disclosure routes that are available, if people felt the need to make use of them. Greenway Park (13) D51_D01_S28295_GREENWAYPK_197126_300605Stage4.doc Version 1.30 Page 17 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. Staff who will be expected to practise physical interventions attend an initial 5 day residential course. There are then refresher courses, every 2 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. So 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. The organisation was still trying to establish whether the training provider it uses for this topic is to be given accreditation, under the national best practice guidance that has been produced for physical interventions. This will ensure that the philosophy and techniques taught are in keeping with Department of Health expectations. A recommendation from previous inspections concerned guidance on the use of physical interventions for individual service users. Although this is detailed, the inspector considered that it could usefully be developed further. It should 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 is being undertaken to address this recommendation. The home has been consulting with all relevant parties. Written descriptions of some techniques in use have been obtained. But they are quite lengthy, and therefore impractical to include in individual guidelines. It was discussed during the inspection that it may be sensible to have descriptions of any approved techniques in general procedures. Individual service user plans can then be cross referenced to these, depending which of the techniques may be applied to a particular person. Greenway Park (13) D51_D01_S28295_GREENWAYPK_197126_300605Stage4.doc Version 1.30 Page 18 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 standard(s) 24, 25, 26, 27, 28 & 30 Service users live in a comfortable, clean and safe environment. 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 3 rooms on the ground floor, and 4 upstairs, including a shared room. This has an en-suite bathroom. The shared bedroom has been occupied by the same 2 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. All service users’ bedrooms were seen during this inspection. All were homely and comfortable, and reflected the personality of their occupants. Greenway Park (13) D51_D01_S28295_GREENWAYPK_197126_300605Stage4.doc Version 1.30 Page 19 Apart from the en-suite bathroom, there is another bathroom for general use, which is also upstairs. Downstairs, there is another separate WC. 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 2 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. During good weather, such as on the day of this inspection, the household may dine outside on the patio area. 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 was reported to be fairly limited in this home. Greenway Park (13) D51_D01_S28295_GREENWAYPK_197126_300605Stage4.doc Version 1.30 Page 20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33 & 35 Service users are supported by suitable numbers of appropriately trained staff. EVIDENCE: Greenway Park (13) D51_D01_S28295_GREENWAYPK_197126_300605Stage4.doc Version 1.30 Page 21 Staff are on duty at all times. This includes 1 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 2 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 4 or 5 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 3 seniors and 5 carers specifically allocated to Greenway Park. The staff team is mostly female. But there is a male presence amongst senior staff. 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 appear to 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. Staff who met with the inspection team were able to describe their roles and responsibilities clearly. All 3 senior carers have achieved NVQ Level 2 awards in care, and 1 was now due to start Level 3. Other carers in the home were all fairly new appointments. At least 1, and possibly 2, were to start NVQ Level 2 in September 2005. Staff training is provided on a range of relevant topics. This includes induction in line with the national framework for learning disability services. The organisation was in the process of reviewing its arrangements for this. Greenway Park (13) D51_D01_S28295_GREENWAYPK_197126_300605Stage4.doc Version 1.30 Page 22 As well as the mandatory elements that are covered, the training programme includes elements based on the needs of the service user group. Greenway Park (13) D51_D01_S28295_GREENWAYPK_197126_300605Stage4.doc Version 1.30 Page 23 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 41 & 42 Service users benefit from a well run home, with clear leadership and involvement from senior figures. Quality assurance measures underpin service developments, and include actions based on the view of service users. Effective record keeping is maintained, upholding service users’ best interests. Service users’ health and safety is protected. EVIDENCE: Greenway Park (13) D51_D01_S28295_GREENWAYPK_197126_300605Stage4.doc Version 1.30 Page 24 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. The service benefits from a strong presence of senior managers and carers at all times. There are usually 2 of this group present during the days. On-call arrangements also ensure that a senior person can attend quickly, if the need arises. Both Mr Tennant and Mr Taylor have completed the new Registered Managers Award (RMA) qualification. Mrs Pearson has now also done so, and will go on to study for the NVQ Level 4 award in care. Mr Willis is also working towards the NVQ 4. Greenway Park is successful in promoting an open and inclusive atmosphere. The frequent presence of the registered persons in the service ensures their accessibility to all key parties. Service users were observed to have positive relationships with all staff, including the most senior figures. Staff confirmed that they feel valued and involved. They are able to approach senior colleagues whenever there is anything they wish to discuss. The organisation has a quality assurance process in place. A statement sets out information about the principles, and the system used. The owner/managers take the chief lead on overseeing this area, as they have the closest responsibility for the conduct of the home. The rest of the management team are also involved in reviews, which take place about every 6 months. Service delivery is audited in a number of ways. This includes accessing the views of service users, families, and other key people. It is important to ensure that the system includes a range of differing sources of evidence. Action will be taken on any issues identified. An annual development plan had been produced for the organisation. This included some issues specific to Greenway Park. A range of statutorily required records are maintained. The sample viewed at this unannounced inspection were being kept satisfactorily. Staff receive training in various health and safety topics. Checks and maintenance are carried out at appropriate intervals. Greenway Park (13) D51_D01_S28295_GREENWAYPK_197126_300605Stage4.doc Version 1.30 Page 25 The fire log book was viewed, and showed that almost all necessary tests, instruction and practices were recorded as being carried out, and up to date. Emergency light tests were not shown as having been conducted in March or May 2005. After subsequent enquiries, it appeared that they had taken place. But the record did not clearly reflect this. Greenway Park (13) D51_D01_S28295_GREENWAYPK_197126_300605Stage4.doc Version 1.30 Page 26 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 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Greenway Park (13) Score x x 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 x 3 3 x D51_D01_S28295_GREENWAYPK_197126_300605Stage4.doc Version 1.30 Page 27 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 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 YA20 Good Practice Recommendations Guidance about the use of as required medication for service users should include information about how to decide which dosage is given, if the prescription allows for some variation. 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. The home has been engaged in further consultation with its training provider. Care should be taken to ensure that all prescribed fire safety checks are carried out and clearly recorded at the set intervals. 2. YA23 3. YA42 Greenway Park (13) D51_D01_S28295_GREENWAYPK_197126_300605Stage4.doc Version 1.30 Page 28 Commission for Social Care Inspection Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Greenway Park (13) D51_D01_S28295_GREENWAYPK_197126_300605Stage4.doc Version 1.30 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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