CARE HOMES FOR OLDER PEOPLE
GREASBROUGH CARE HOME Potters Hill Greasbrough Rotherham S61 4NU Lead Inspector
Rosemary Reid Unannounced 02 August 2005 9:00. 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 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 CARE HOME J55-J07 S3078 Greasbrough V184048 020805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Greasbrough Care Home Address Potters Hill Greasbrough Rotherham South Yorkshire S61 4NU 01709 554644 01709 559332 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) Dr. M H Husain OBE Mrs Susan Briggs Care Home with Nursing 60 Category(ies) of OP Old Age: 60 registration, with number PD Physical Disability: 60 of places GREASBROUGH CARE HOME J55-J07 S3078 Greasbrough V184048 020805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 1. To admit up to three service users between the age of 60 and 65 years in the category of Old Age for which the home is registered. Date of last inspection 25 November 2004 Brief Description of the Service: Greasborough 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 Greasborough on the outskirts of Rotherham. The home is owned by Dr. M H Hussain, OBE and Mrs. J M Hussain. 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 CARE HOME J55-J07 S3078 Greasbrough V184048 020805 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place from 9:00am to 16:30. Mrs. Briggs was appointed as the manager in the early part of this year and in June 2005 was registered as the manager and she was available throughout the inspection Five staff, four residents, three 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. 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 of which were returned immediately. At the time of writing no comments cards had been received from residents or relatives at the Commission’s office. There were no complaints received during the inspection and all were satisfied with the delivery of service provided at Greasborough Care Home. All of the relatives spoken with had positive comments about the care their relative received. The comments from staff indicated that they felt supported by the new manager and relatives said that there were improvements since she 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:
A new care plan format has been introduced and all care plans have been rewritten since the new manager has been in post. Each care plan is reviewed on a monthly basis. The home has a good relationship with the Tissue Viability Nurse and has a large selection of pressure relieving equipment for the benefit of residents. All of the service users and the relatives spoken with were highly satisfied with the delivery of care and had no complaints. Staff were observed to have good rapport with residents. Induction programme and training for all staff had been a main focus of the manager. It is the policy of the home that all staff are enrolled on the NVQ as soon as possible from starting at the home. All areas of the home were clean and tidy with no offensive odours. GREASBROUGH CARE HOME J55-J07 S3078 Greasbrough V184048 020805 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. GREASBROUGH CARE HOME J55-J07 S3078 Greasbrough V184048 020805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection GREASBROUGH CARE HOME J55-J07 S3078 Greasbrough V184048 020805 Stage 4.doc Version 1.40 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 standard(s) 1, 3 Improvements have taken place in that the Statement of Purpose and Service User Guide are in each bedroom/and given to service users and/or their relatives pre-admission or at admission to ensure that they receive information they need to make an informed choice about where to live. 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. 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. Records show that staff use ticks it is recommended that this practice cease.
GREASBROUGH CARE HOME J55-J07 S3078 Greasbrough V184048 020805 Stage 4.doc Version 1.40 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 standard(s) 7 - 11 The care plan system is clear and provides staff with direction that they need to meet service users needs. Staff are not working to the policies for the administration of medication, which promotes the wellbeing of residents. EVIDENCE: Four care files were examined all of which had been updated to reflect residents changing needs. Staff are reviewing 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. For example, three relatives spoken with confirmed that they were involved with their relative’s care. One relative made the comment “Staff are good to my mother” another relative said, “We are always made welcome and I don’t have any problems with staff or the care.” Signatures are obtained either from the resident or their relative in agreement of the care plan. Although improvements have taken place there is going to be a course on writing and report. Medication policies and procedures are in place and staff had undertaken training in the administration of medication, which promotes safe handling and
GREASBROUGH CARE HOME J55-J07 S3078 Greasbrough V184048 020805 Stage 4.doc Version 1.40 Page 10 administration of medication. However, there were members of staff who when administering medications did not follow the medication policies by failing to record the administrations of drugs. Medication recording records were not stored securely to preserve confidentiality. The medication trolleys are bolted but stored on the corridor rather than a locked cupboard. There are policies and procedures dealing with care of the dying and where known residents’ wishes for their funeral arrangements are recorded within the file. GREASBROUGH CARE HOME J55-J07 S3078 Greasbrough V184048 020805 Stage 4.doc Version 1.40 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 standard(s) 12 - 14 The home promotes that service users maintain contact with families/friends, which benefits service users wellbeing. Formal residents meetings do not take place; the manager speaks to small groups of residents and records their comments informally. The manager promotes and advance residents’ rights by the use of an advocacy service. The home is working on an activities programme inside and outside the home to improve the quality of the residents EVIDENCE: There are no restrictions to visitors to the home. Visitors can be seen in the privacy of the service user’s bedroom or in quieter communal areas within the home. Care plans show where service users are helped to exercise choice and control over their lives for example in the time they arise or retire to their bedroom. The manager issued quality assurance questionnaires to ascertain residents’ wishes and choice with regard to activities, variety of food and all other aspects of care. The activities co-ordinator had been off sick for a considerable time and had returned to work the week of the inspection. Residents and staff confirmed that activities have taken place and are recorded.
GREASBROUGH CARE HOME J55-J07 S3078 Greasbrough V184048 020805 Stage 4.doc Version 1.40 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 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. Complaints 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. GREASBROUGH CARE HOME J55-J07 S3078 Greasbrough V184048 020805 Stage 4.doc Version 1.40 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 standard(s) EVIDENCE: These standards have not been assessed. 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 has phase been completed then the communal areas will be decorated and new carpet fitted. GREASBROUGH CARE HOME J55-J07 S3078 Greasbrough V184048 020805 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 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 the following staffing levels - the manager, two nurses, one senior carer and six carers plus Welfare person (Activities co-ordinator) three domestics, three laundry assistance along with kitchen staff and handyman. Minimum staffing levels must be no regression from the previous staffing notice. The staffing notice was re-issued. Staff said there was enough staff on duty but added it can be difficult when service users are ill or need extra assistance and when staff phoned in sick at short notice. Staff had staff induction which complies with TOPPS, which includes Health and Safety training ensuring that service users are in safe hands at all times. There has been other training such as handling Aggression, Nutrition, Wound care and a future course on Tissue Viability. All staff (with the exception of one) are enrolled or have achieved NVQ, which evidences staff development and competence. There are robust recruitment policies and CRB and POVA checks are undertaken. Staff meetings are held with minutes taken. GREASBROUGH CARE HOME J55-J07 S3078 Greasbrough V184048 020805 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 36, 38 In the time that the manager has been at Greasborough Nursing and Residential Care Home she has worked hard to change the ethos of the home and for the home to be managed for the best interests of the service users. Training has taken place for the health and safety of the residents and staff. EVIDENCE: 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 manager. Staff said that they felt supported by her they went on to say they received support and guidance on a daily basis and appraisals had started, which will be followed by formal staff supervision sessions to enable them to formally discus their role and receive feedback. Staff had received training in health and safety, moving and handling, fire prevention instruction and infection control and some staff had achieved their
GREASBROUGH CARE HOME J55-J07 S3078 Greasbrough V184048 020805 Stage 4.doc Version 1.40 Page 16 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. However, there are bolts on the outside of staff toilet doors and linen cupboard which is a risk that someone could be locked in the cupboard or staff toilet, which has occurred to a staff member. Health & Safety certificates were checked and found to be satisfactory. The owner, Dr. Hussain undertakes monthly monitoring visits and the findings recorded. The atmosphere in the home was relaxed for residents. GREASBROUGH CARE HOME J55-J07 S3078 Greasbrough V184048 020805 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x
COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 2 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 x x x 3 x 2 GREASBROUGH CARE HOME J55-J07 S3078 Greasbrough V184048 020805 Stage 4.doc Version 1.40 Page 18 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 MNS OP 9 Regulation Reg 13 (2) Sch 3 (i) Requirement Medication records must be completed accurately and at the time of administration as per medications policies and procedures. Records must be stored to preserve residents confidentiality and privacy. Medication trolleys must be stored and comply with The Medicine Act 1963, of the Royal Pharmacutical Society, requeirments of the Misuse of Drugs Act 1974. Immediate action was taken with regard to records There must be no regression from the staffing levels in the home as per staffing notice. The bolts on staff toilets/linen cupboard doors must be removed as a matter of Health & Safety Immediate action was taken. Timescale for action 1st Sept 2005 2. MNS OP 27 Reg 18, 19 Reg 13 (4) 1st Oct 2005 1st Sept 2005 3. MNS OP 38 GREASBROUGH CARE HOME J55-J07 S3078 Greasbrough V184048 020805 Stage 4.doc Version 1.40 Page 19 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 MNS OP 7 Good Practice Recommendations It is recommended that the use of ticks are not used in the recording of case and medications records. GREASBROUGH CARE HOME J55-J07 S3078 Greasbrough V184048 020805 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection First Floor, Barclay Court Heavens Walk Doncaster DN4 5HZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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