Inspection on 13/08/07 for 5 Greenbrook Court

This inspection was carried out on 13th August 2007.

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 found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

5 Greenbrook Court 10/02/06

5 Greenbrook Court 07/06/05

5 Greenbrook Court 21/12/04

5 Greenbrook Court 28/04/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 5 Greenbrook Court St Michaels Road Newcastle Staffordshire ST5 9QB Lead Inspector Peter Dawson Key Unannounced Inspection 13th August 2007 09:00 5 Greenbrook Court DS0000004947.V344183.R01.S.doc Version 5.2 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 5 Greenbrook Court DS0000004947.V344183.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 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. 5 Greenbrook Court DS0000004947.V344183.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 5 Greenbrook Court Address St Michaels Road Newcastle Staffordshire ST5 9QB 01782 628190 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) Choices Housing Association Limited Mrs Tracey Flanagan Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6), Physical disability (6), of places Physical disability over 65 years of age (6) 5 Greenbrook Court DS0000004947.V344183.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Minimum age on admission for PD and LD - 55 years Date of last inspection 29th September 2006 Brief Description of the Service: Greenbrook Court is a care home registered for six older people over 55 years of age with a learning and physical disability. The accommodation is owned by The Beth Johnson Housing Association, and the registered provider is Choices Housing Association. The property is located on the outskirts of Newcastleunder-Lyme and is within easy reach of a range of local community facilities. The property is a conversion of three bungalows into the one building, surrounded by a few other linked bungalows in a small cul-de-sac that has been developed to meet the needs of older people. It comprises six bedrooms a large lounge/dining room, a small domestic kitchen, and an assisted bathroom with toilet, a shower room and an additional separate toilet. In addition there is a small laundry room and a separate office. The lounge has patio doors fitted that lead out on to a patio with an enclosed lawn. There are communal gardens and shared parking facilities at the front courtyard. The home has shared access to appropriate transport to take wheelchairs that is available on a pre-booked basis. The weekly fees for this service are £821 5 Greenbrook Court DS0000004947.V344183.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out by one inspector on one day from 8.45 am – 4.45 p.m. The National Minimum Standards for Younger Adults were used to assess the standards of the home. The Manager was present during the inspection and had provided a comprehensive Annual Quality Assurance Assessment (AQAA) prior to the inspection. Information contained in the AQAA provides a basis for some information in this report. There was an inspection of the total environment, including all bedrooms. All 6 residents were seen and 2 verbally able to express a view about the home, gave very positive feedback about their care and staff support. The care of the other residents was assessed from observations, discussions with staff and inspection of records. Residents seemed happy and comfortable in their environment and positive relationships were evident between residents and staff. There were discussions with the 3 members of staff on duty during the inspection as well as the Manager. It was not possible to obtain written feedback from relatives prior to the inspection due to a short timescale. Some written feedback to the home from relatives supported the positive comments of residents and observations during the inspection. What the service does well: The presentation of the home is good, it is bright, clean, comfortable and homely. The building and contents are well maintained. Bedrooms are all for single use and very well personalised. Access to all areas is good. The atmosphere is homely and relaxed, staff engage very positively and sensitively with residents. There is good, well-documented care planning information including a summary 24 hour plan of care, detailed information in person centred care plans with clear goals. Risk assessments are comprehensive and balanced to promote independence where possible. There are good records identifying health care needs in the Health Action and Assessment plans and the actions taken to meet those needs contained in the Health Care records for each resident. 5 Greenbrook Court DS0000004947.V344183.R01.S.doc Version 5.2 Page 6 Residents are involved in domestic routines as a means of involvement and ownership and the promotion of social skills. What has improved since the last inspection? What they could do better: 5 Greenbrook Court DS0000004947.V344183.R01.S.doc Version 5.2 Page 7 Three members of staff should be on duty during the day to ensure regular community contact for all residents. Some goals remain unmet because of shortfalls in this area. Monitor residents daily diaries to ensure that there are regular external visits for all residents. PRN (as required) medication identified and unused for sometime, should be reviewed with the GP and written protocols obtained from the prescriber where needed. Ensure that all staff have read and understood risk assessments and there is evidence to confirm this. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 5 Greenbrook Court DS0000004947.V344183.R01.S.doc Version 5.2 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 5 Greenbrook Court DS0000004947.V344183.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good Written information needed to make a judgement about the home is currently being updated and in different formats. Pre-admission procedures including assessments and visits to the home are in place and good. All have written contracts. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose and Service Users Guide are presently being updated. The work on the Statement of Purpose is almost completed the Guide will be updated also. Copies will be available for prospective residents and copy sent to CSCI. Both will be in pictorial and audio formats to inform prospective residents of the services offered by the home. Two people admitted to the home over the past months were seen and their records inspected. Both had been subject to assessments by the home staff prior to admission and there were Care Management assessments provided. One admission had been an emergency admission from hospital but appropriate discussion/information exchanged with the previous Choices home prior to the admission, there was no time for this person to visit Greenbrook Court prior to admission but two reviews had been carried out post admission 5 Greenbrook Court DS0000004947.V344183.R01.S.doc Version 5.2 Page 10 by the Social Worker. The other person had made 2 visits to the home with staff from previous placement, then visited on her own prior to an overnight stay. The latter is the preferred option of the home. Permanence is confirmed 6 months following placement. One of the two people able to express a view said that he had been helped to settle well into the home with support from all staff members. He was well supported by his family and pleased to received written confirmation from the Local Authority of the permanent placement on the day of this inspection. 5 Greenbrook Court DS0000004947.V344183.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Good person centred plans and active involvement of residents in greater decision making and participation in daily life. Risk assessments are not restrictive with the object of maximising independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each resident has a person centred plan which is reviewed regularly. All have allocated personal carers to aid implementation of personal goals and priorities. Person-centred planning is implemented with inputs from residents providing the basis for care and achievable goals. Plans seen covered aspects of personal, social and healthcare needs. All are involved in 6 monthly reviews and the Manager is re-structuring the reviews to include and involve those residents unable to understand the discussions and procedures to make a more positive contribution to the review process. The Manager has completed a 4 5 Greenbrook Court DS0000004947.V344183.R01.S.doc Version 5.2 Page 12 day person-centred teams training course and keen to extend the involvement of all residents in aspects of decision making. There is a 24 hour support plan, which includes a summary of needs giving a summary of actions required to meet person care needs. There are also risk assessments and this information is readily available to inform permanent staff or new or relief staff a concise and adequate summary of actions needed to meet personal needs. Risk assessment are in place relating to all aspects of daily living with defined balances of risk strategies with outcomes that will promote greater independence for people. Risk assessments are reviewed regularly as part of care planning and all staff should sign to confirm they have read and understood the risk assessments, all are required to re-read those assessments every 6 months where no changes have been made. There were some gaps in signatures of staff for the risk assessments and the Manager intends to re-enforce the need for staff to have read and understand risk assessments for all residents. Residents are encouraged to express choices and decisions as part of everyday life and aredefined in detail in care plans. Regular residents meetings are held to promote discussion about aspects of daily life in the home some were seen to be making positive choices about the mi-day meal. There are some communication difficulties – 3 residents able to express their views verbally, 2 have limited verbal skills and 1 has none. Staff indicated the various ways in which they were able to ascertain the wishes and choices of residents in nonverbal ways, coupled with most staff having detailed knowledge and experience of the group over a period of years. 5 Greenbrook Court DS0000004947.V344183.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. Opportunities for personal development are evident in the home. Progress has been made in involving residents in community activity but this is still limited by staffing levels. Personal, family and sexual relationships are promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A requirement was made in the last report to ensure residents had greater and regular access to community facilities. This is limited by inadequate staffing numbers at relevant times to support the promotion of those activities. Some progress has been made in this area. All residents now have personal diaries completed on a daily basis recording daily activities. In some instances there has been increased external activity but there are limitations due to the 5 Greenbrook Court DS0000004947.V344183.R01.S.doc Version 5.2 Page 14 fact that at some periods during the day there are 2 not 3 staff on duty. In simple terms this means that if someone is taken to the local shops for instance, this can only be done if there are 3 people on duty. More ambitious outings are inevitably limited. In one persons plan social objectives commendable in line with his interests and wishes were to Visit Hanley Bus Station, Manchester Airport, see comedy show at the Theatre and Hanley venue for musical show. The chances of achieving these recent goals seemed limited: The daily diary of the person showed that he had not been outside the home in the previous 2 weeks. A more consistent staffing level throughout the day would allow individual goals to be achieved. Contacts with family and friends are considered a vital part of care, it was evident from information seen and discussions with residents that these contacts are promoted wherever possible. Two residents also have friends in other homes that they visit and receive at Greenbrook Court, one regularly visits (weekly) his “girlfriend” living in another home 6 miles away. All residents now have annual holidays. Two had returned from a weekend in Blackpool just prior to the inspection and eager to share the detail of their enjoyable visit, ultimately saying they were returning for the illuminations in October. Breaks are financed by Choices and available to all individually or if preferred with another resident. Activities in the home are encouraged. Staff were seen to engage with residents in a positive way promoting discussion with those able to verbally and to communicate and provide a practical focus as a means of communication and achievement with those unable to do so. All are encouraged to engage in practical domestic tasks and skills where possible. Staff clean bedrooms but in the presence of and encouraging residents as part of the process. One person is able to make own drinks in the kitchen area and uses the Hoover from his wheelchair. A resident with severely restricted mobility peels the potatoes with the necessary bowls etc on her knee in her reclining chair. It was interesting to see at lunch time when residents had made a decision to have sandwiches they all buttered bread with prompts or encouraged “hand over hand” with staff to do the same. All made a contribution to preparing the meal. Residents in this home have quite diverse needs in their chosen lifestyles: 2 are under 60 years of age, one is 63 and three are over 80 years (one is in fact 85 years). Routines, services and facilities have to be flexible to cater for those needs. 5 Greenbrook Court DS0000004947.V344183.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Personal support needs are well documented with clear instructions to staff. The physical, healthcare and emotional needs of residents are met. Medication administration is generally good, although protocols must be obtained from the prescribers of PRN medication. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care planning information contain very detailed information about the support and personal care needs of residents. The 24 hour plan of care outlines the steps to be taken by staff to support the person throughout the 24 hour period. More details are contained in the Person Centred Plans. Staff spoken with had a clear understanding of the inputs required to ensure preferred routines and lifestyles are promoted. There were clear and detailed instructions concerning the health care needs of residents this was evidenced from the 4 care plans seen. A resident admitted 5 Greenbrook Court DS0000004947.V344183.R01.S.doc Version 5.2 Page 16 recently following a stroke and hospitalisation was unable to mobilise upon admission but was now walking with staff oversight. Physiotherapists had visited regularly and spent time with him by appointment during this inspection. Two residents with risk of choking/aspiration had been assessed by the Speech & Language Specialist Nurse and Easi-chew diets put into place. There were clear instructions to staff about supervised eating and the controls necessary to avoid risks. A person with severe cellulites/oedema has been assessed and monitored by the Nursing Service - staff providing support with compression bandages, diuretic medication and GP involvement. A reclining chair is provided to relieve pressure. A resident sleeping for long periods during the day was referred to and being monitored closely by the Consultant with a switch of medication. Staff were monitoring very closely the changes and ensuring the balance between medication and quality of life. Two people have been identified as having dementia care needs – training for all staff has taken place in the home by a Nurse Specialist. The health care needs were well documented in Health Action & Assessment Profiles and Health Care Records. All had annual health reviews with the GP practice. There were 6 requirements made regarding medication at the last inspection, the majority related to the provision of rectal diazepam. This has been reviewed with the GP, not given for a long period of time and now been removed from use on the advice of the GP. Five requirements have been actioned one has not, which is to agree protocols for PRN (as required) medication with the GP. It was found that amitriptyline and diazepam were prescribed PRN but there were no protocols in place. The prescribers instructions must be agreed and documented for this medication. All staff have had training in medication administration in-house since the last inspection. There are assessments for competency. One person part-self-medicates at this time as a means of maximising independence. Examination of the medication system, supplied by Boots Chemists in MDS form (blister packs) was inspected. There were minimal stocks of medication, all records had been signed by staff when medication administered and medication returned to the pharmacy was signed by staff and countersigned by the pharmacy. 5 Greenbrook Court DS0000004947.V344183.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. There are good and adequate systems in place for dealing with complaints and all staff had updated training in adult protection. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a formal complaints procedure on display in the home, all relatives have a copy. There is a pictorial and audio version of the procedure available to residents. Two minor complaints from a neighbour had been dealt with sensitively and appropriately. It had been made clear to the neighbour that the complaints were taken seriously and the home prepared to take whatever action they could to resolve the issues raised. They related to noise levels and rubbish disposal. A recommendation was made in the last report to provide training for staff in Safeguarding Adults (Adult Protection). Most staff did received training in 2004/5 but all have, or have planned, updated training in this area. There have been no Safeguarding referrals relating to the home over the past year. 5 Greenbrook Court DS0000004947.V344183.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. A homely, comfortable, well-maintained and safe environment. Bedrooms meet chosen lifestyles and advice sought from external professionals in provision of specialist equipment. Both bedrooms and communal areas are to a high standard, well maintained, comfortable and safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is a single storey building on a small housing complex for older people and is not identifiable as a home. The building is well maintained with ongoing maintenance needs identified and swiftly actioned. The building is owned by a Housing Association and the providers are presently negotiating to purchase the property to allow them total flexibility in providing improvements/additions to the property. 5 Greenbrook Court DS0000004947.V344183.R01.S.doc Version 5.2 Page 19 All bedrooms are for single use. There is registration to provide care for up to 6 people, although for sometime only 5 have been in residence. This has changed since the last inspection with a sixth person admitted. The room was used previously as a sensory room, and although this has been lost the equipment is still used in the bedrooms of many residents. The room has been redecorated and refitted the new resident admitted as an emergency some 3 months ago he said that he was quite happy with his bedroom and had extensively personalised it. There is ongoing redecoration of the building and all areas, both communal and individual bedrooms were seen and were well presented with good décor, furnishings and equipment. Bedrooms are well personalised reflecting the individuality of the person and the environment is bright, pleasant, comfortable and replicates a domestic environment. A specialist chair provided for a resident was identified in a poor state of repair in the last inspection, but this has been re-upholstered (difficult to replace) and quite satisfactory. There are aids and adaptations throughout the home to assist with the physical disabilities of residents. Handrails are in corridor areas, a new grab-rail fitted next to bed in residents bedroom recommended by the Occupational Therapist, new assisted bath hoist provided. A new hoist provided on advice also. Although this is used little at this time and because of its size and lack of storage space it has to be stored in a bedroom. A resident at risk of noctural seizures has been provided with a sensor in her bedroom to identify irregular movements. The need was identified by the home and recommended by a clinical nurse specialist. The walk-in shower area has been totally refitted and provides a pleasing and excellent facility and an alternative to the use of the assisted bath. Residents are benefiting from this improvement. There is a small rear grassed garden area, part of which is private and used in the summer. Access to the garden is reasonable but there are plans to improve the this access for wheelchairs etc. The standards of hygience throughout the home were high. Staff understood the need for good infection control practice and protective equipment seen readily available strategically in the home. 5 Greenbrook Court DS0000004947.V344183.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. There is a well-trained, competent, committed staff group with training needs met in full. Recruitment procedures are robust and comply with regulation. The numbers of staff during the day are not adequate to meet the total needs of the resident group and must be reviewed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Previous requirements have been made to ensure that staffing records are kept in the home as required by regulation – on the last inspection it was not possible to assess these outcomes for that reason. Arrangements have now been made for these records to be kept securely in the home and they were inspected. Samples of staff files showed all 5 Greenbrook Court DS0000004947.V344183.R01.S.doc Version 5.2 Page 21 requirements of Schedule 2 in relation to documentation was provided for all. CRB checks were available and obtained prior to employment. Recruitment is arranged centrally by the Choices Organisation who arrange panel first interviews. Subsequent (second) interviews/assessments are carried out in individual homes to assess the qualities, competencies and suitability of potential recruits in working with residents. There is an established static staff group in this home, there have been no changes to staff in the past year. This provides needed continuity of care for residents. NVQ 2 is mandatory for all new staff, five have trained to NVQ3 level. There is a comprehensive 6 month induction programme for new stall to LDAF (Learning Disability Award Framework) standards. There is a regular staff supervision and appraisal system – all staff have 3 monthly reviews and a personal development plan. Ten full-time equivalent staff are employed. The number of weekly care staffing hours are reported to be 370, this figure is questionable – it allows for 3 staff continuously throughout the waking day and one at night – in practice there are not 3 staff on duty throughout the day. – 7.30 – 9.30 x 2 staff 9.30 – 3 or 5pm x 3 staff. 5 – 10 pm x 2 staff. Staffing hours of 370 per week include staff holidays and training so is therefore not an accurate figure. Some concerns were expressed in the last report about the lack of opportunity for residents to access community facilities and although this has improved there are still limitations – it is not possible to provide external activities for any resident with only 2 staff on duty. Particularly, there are only 2 staff on duty from 5 – 10 pm, eliminating evening external activities, although it has to be said that a new resident attending an evening theatre group was escorted by additionally recruited member of staff. There is also now an additional 6th resident and some additional funding is presently being sought for care/support hours for that person. It may be difficult to support that request in light of the gaps in the daytime rota. Several residents have quite high physical dependency needs - to meet the total personal, health, social and recreational needs of residents three members of staff are required throughout the working day. At night there is only 1 member of staff on duty, who is supported by an oncall learning disability nurse based elsewhere. The Manger feels that this is adequate and safe. 5 Greenbrook Court DS0000004947.V344183.R01.S.doc Version 5.2 Page 22 Staff training is good and in addition to NVQ training - statutory training in Emergency First Aid, Food Hygiene, Fire Safety, Personal safety, Moving & Handling has been provided for all. Additional professional training has been provided since the last inspection in dementia care and safeguarding. The home provides Keele University nursing students with effective placements and this is often a recruitment area for new staff. 5 Greenbrook Court DS0000004947.V344183.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good The home is well managed and run in the interests of residents. The Providers support the home with ongoing reviews, management support and robust procedures. The Manager is well qualified and experienced and takes a positive lead. Good record keeping, policies and procedures ensure the best interests of residents. Health & Safety policy and practice protect residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 5 Greenbrook Court DS0000004947.V344183.R01.S.doc Version 5.2 Page 24 The Registered Manager is a qualified nurse, has been a Registered Manager for 10 years and has completed the required Registered Managers Award. She is recognised as a competent and fit person to run the home by CSCI. The Manager continues to update her knowledge and skills by attendance at courses and involvement in project groups within the Choices Organisation. She has an open style of management with observed good dialogue with both residents and staff and there is a relaxed and warm atmosphere in the home. She works full-time on the staffing rota. The Manager is supported by a Principal Officer from Choices who carries out regular monthly unannounced visits to the home and provides the Manager and CSCI with reports of the visit. Regular meetings take place with the other home managers in the organisation and attendance at Senior Management meetings are cascaded to all staff positively communicating the changes and practice of the organisation. Regular staff meetings are held with pro-active involvement of staff (minutes seen). A requirement of the last report to review and update the fire risk assessment has been carried out in conjunction with the Fire Officer. Personal evacuation plans have been established for all residents to ensure their evacuation and safety in the event of an emergency. No accident notifications have been provided to CSCI over the past year. It was confirmed in discussions and documentation seen that there have been no accidents in the home during that period. Other notifications required under Regulation 37 have been received as required. 5 Greenbrook Court DS0000004947.V344183.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 Standard No Score 1 x 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 2 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 3 X 3 3 3 3 5 Greenbrook Court DS0000004947.V344183.R01.S.doc Version 5.2 Page 26 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 YA20 Regulation 13(2) Requirement PRN medication must be reviewed with the GP & written protocols obtained from the prescriber where needed. Staffing numbers must be sufficient to meet the health and social care needs of residents. Timescale for action 14/09/07 2 YA33 18(1)(a) 14/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000004947.V344183.R01.S.doc Version 5.2 Page 27 5 Greenbrook Court 1 2 YA1 YA13 Continue the process of updating the Statement of Purpose & Service Users Guide. Continue to promote external activities as defined in assessed needs and individual plans. 5 Greenbrook Court DS0000004947.V344183.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Local Office 1st Floor, Ladywood House 45-56 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 5 Greenbrook Court DS0000004947.V344183.R01.S.doc Version 5.2 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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