CARE HOMES FOR OLDER PEOPLE
Greasbrough Residential / Nursing Home Potters Hill Greasbrough Rotherham South Yorkshire S61 4NU Lead Inspector
Ms Rosemary Reid Unannounced Inspection 11:00 6 February 2006
th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Greasbrough Residential / Nursing Home DS0000003078.V266372.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Greasbrough Residential / Nursing Home DS0000003078.V266372.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Greasbrough Residential / Nursing Home Address Potters Hill Greasbrough Rotherham South Yorkshire S61 4NU 01709 554644 01709 559332 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) Dr M. H. Husain Mrs. J. M. Husain Susan Briggs Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (60), Physical disability (60) of places Greasbrough Residential / Nursing Home DS0000003078.V266372.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. To admit up to three service users between the age of 60 to 65 years in the category for Old Age which the home is registered 2nd August 2005 Date of last inspection Brief Description of the Service: Greasbrough Nursing and Residential Home provides both nursing and residential care for up to sixty older people. The home occupies a site on the main road in the centre of Greasbrough on the outskirts of Rotherham. Dr. M H Hussain, OBE and Mrs. J M Hussain own the home. All rooms are single occupancy with ensuite facilities. The building is on two levels and there are lifts to the first floor. There are bedrooms and communal areas on both levels. There is a pleasant courtyard within the centre of the building and other garden areas. There is a car park to the rear of the home. Greasbrough Residential / Nursing Home DS0000003078.V266372.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 from 11:00am to 15:30. Four staff, four residents, two relatives were spoken with and the residents were observed during the inspection. A poster was placed in the entrance of the home to inform residents, staff and visitors to the home that an unannounced inspection was taking place. At the previous inspection comment cards and prepaid envelopes were left at the home so that service users or their representatives can contact the CSCI with their views about the home. One comment card was received by the CSCI, which was complimentary to the service given by staff at Greasbrough Nursing Home. There were no complaints received during the inspection and all were satisfied with the delivery of service provided at Greasbrough Care Home. The two relatives spoken with had positive comments about the care their relative received. The comments from staff indicated that they felt supported by the manager and relatives said that the improvements to all areas within the home had continued during the year that Mrs Briggs had been in post. The inspection focused on the requirements from the previous inspection, four residents files were case tracked along with medication, staffing rota and Adult Protection. Dr Hussain visits the home regularly on a professional basis and as owner, has a weekly management meeting along with undertaking monitoring visits. Feedback was given at the conclusion of the inspection to the manager. What the service does well: What has improved since the last inspection?
Greasbrough Residential / Nursing Home DS0000003078.V266372.R01.S.doc Version 5.0 Page 6 The home has taken action in all the requirements from the previous inspection. Mandatory training for all staff has been undertaken for example moving and handling, fire prevention; infection control and new staff have started inductions programmes. Training has also taken place on First Aid and Food Hygiene for some but not all staff. Staff appraisals and staff supervision sessions have been undertaken. Staffing levels had increased and all staff that spoke to the inspector said that they felt supported and guided by the new manager. Four staff working towards NVQ level 2 and one staff member working towards achieving NVQ level 3. Domestics have NVQ 1 & 2 in care. Medication records had been completed accurately and at the time of administration to protect residents. Each shift has a member of staff who is a First Aider. The medications trolleys, which are bolted to the wall, are stored in locked rooms. The building of an outside storeroom was in the final stages of completion. The improvement of the activities programme with the inclusion of music therapy and movement, which was part of a study. Records for social care have commenced. 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. Greasbrough Residential / Nursing Home DS0000003078.V266372.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Greasbrough Residential / Nursing Home DS0000003078.V266372.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4, 5 New documentation in assessment and care plans in a new format are in place to ensure the home meets residents’ needs. The home gives a statement of the terms and conditions to residents to inform residents of their rights of occupancy/residency. Prospective service users can arrange visits to the home and their relatives have the opportunity to visit the home and the delivery of care at Greasbrough Nursing Home. EVIDENCE: The home had a Statement of Purpose and Service User Guide and there was evidence on file that residents and/or their relative signs to confirm that they hat they had received their copy of the Service User Guide and a statement of terms and conditions/contracts. Records show that all new service users have an assessment from a member of the assessment team and the home has an assessment document which is used pre-admission or on admission to the home. During the inspection a family had asked to look around the home to assess the suitability of the facilities. There was also evidence that a prospective service user was coming to view the bedroom, the amenities and care within in the home.
Greasbrough Residential / Nursing Home DS0000003078.V266372.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 The care plan system is clear and provides staff with direction that they need to meet service users needs. Staff are working to the policies for the administration of medication, which promotes the wellbeing of residents. EVIDENCE: Care issues are discussed at the staff handover and the inspector listened to staff giving up to date information from day shift to afternoon shift with regard to the care of residents. Four care files were examined all of which had been updated to reflect residents changing needs. Care plans monthly to ensure that residents assessed and changing needs are in the care plan and the goals are met. Where possible relatives are involved in the development of the care plan. At the previous inspection, three relatives spoken with confirmed that they were involved with their relative’s care. Two relatives who visited during the inspection confirmed they had no concerns or complaints with the care that is given to residents. Records show that signatures are obtained either from the resident or their relative in agreement of the care plan.
Greasbrough Residential / Nursing Home DS0000003078.V266372.R01.S.doc Version 5.0 Page 10 Medication policies and procedures are in place and found to be correct. Staff had undertaken training in the administration of medication, which promotes safe handling and administration of medication. Medication trolleys had been moved to locked rooms to ensure safety and compliance to legislation. Medication reviews have taken place for each resident. Greasbrough Residential / Nursing Home DS0000003078.V266372.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this inspection. EVIDENCE: All these standards were assessed at the previous inspection, which complied with the National Minimum Standards for Older People. However, the manager has promoted more activities within the home on an individual and group basis. As past of a study, music therapy and movement has been successful and enjoy by many residents. The manager stated that a future development to undertake more social activities as part of holistic care for the well being of residents at Greasbrough Nursing Home. Greasbrough Residential / Nursing Home DS0000003078.V266372.R01.S.doc Version 5.0 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 - 18 The home has policies and procedures to protect service users from abuse. The home has a clear complaints system, which service users and relatives have used to register their grievances and/or concerns EVIDENCE: There have been no Adult Protection investigations since the previous inspection. Adult Protection matters are part of the induction and included a unit on the NVQ course. All care and domestic staff are enrolled or have achieved a NVQ course. In discussions with staff they gave a good account of what their responsibility was regarding allegations of abuse and were aware of the adult protection policy. There was evident that when complaints are made they are recorded. Mrs Briggs, the manager and Dr Hussain have taken action to resolve complaints and issues. No complaints were given to the inspector during the inspection. Relatives and residents had only constructive comments to make about the owner, manager and the staff group. The day after the inspection an anonymous complaint was made to the CSCI. Through the inspection process it was evidenced that the complaint did not have any foundation. Greasbrough Residential / Nursing Home DS0000003078.V266372.R01.S.doc Version 5.0 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Service users live in a safe, well-maintained environment, which was clean pleasant and hygienic. EVIDENCE: These standards were not fully assessed due to the imminent changes that are taking place at the home. The Commission has been informed that there is going to be slight alterations to the entrance and lounge area in the near future. Once this phase had been completed then the communal areas will be decorated and new carpet fitted. All health and safety matters were up to date and risk assessments were undertaken. A tour of the building was undertaken and found to be clean with no mal odours. Greasbrough Residential / Nursing Home DS0000003078.V266372.R01.S.doc Version 5.0 Page 14 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 - 30 The number and skill mix of the staff met residents’ needs, staff are have had induction and training to do their jobs EVIDENCE: Rotas were examined which showed there was sufficient staff and skill mix to meet residents’ needs. Since the previous inspection there had been an increase to staffing levels. Training records were examined, which showed that staff had staff induction, and training which includes Health and Safety issues ensuring that service users are in safe hands at all times. Each member of staff had a training record that showed there been training such as Handling Aggression, Nutrition, Wound care and Tissue Viability and this was on going. All staff are enrolled or have achieved NVQ, which evidences staff development and competence. There are robust recruitment policies and CRB and POVA checks are undertaken for all staff, which are confirmed by examination of staff records. Staff meetings are held with minutes taken. Greasbrough Residential / Nursing Home DS0000003078.V266372.R01.S.doc Version 5.0 Page 15 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 - 38 The health, safety and welfare of service users and staff are promoted and protected EVIDENCE: The two relatives made comment that they felt that the atmosphere in the home was relaxed for residents and that the manager had made many improvements such as: a happier atmosphere, more activities and the moral of staff since she came into post in February 2005. Residents confirmed that they felt that the home was run in their best interests. The majority of residents and/or their families oversee financial matters. However, any financial transaction is recorded and receipts given and obtained. Mrs S Briggs is the registered manager who came into post in February 2005 who is a Registered nurse has had previous experience as a registered
Greasbrough Residential / Nursing Home DS0000003078.V266372.R01.S.doc Version 5.0 Page 16 manager. She has reviewed policies and procedures and record keeping has improved since she has been in post. Staff said that they felt supported by her they went on to say they received support and guidance on a daily basis. Staff appraisals and staff supervision sessions have taken place and this was confirmed by records and in discussion with staff. Staff had received training in health and safety, moving and handling, fire prevention instruction and infection control and some staff had achieved their food hygiene certificate and eight had attended first aid course, all of which maintain a safe environment for them to work in, therefore reducing the risk of harm. Health & Safety certificates were checked and found to be satisfactory. The owner, Dr. Hussain undertakes monthly monitoring visits and the findings recorded. Greasbrough Residential / Nursing Home DS0000003078.V266372.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 X 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Greasbrough Residential / Nursing Home DS0000003078.V266372.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Greasbrough Residential / Nursing Home DS0000003078.V266372.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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