Inspection on 25/04/06 for Green Bank EMI Care Home

This inspection was carried out on 25th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Green Bank EMI Care Home 15/06/09

Green Bank EMI Care Home 27/06/07

Green Bank EMI Care Home 19/10/05

Green Bank EMI Care Home 26/04/05

Green Bank EMI Care Home 07/12/04

Green Bank EMI Care Home 09/07/04

Green Bank EMI Care Home 29/07/02

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

CARE HOMES FOR OLDER PEOPLE Greenbank 11 Hastings Road Bexhill-on-sea East Sussex TN40 2HJ Lead Inspector Rebecca Shewan Unannounced Inspection 25th April 2006 09:15 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 Greenbank DS0000021120.V288485.R01.S.doc Version 5.1 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. Greenbank DS0000021120.V288485.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Greenbank Address 11 Hastings Road Bexhill-on-sea East Sussex TN40 2HJ 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) 01424 211704 Mrs Judy Pillow Miss Sophie Williams Care Home 16 Category(ies) of Dementia - over 65 years of age (16) registration, with number of places Greenbank DS0000021120.V288485.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is sixteen (16). Service users must be older people aged sixty-five (65) or over on admission. Service users with a dementia type illness only to be accommodated. Date of last inspection 19th October 2005 Brief Description of the Service: Greenbank is located close to Bexhill-on-Sea old town and about one mile from the seafront. There is access to local shops, public transport, churches and other community services. Greenbank is a long established family owned home registered to accommodate up to 16 older people with a Dementia type illness. The property was originally a two storey Victorian house, which has since been extended to accommodate residents on the ground floor of the building. There are fifteen bedrooms, one of which may be used as a shared occupancy room but is currently used as single occupancy. All bedrooms have en-suite facilities and there are toilets and bathroom/shower rooms located throughout the premises. There are two large lounge areas, one of which is utilised as a quiet lounge. The home has a good sized dining area, which overlooks the homes secure fishpond. There is a large well maintained garden to the rear of the property with has easy access for residents. Potential new residents can obtain information relating to the home via Care Managers, Placing Authorities by word of mouth and by contacting the home direct. The range of fees charged (at the time of this report) are £400 - £450 per week, with extra charged for hairdressing, chiropody, newspapers and toiletries. Greenbank DS0000021120.V288485.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the morning and afternoon of the 25th April 2006. Regulation 37 incident reports and previous inspection reports held by the Commission for Social Care Inspection were read before the inspection. Please note that the Registered Manager was not present at the inspection due to being on annual leave at the time. The inspection of the home took six and three quarter hours. A tour of the whole home was undertaken and the Registered Provider, five staff and four service users (known as Residents) were spoken with, records such as care plans, policies and procedures, maintenance records and medication records were also viewed. Ten Service User Surveys were also distributed of which one was returned (which was completed by a resident’s relative). Resident’s views are included in this report where it was possible to gain them, with consideration given to the residents communication difficulties related to their diagnosis of dementia. Comments received included: • • • • ‘We like living here, everyone is friendly’ ‘Staff are caring and considerate’ ‘Food is always good and plentiful’ ‘We are completely satisfied by the care and attention my relative receives’. The Registered Provider was requested to complete a Pre-Inspection Questionnaire, which was returned in a timely manner. However, contact details for resident’s Care Managers, Social Workers and Placing Authorities had not been included in this documentation. Therefore, the views of these individuals/organisations have not been obtained for the purpose of this report. What the service does well: The home ensures that pre- admission assessments are carried out on all new and potential resident’s. The health needs of residents are well met with evidence of good multi disciplinary working taking place, on a required basis. Staff were observed providing personal support to residents in such a way that promoted and protected resident’s privacy and dignity. Residents are treated with respect and there is a good rapport between staff of the home and residents. Mealtimes are unhurried and all meals are home cooked with alternatives and a vegetarian option available for each mealtime. Greenbank DS0000021120.V288485.R01.S.doc Version 5.1 Page 6 The home has an efficient complaints procedure in place, whilst the homes procedures, processes and staff training should protect resident’s in the event of an allegation of abuse. The location and layout of the home are suitable for its stated purpose. All areas of the home, including the secure garden, are accessible to residents. A competent staff team, sufficient in number, meets the resident’s needs. The home has a suitable staff team with the necessary skills and experience to the meet the needs of current residents with good maintenance of staff recruitment files. The management and administration of the home is good, with evidence of consideration being given to resident’s choice and opinion. What has improved since the last inspection? What they could do better: Residents care plans are to be reviewed on a monthly basis in order to ensure that resident’s needs are continuously monitored and that care staff are aware of any changes to resident needs. In order to prevent the risk of cross infection to both residents and staff, appropriate hand washing facilities are made available in the home’s communal toilet, bathroom and shower areas. The results of residents, relatives and visitors questionnaire surveys and make these available to current and prospective residents, their representatives and other interested parties, including the CSCI. The Registered Provider must also conduct monthly unannounced visits and a copy of the report sent to the CSCI Greenbank DS0000021120.V288485.R01.S.doc Version 5.1 Page 7 Eastbourne Area Office, as part of the home’s ongoing continuous self monitoring processes, in order to improve the services provided. In the interests of the health, safety and welfare of residents and staff; all rugs throughout the premises are to be made secure, Portable Appliance Testing and a Gas inspection must be conducted and a certificate of compliance obtained by the home and that when residents are mobilised using their wheelchair, footplates must be in place at all times. The home are advised to implement a maintenance development plan to identify environmental improvements/up grading along with realistic timescales, in order to provide a well maintained environment for residents. This is an outstanding recommendation from the previous inspection. The home are also advised to annually review the homes Policies and Procedures and make them consistent with those generated in the staff handbook to provide, to ensure that staff are working to the same set of policies and procedures. Please note that prior to the report being generated, the home have provided the CSCI Eastbourne Area Office with an action plan detailing how the Immediate Statutory Requirements have been addressed. 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. Greenbank DS0000021120.V288485.R01.S.doc Version 5.1 Page 8 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 Greenbank DS0000021120.V288485.R01.S.doc Version 5.1 Page 9 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&6 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The home has good processes for assessing potential new resident’s with services being offered to only those resident’s whose needs can be met. EVIDENCE: Pre- admission assessments are carried out by either the homes Registered Manager or Deputy Manager. Records inspected showed that pre- admission assessments are carried out on all new and potential resident’s and it was noted that the documentation allows the assessor to gain thorough details of individuals medical, social and personal care needs. The home also obtains a copy of a care management assessment from a placing authority where this exists. Intermediate care is not offered by this home. Greenbank DS0000021120.V288485.R01.S.doc Version 5.1 Page 10 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 Quality in this area is adequate. This judgement has been made using the available evidence including a visit to this service. Residents are offered a good provision of health care and personal support by the home, however there is improvement required to ensure that up to date the policies and procedures in place to provide the basis for the care delivered. EVIDENCE: Individual residents care plans were viewed and it was noted that these were detailed in content, covered all aspects of resident’s needs and had been devised with residents and/or their representative’s involvement, where this is possible. However, from the care plans sampled it was evidenced that monthly reviews had not been maintained on a consistent basis. Staff spoken with were aware of residents needs and their current capabilities. From the records sampled and from discussions with staff it was evidenced that the health needs of residents are well met with evidence of good multi disciplinary working taking place, on a required basis. Staff said that residents have a choice of GP and can retain contact with professionals such as dentists and opticians whom they had visited before coming to the home. Greenbank DS0000021120.V288485.R01.S.doc Version 5.1 Page 11 The home has good procedures in place for the monitoring and recording of all drugs entering and leaving the home and drugs being administered. From the records viewed and from discussions with care staff it was evidenced that a recent update in Medication training had been undertaken. However there is a need for the home to review its Medication Policy as the last evidenced review date was 2002. Staff were observed providing personal support to residents in such a way that promoted and protected resident’s privacy and dignity. Residents spoken with at the time of the inspection said that the ‘staff were kind and caring at all times’. Greenbank DS0000021120.V288485.R01.S.doc Version 5.1 Page 12 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): 12, 13, 14 & 15 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The home provides good social, cultural and recreational facilities, including a balanced diet to residents. With residents choice and wishes being respected. EVIDENCE: Resident activities are arranged and can be altered according to resident’s requests. Residents are free to participate in activities, held by the home or within the local community, or not as they wish. Staff said that residents are actively encouraged to maintain family contact and resident’s family, friends and representatives are welcomed at any time and in accordance with the resident’s wishes. Residents can entertain their guests in any of the homes communal areas or privately in their own bedrooms. The Registered Provider and the Deputy Manager said that many of the residents enjoy close contact with their families and friends. Resident’s religious wishes are observed and arrangements are in place for residents to receive non-denominational or Roman Catholic Holy Communion. Discussions with the Registered Provider and Deputy Manager highlighted that although many of the current residents fall into a specific age group and have similar religious beliefs, the home would welcome any potential new resident who has special cultural/religious/spiritual beliefs and would make provision to accommodate their needs. Greenbank DS0000021120.V288485.R01.S.doc Version 5.1 Page 13 The home assists residents with maintaining independence in their daily living and daily routines, where able. Residents are treated with respect and there is a good rapport between staff of the home and residents. This was observed at the time of the inspection. The home’s menus are devised on a weekly basis. The menus viewed showed that there is a variety of food and that the menus are varied. All meals are home cooked with alternatives and a vegetarian option available for each mealtime. The home’s Cook (on the day of the inspection) said that medical, therapeutic or religious diets are provided as needed. Residents said that they enjoy the food served in the home. The meal served during the inspection was ample in quantity and attractively presented. Resident’s who required assistance with eating their meal, were observed to be fed in a dignified and unhurried manner. Greenbank DS0000021120.V288485.R01.S.doc Version 5.1 Page 14 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 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. Resident’s benefit from a robust and efficient complaints procedure, whilst the homes procedures, processes and staff training should protect resident’s in the event of an allegation of abuse, with some improvement being required to improve the policies and procedures in place. EVIDENCE: The home has an established complaints procedure in place. From the section in the service user survey received relating to complaints, this showed that the resident’s relative always felt listened to and that they always knew who to speak to in the event of a complaint/concern. Neither the home nor CSCI have received any complaints, relating to the home, in the last twelve months. However there is a need for the home to review the complaints policy as the last evidenced review date was 2002. The Deputy Manager said that staff had completed training in the protection of vulnerable adults within the last year, staff spoken with at the time of the inspection and records viewed confirmed this. Criminal Record Bureau (CRB) checks have been carried out on all existing staff. Both CRB and Protection of Vulnerable Adult (POVA) checks are carried out on all new staff. This was evident from the staff files that were viewed and from staff spoken with during the inspection process. Staff said that they had recently attended training in the Protection of Vulnerable Adults and were confident that in the event of an allegation of abuse, they would know the correct procedure to follow. Greenbank DS0000021120.V288485.R01.S.doc Version 5.1 Page 15 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 Quality in this area is adequate. This judgement has been made using the available evidence including a visit to this service. The home provides a safe, well-maintained environment for residents. With improvements required to ensure that appropriate infection control measures are adhered to and reduce the risk of hazard to residents and staff. EVIDENCE: The location and layout of the home are suitable for its stated purpose. All areas of the home, including the secure garden, are accessible to residents. From the tour of the premises it was evidenced that the cupboard containing the hot water boiler has been fitted with a secure lock. An implemented a maintenance development plan to identify environmental improvements/up grading along with realistic timescales, is not in place. This was discussed with the Registered Provider and the Deputy Manager at the time of the inspection and it was concluded that the home would benefit from such a plan, which could also be incorporated into the home’s monthly unannounced (Regulation 26) visit reports. Greenbank DS0000021120.V288485.R01.S.doc Version 5.1 Page 16 The home was odour free throughout. It was evidenced that a clinical waste contract is in place. The home has an infection control policy in place and the Registered Provider said that all staff are trained in infection control procedures, this was confirmed by staff training records and by staff spoken with at the time of the inspection. Staff were observed practising good infection control procedures. However, it was evident from the tour of the premises that bars of soap were provided in some of the home’s communal bathroom, toilet and shower areas, presenting an infection control hazard to resident’s and staff. It is of note that this matter had been addressed prior to the conclusion of the inspection in that the bars of soap had been removed. However, there is a need for the home to provide appropriate hand washing facilities in order meet the needs of resident’s and staff. Greenbank DS0000021120.V288485.R01.S.doc Version 5.1 Page 17 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 & 30 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The home has a suitable staff team with the necessary skills and experience to the meet the needs of current residents. EVIDENCE: A competent staff team, sufficient in number, meets the resident’s needs. There is a staff rota in place, which was made available to the inspector with the homes pre-inspection questionnaire. This document details the employee’s job title, number of contracted hours and shifts allocated to be undertaken. Residents said that staff are ‘always helpful and pleasant in their manner’. The Deputy Manager said that of the homes fourteen care staff, three obtained an National Vocational Qualification (NVQ) level two or above in care, with a further two staff undertaking an NVQ level two course. This was confirmed in the homes Pre-Inspection Questionnaire and from staff training records viewed. Staff confirmed that the home is committed to its staff achieving NVQ level two and that courses and funding were being sought for further care staff to undertake the training. The home does not currently meet the Statutory Requirement that a minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved. Staff recruitment files were viewed and it was evidenced that these files contain all items required under the Care Homes Regulations 2001.Not all staff Greenbank DS0000021120.V288485.R01.S.doc Version 5.1 Page 18 photographs were recent, the Registered Provider said that staff photographs would be taken and maintained on individual staff files. The home has an Equal Opportunities policy in place and is an equal opportunities employer. A number of the current staff team are from abroad. All necessary visa and Home Office related documents were found to have been obtained and kept on file for these employees. Staff training files were viewed and it was evident that staff training in Induction and common foundation, Fire Safety, Manual Handling, Health and Safety, Food Hygiene, Protection of Vulnerable Adults and infection control are conducted. Care staff who were spoken to also confirmed this. Greenbank DS0000021120.V288485.R01.S.doc Version 5.1 Page 19 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, 33, 35, 36, 37 & 38 Quality in this area is adequate. This judgement has been made using the available evidence including a visit to this service. The management and administration of the home is good, with evidence of consideration being given to residents choice and opinion however there is a need for immediate improvements to be made to ensure that the health, safety and welfare of residents and staff are protected at all times. EVIDENCE: The Registered Manager has many years relevant experience in caring for older people. Residents and staff said that the Registered Manager was friendly and approachable. There is a Quality Assurance procedure in place, which consists of an annual development plan and annual questionnaires of all parties involved with the home. Quality Assurance questionnaires were given to all resident’s and visitors to the home in December 2005, however the results of which have not Greenbank DS0000021120.V288485.R01.S.doc Version 5.1 Page 20 been published and made available to all. Monthly monitoring visits are not being carried out by the Registered Provider as part of the homes Quality Assurance systems. Therefore there is need for the home to have monthly unannounced (Regulation 26) visits and reports completed, in accordance with this regulation. The Registered Provider said that the home does not take any responsibility for resident’s finances. It was evident from the staff files viewed that care staff are appropriately supervised. Formal supervision of staff is conducted on a two monthly basis, records that were viewed and discussions with care staff confirmed this. Staff meetings are held, however there has not been a meeting since November 2005. The next planned meeting was scheduled to be held two weeks after the date of the inspection. Staff spoken with confirmed this. It was evidenced that the ‘Greenbank Newsletter’ has not been published since the previous inspection and due to home’s management team concentrating on the training of new and existing staff, it has been decided that the newsletter will now be published half yearly. The homes policies and procedures file was viewed and it was evidenced that all policies and procedures were last reviewed in 2002, however there is a new Staff Handbook in place. Therefore there is need for the home to ensure that the policies and procedures are reviewed and updated if necessary. The home should also cross reference the policies held in the main office to ensure that they are consistent with those detailed in the new staff handbook. The home’s maintenance files were viewed and it was evident that fire drills, fire alarm testing and fire equipment checks and water checks had been carried out. However it was evidenced that Portable Appliance Testing (PAT) and a gas safety certificate/inspection had not been conducted since 2002. From the tour of the premises it was also evidenced that there were a number of rugs located throughout the building, which were unsecured and presented a trip hazard. During the inspection care staff were also observed mobilising one resident in their wheelchair without footplates in place, presenting an increased risk of hazard to the resident. Therefore Immediate Statutory Requirements were made relating to these issues. Greenbank DS0000021120.V288485.R01.S.doc Version 5.1 Page 21 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X 3 2 1 Greenbank DS0000021120.V288485.R01.S.doc Version 5.1 Page 22 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. 2. 3. Standard OP7 OP9 OP26 Regulation 15 (2) (b) Requirement Timescale for action 25/05/06 25/05/06 25/04/06 4. OP28 5. OP33 6. OP33 7. OP38 That residents care plans are reviewed on a monthly basis. 13 (2) That the homes Medication Administration Policy is reviewed and amended as appropriate. 13(3) & That appropriate hand washing (4)(a) facilities are made available in all (b)(c) communal toilet, bathroom and shower areas. This is an immediate requirement. 18 (c) (i) That a minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved. 24 That results of residents, relatives and visitors questionnaire surveys must be published and made available to all. 26 That Regulation 26 visits are conducted by the Registered Provider and a copy of the report sent to the CSCI Eastbourne Area Office on a monthly basis. 12 (1) (a) That all rugs throughout the (b) & 13 premises are made secure in the (4) (a) (b) interests of the health, safety (c) and welfare of residents and staff. This is an immediate DS0000021120.V288485.R01.S.doc 25/07/06 25/07/06 25/05/06 25/04/06 Greenbank Version 5.1 Page 23 8. OP38 9. OP38 10. OP38 12 (1) (a) (b) & 13 (4) (a) (b) (c) 12 (1) (a) (b) & 13 (4) (a) (b) (c) 12 (1) (a) (b) & 13 (4) (a) (b) (c) requirement. That Portable Appliance Testing is conducted and a compliance certificate obtained. This is an immediate requirement. That a current Gas inspection is conducted and a certificate of compliance obtained. This is an immediate requirement. That resident wheelchairs are appropriately maintained and that footplates are in use at all times. This is an immediate requirement. 25/04/06 25/04/06 25/04/06 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 OP19 Good Practice Recommendations That the home implements a maintenance development plan to identify environmental improvements/up grading along with realistic timescales. This is outstanding from the previous inspection. That the homes Policies and Procedures are reviewed annually and made consistent with those generated in the staff handbook. 2. OP37 Greenbank DS0000021120.V288485.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Greenbank DS0000021120.V288485.R01.S.doc Version 5.1 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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