Inspection on 24/10/05 for Greatwood House

This inspection was carried out on 24th October 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

Greatwood House 21/11/06

Greatwood House 16/05/05

Greatwood House 05/10/04

Greatwood House 14/04/04

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

CARE HOMES FOR OLDER PEOPLE Greatwood House Mancunian Road Denton Tameside M34 1GX Lead Inspector Janet Ranson Unannounced Inspection 24th October 2005 10:00 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 Greatwood House DS0000005569.V259581.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. Greatwood House DS0000005569.V259581.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Greatwood House Address Mancunian Road Denton Tameside M34 1GX 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) 0161 336 5324 0161 320 3896 greatwood@tamesidecare.co.uk Tameside Care Limited Mrs Deborah Thompson Care Home 60 Category(ies) of Dementia - over 65 years of age (60), Old age, registration, with number not falling within any other category (60), of places Physical disability over 65 years of age (60) Greatwood House DS0000005569.V259581.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 60 service users to include: *up to 60 service users in the category of OP (Old age not falling into any other category). *up to 60 service users in the category of PD(E) (Physical disability over 65 years of age). *up to 60 service users in the category of DE(E) (Dementia over 65 years of age). The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 16th May 2005 2. Date of last inspection Brief Description of the Service: Greatwood House is a purpose built; single storey building that has been adapted and improved over a period of time. The latest extension provided a self-contained wing to the rear and a large conservatory in the existing building. The home is registered with the Commission for Social Care Inspection to provide personal care for 60 older people some of whom may have a physical disability or dementia. All the accommodation is provided in single rooms, 37 of which have been improved to include en-suite facilities. The home is divided into small units each one having its own small kitchen, dining area and lounge. Originally commissioned by the local authority, Greatwood House is now owned and managed by Tameside Care Limited. The home is located within a large estate, close to community resources and transport networks. Greatwood House DS0000005569.V259581.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over five hours. The purpose of the inspection was to ascertain the quality of life for service users, check compliance with the requirements made at the previous inspection (16th and 17th May 2005) and to investigate an anonymous letter of complaint received by the Commission for Social Care Inspection. The inspection process included checking the daily menus for variation and choice, speaking to the residents about the meals and interviewing the cook. Staff records and rotas were examined and a tour of the building took place. The manager was present throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better: The organisation must address the issues concerning recruitment and selection to ensure that all gaps in employment are investigated and documented, and references are appropriate to the proposed designation. Greatwood House DS0000005569.V259581.R01.S.doc Version 5.0 Page 6 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. Greatwood House DS0000005569.V259581.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 Greatwood House DS0000005569.V259581.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): 3 Standard 3 was inspected during the previous announced inspection (May 2005) when it was judged to meet fully with the standard. Intermediate care is not provided at Greatwood House. EVIDENCE: Greatwood House DS0000005569.V259581.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, 8, 9 & 10 The above standards were inspected at the previous inspection (May 2005) when they were judged to meet fully with the standard. EVIDENCE: Greatwood House DS0000005569.V259581.R01.S.doc Version 5.0 Page 10 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): 15 The quality, variety and choice of the food have improved to provide a more appealing menu. EVIDENCE: At the previous inspection several negative comments were received concerning the food provided at the home. The various comments were received, both in writing and verbally, concerning the choice and variety. At this time meals were observed on two separate occasions and it was noted that corned beef was the only option to the main meal. The home was required to review and revise the menu in conjunction with the residents, in order that variety and choice was provided at each meal. It was understood that the home had carried out a survey with the residents and had sought their views on the meals. During this inspection the menu was examined. Great improvements had been made to the content and printed menus had been placed on each table. From observation the meal served at the time of the inspection was well received and the residents confirmed this to be the case. Greatwood House DS0000005569.V259581.R01.S.doc Version 5.0 Page 11 The residents described a recent afternoon tea party, served as part of a reminiscence session, which was enjoyed by all who took part. Black and white photographs (particularly imaginative) of the event were displayed in the main corridor. It is understood this will become a regular feature at Greatwood House. The residents had also previously complained to the inspector about having to wait at breakfast time until other people were ready for their meal. This issue was discussed with the residents at this time when they confirmed they were now satisfied with the breakfast service. The cook spoke with the inspector. She explained that a total of 78 meals were cooked at lunch and teatime to include the people using the day centre. The new menu had been well received and as the cook also serves all the meals, she was well placed to receive comments, observe reactions and monitor waste. Greatwood House DS0000005569.V259581.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 residents and their visitors were confident any complaints would be treated with respect and acted upon. Systems and procedures in the home ensure the residents are protected from abuse. EVIDENCE: An anonymous letter of complaint stated the writer’s lack of confidence that their complaint had been ignored and “serious assaults” had been reported but ignored by the management. This was found not to be the case. On receipt of the allegations the manager had instigated the correct procedure and an investigation had taken place. The complainant had been involved in the investigation and advised that the allegation was unfounded. All records concerning the investigation were available for inspection. Greatwood House DS0000005569.V259581.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): 26 Greatwood House is maintained in a clean and hygienic state with no offensive smells noted. EVIDENCE: A comment written in the anonymous letter received by the Commission for Social Care Inspection, stated “… the home is filthy and it smells.” This was found not to be the case. The home employs a team of housekeepers who maintain the home in a clean and hygienic state. The residents confirmed that the home and their accommodation were usually very clean. Greatwood House DS0000005569.V259581.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, 28 & 29 Application of the organisation’s recruitment policy and night staffing levels fails to protect the residents. EVIDENCE: An anonymous written complaint stated that staffing at night was, at times, below the acceptable level. This was found to be the case. The manager explained that some night staff telephone the home at short notice to say they would be unable to work that night. It is the responsibility of the senior staff to try to cover the duty and there have been occasions when this has not been possible. This leaves three staff to meet the needs of up to 60 residents in a very large building and is unacceptable. As part of the inspection, the content of a staff file was examined. A gap in an employment history had failed to be investigated by the interviewer and of the two references on file, neither were from a previous employer. It should be noted that the staff member had left Greatwood House. The organisation continues to be committed to the National Vocational Qualification system at levels 2 and 3. At the previous inspection there was a ratio of 70 of carers with level 2. It is understood that the home continues to support carers to enrol on level 2. Greatwood House DS0000005569.V259581.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 & 37 The organisation has failed to promote the residents’ best interests through their record keeping. EVIDENCE: The manager is registered as a fit person with the Commission for Social Care Inspection. She has adopted an open and relaxed management style and is supported by team leaders. The organisation has a responsibility to report certain incidents that may affect the residents’ well-being or safety to the Commission. The incident outlined in the anonymous letter of complaint had been correctly investigated by senior managers but should also have been reported under Regulation 37 of the Care Homes Regulations 2001 to the Commission. Greatwood House DS0000005569.V259581.R01.S.doc Version 5.0 Page 16 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 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X 2 X Greatwood House DS0000005569.V259581.R01.S.doc Version 5.0 Page 17 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. 1 Standard OP27 Regulation 18(1)(a) Requirement Timescale for action 01/12/05 2 OP29 19(5) 3 OP37 37 (1) (e) The registered person must, having regard to the size of the home, ensure that staff are employed at all times in numbers to meet the residents’ identified needs. The registered person must 01/12/05 ensure that any gaps in employment history are investigated and such outcomes are recorded on the interview records. The registered person must 01/12/05 ensure that any incident or accident in the home that may affect the residents’ well being or safety is reported to the Commission for Social Care Inspection. Greatwood House DS0000005569.V259581.R01.S.doc Version 5.0 Page 18 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 Greatwood House DS0000005569.V259581.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 Greatwood House DS0000005569.V259581.R01.S.doc Version 5.0 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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