Inspection on 25/06/07 for Green Haven

This inspection was carried out on 25th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Green Haven 31/08/06

Green Haven 23/01/06

Green Haven 18/07/05

Green Haven 11/02/05

Green Haven 26/08/04

Green Haven 19/01/04

Green Haven 26/06/03

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

CARE HOMES FOR OLDER PEOPLE Green Haven 18 Montpelier Road Ealing London W5 2QP Lead Inspector Sarah Middleton Unannounced Inspection 25th June 2007 09:30 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 Green Haven DS0000027707.V334836.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Green Haven DS0000027707.V334836.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Green Haven Address 18 Montpelier Road Ealing London W5 2QP 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) 0208 997 2142 0208 997 4235 Haven Green Housing Association Limited vacant post Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability over 65 years of age (0) of places Green Haven DS0000027707.V334836.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th December 2006 Brief Description of the Service: Green Haven provides a service for 22 older people. The home is well established and has been in operation since 1961. A voluntary committee manages Green Haven and meets every other month. The committees chairperson is the homes registered Responsible Individual. The home is supported by a group of volunteers known as the Friends of Green Haven. However, the home aims to support the residents in maintaining links with the community as far as is practical and in accordance with the residents’ wishes. Green Haven is a large detached property in a quiet residential area of Ealing. The home has parking to the front of the building and a large garden and veranda at the back. It has three floors, with bedrooms on each floor. Those above the ground floor are accessed using the passenger lift. All bedrooms are single and one has en-suite facilities. The home has a large lounge and separate dining room. Fees range from approximately £431-£462 per resident per week. Green Haven DS0000027707.V334836.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The term “service user” has been replaced in this report with the term resident, which refers to the people living in the home. This was an unannounced inspection carried out as part of the regulatory process. The inspection visit to the home was from 9.30am-6.30pm. The Inspector viewed samples of resident’s files, staff employment files and maintenance records. Three members of staff, one visitor and six residents were spoken with as part of the inspection process. Six residents had also completed postal surveys and any relevant contributions have been included in this report. The Manager Designate is still in the process of applying to become the Registered Manager. He, along with the Deputy Manager assisted with the inspection process. Equality and diversity issues are acknowledged by the home and where identified have been included into this report. All of the key standards were assessed and four of the five previous requirements were met and seven new requirements were made at this inspection. What the service does well: What has improved since the last inspection? Green Haven DS0000027707.V334836.R01.S.doc Version 5.2 Page 6 Residents’ files now have photographs of each resident, including those staying at the home for a short period of time on a respite basis. Where possible, residents had been able to make contributions to their care plan. The ceiling in bedroom number twenty, where there had been a leak, had been painted. The Manager Designate had devised a summary report outlining how the home meets the National Minimum Standards and records the improvements the home had made. 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. The summary of this inspection report can be made available in other formats on request. Green Haven DS0000027707.V334836.R01.S.doc Version 5.2 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 Green Haven DS0000027707.V334836.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, Standard 6 is N/A Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have their needs assessed prior to moving into the home. EVIDENCE: The Inspector viewed the pre-admission assessment regarding three residents who had moved into the home over the past few months. Two were living in the home on a respite, short-term basis. The Manager Designate obtains an up to date assessment and risk assessment from the referrer and then carries out a detailed pre-admission assessment. The Manager Designate had updated the pre-admission assessment and this was more detailed, covering a wide range of subjects, such as physical health, mobility, mental health needs, dietary needs and cultural and social needs. The prospective resident, or their representatives are encouraged to visit the home. Green Haven DS0000027707.V334836.R01.S.doc Version 5.2 Page 9 A visitor who spoke with the Inspector confirmed that she had chosen the home on behalf of her mother. The Inspector was satisfied that a detailed pre-admission procedure is in place for all prospective residents, including those staying in the home for a short period of time. The assessor, usually the Manager Designate or Senior members of staff take every opportunity to obtain as much information from the resident, the referrer and family members, as is possible. Green Haven DS0000027707.V334836.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have detailed care plans completed in order to identify and meet their personal and social needs. Due to a lack of professional input, one resident’s health needs were insufficiently being met The home’s medication procedures and systems were not protecting residents from medication errors occurring. Residents feel they are respected and that their privacy is upheld. Green Haven DS0000027707.V334836.R01.S.doc Version 5.2 Page 11 EVIDENCE: The Manager Designate has introduced new care plans and risk assessments. These consider the residents’ identified needs in more detail. The home assesses the risks in a resident’s life and from this a care plan, if necessary, is developed. Various areas are assessed, such as manual handling, risk of falling and pressure sore risk assessment. Care plans assess a resident’s personal; social and health needs and records how these needs are to be met. Care plans and risk assessments are reviewed monthly and updated as and when necessary. One resident who is at risk of developing a pressure sore had a risk assessment completed. Currently senior members of staff complete the care plans and risk assessments, although recently the Manager Designate has encouraged some care workers to complete these as well. The home obtains a photograph of each resident and residents are able to contribute to their care plans and sign each section of their plan. The Inspector viewed evidence to confirm residents’ involvement in their care plan. One resident has a pressure sore and is being treated by the community district nurse. Another resident, whose health has rapidly deteriorated over the past weeks, has broken skin that could develop into pressure sores. This particular resident had appropriate risk assessments in place. The Manager Designate and Deputy Manager informed the Inspector that referrals had been made to the GP for a district nurse to visit this resident, but so far no visit had occurred. The home was concerned that they do not have the necessary nursing skills available to care for this particular need. A member of staff also commented on the recent changes regarding this resident’s needs and that this resident now needed nursing care. The Inspector acknowledged the work the home was doing to try to resolve this issue. However, residents need to know their needs will be met by the home or by a relevant professional and therefore a requirement was made for this to be addressed. The Manager Designate informed the Inspector that there are ongoing difficulties in obtaining a GP for some new residents, especially those staying in the home for a short period of time. The home has made contact with various GP’s in order to identify a GP for some of the residents. The Inspector was satisfied that all residents currently have access to a GP. The home does not currently use body charts for staff to complete. These charts can be used to record where a resident might have a mark, pressure sore or bruise. The Inspector strongly advised the Manager Designate to obtain such documents for staff to use as and when needed. Nutritional screening assessments are carried out and residents are weighed on a regular basis. The Manager Designate is considering purchasing weighing scales for those residents who use wheelchairs. Green Haven DS0000027707.V334836.R01.S.doc Version 5.2 Page 12 Residents have access to various health professionals, who visit the home, such as, Chiropodist, Opticians and Community Psychiatric Nurses. Any visits or treatment provided is recorded onto daily records. The Inspector suggested for the Manager Designate to consider devising a medical appointments form so that it is easy to view when a resident has attended an appointment, along with any planned treatment. The Inspector viewed a sample of medication. Senior members of staff administer medication and are involved in recording when medication is delivered. The majority of medication is in blistered sealed packs. There were no residents self-medicating at the time of the inspection. Medication is stored in a locked cabinet. The Inspector viewed the controlled drugs, which is stored separately. A separate record is also used and two members of staff administer and witness this medication. The controlled drugs counted were correct. The Inspector found several errors when checking other medication. On the Medication Administration Records viewed there were gaps noted on some sections where the accurate quantities of medication had not always been recorded. Furthermore on some of the Medication Administration Records the wrong amount of medication was written in the quantity section, therefore it was impossible for the Inspector to count any of the loose medication that was stored in boxes or bottles. The Inspector immediately raised this issue with the Manager Designate, as it was not clear if residents had received the correct amount of medication. The Inspector had been informed that every week an audit takes place where all medication and records are counted and checked. There was no evidence to suggest these checks had taken place and if they had, the member of staff carrying out these checks had not identified the mistakes the Inspector had noted. A re-stated requirement was made for robust medication to be put in place, including a record of evidence to develop when carrying out checks on medication. A requirement was also made for the recording of medication amounts to be accurately noted each time there is a delivery of medication. Furthermore, the Inspector made a requirement for staff to receive refresher training on medication. A recommendation was made for the home to obtain information on the medication used in the home and this should include information on the side effects of the medication. The Inspector also advised the Manager Designate to consider taking the following action: Green Haven DS0000027707.V334836.R01.S.doc Version 5.2 Page 13 • Complete a full medication audit as soon as possible. • Devise a form for staff to use when they are carrying out medication checks. • Inform the Local Authority’s safeguarding adults co-ordinator of the errors found. • Inform Social Services of the errors found. •Book refresher medication training for all staff that handle and administer medication. • Return medication from the previous month to the Pharmacist. Keeping only the new medication that is delivered to the home. This then avoids overstock of medication being kept in the home and medication errors occurring. • Consider implementing additional medication checks when the monthly Regulation 26 visits occur. The Manager Designate will also meet with the senior members of staff and consider taking appropriate action with those concerned. The Inspector informed the Manager Designate that a referral would be made to the CSCI Pharmacy Inspector, so that a full medication inspection would be carried out. The CSCI Pharmacy Inspector will complete a separate inspection report. After the inspection, the Manager Designate informed the Inspector that he had carried out a full medication audit and had booked refresher training for all senior staff three days after the inspection. The Manager Designate told the Inspector that they would be addressing the shortfalls noted and would keep the Inspector informed of the progress of the investigations. Those residents asked confirmed that their privacy was upheld. One resident stated that staff always knock before entering his bedroom. Residents also said they received their own private mail. Residents all have their own bedrooms and can choose to spend time in their rooms as they so wish. The Inspector observed staff interacting with residents in a caring and sensitive way. Personal care is provided in private and residents said they were happy with the laundry facilities, as their clothes are labelled and consequently do not get lost in the home. Green Haven DS0000027707.V334836.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have the opportunity to engage in various activities in the home that suit their individual preferences. Residents are encouraged to maintain contact with family and friends. Residents are supported to make individual choices and decisions regarding their everyday life. Residents are provided with wholesome, varied and nutritious food. EVIDENCE: The home has made some improvements to the activities provided in the home. The Inspector viewed a weekly structured activity plan. The Manager Designate has increased the numbers of staff working in the morning so that activities can take place. Activities on offer vary from bingo, quiz’s to external people visiting and providing entertainment. Green Haven DS0000027707.V334836.R01.S.doc Version 5.2 Page 15 On the day of the inspection, two people visited and provided a sing-a-long. Those residents asked said they were able to choose if they wanted to take part in an activity. Various denominations visit from the local areas, such as the local priest, who offers Communion, and other churches. The volunteers known as the “Friends of Greenhaven” fund raise for the home and the Manager Designate is hopeful that some volunteers in the future might take residents out into the community. One resident currently attends the local Age Concern day centre. The Inspector spoke with some residents who have family or friends who visit them and take them out on a regular basis. Residents’ social interests and preferences are recorded onto their care plan so that staff are aware of likes and dislikes. As mentioned above, those residents who are able to, go out with family and friends as much as they wish to. Visiting is flexible in the home and the visitor the Inspector spoke with said they were able to visit every day. The visitor said staff were often friendly and helpful. Residents can see visitors in private or in the communal areas. Staff described to the Inspector how they encourage residents to be independent and to do as much as they can for themselves. One resident told the Inspector that he does as much of his personal care as he can. He went on to say staff support him to do tasks independently, so that he can retain some level of independence. The visitor spoken with confirmed that their relative, when she had moved into the home, had brought some personal possessions from their own home. Those residents who are able to would be encouraged to manage their own finances. The Inspector viewed the kitchen and met with the Assistant cook. They have obtained NVQ level 2 and 3 and are hoping to go onto complete a pastry course. The Inspector viewed deserts and found these to be freshly made by the assistant cook. The menus viewed offered more traditional foods to meet residents’ preferences. Choices of meals are available every day and residents confirmed they could also ask for alternatives. The menus are put up in the main hall and on the dining room tables to inform residents of the forthcoming meals. The assistant cook works all day and so can provide hot breakfasts, lunch and suppers. The kitchen was clean and tidy, although it would benefit from being updated. The Manager Designate acknowledged that the kitchen is in need of being modernised and longer- term plans are to update this room. Food opened or prepared had been covered and dated when opened or prepared. The Inspector spoke with a resident who originates from the Caribbean. She said she enjoyed the food provided in the home. Another resident, also from the Caribbean has meals provided to suit his cultural preferences. The Manager Designate confirmed that the cook recognises the residents’ preferences. The Inspector briefly viewed lunchtime and supper and these meals were relaxed and unhurried. Staff were seen to assist some residents with eating. The kitchen staff are to be commended for the fresh and varied meals provided for the residents. Green Haven DS0000027707.V334836.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives can be confident that complaints would be listened to and acted upon. Systems are in place to protect residents from abuse. EVIDENCE: The complaints policy is freely available and those residents asked said they would feel comfortable making a complaint to staff or to the Manager Designate. Systems are in place to record a complaint along with any action taken to investigate the complaint. One complaint had been recorded from a resident, who on a previous occasion had made allegations about members of staff. The home had taken most of the necessary steps, by contacting the GP, Social Services and the Police, but had not informed the CSCI, (see Standard 38) and neither had they made contact with the Local Authority’s safeguarding adults co-ordinator. The allegation was not upheld however the Inspector made a strong recommendation for the Manager Designate to inform all relevant professionals when an allegation has been made. The Manager Designate acknowledged that this had been an oversight and would ensure that this did not happen again. Green Haven DS0000027707.V334836.R01.S.doc Version 5.2 Page 17 The home needs to be mindful of those residents who might make occasional allegations, as any suggestion of abuse must always be taken seriously, regardless of the resident’s mental health needs. Staff receive annual training and information regarding abuse and the home has available the Local Authority’s policies and procedures on adult abuse. The Inspector advised the Manager Designate to obtain the Department of Health’s “No secrets” document, as this also has information about adult abuse. Green Haven DS0000027707.V334836.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The bathrooms on the first and top floor need attention to provide residents with a pleasant place to bathe in. Overall the home was clean, tidy and welcoming for the residents. EVIDENCE: The Inspector carried out a tour of the home and noted several areas where there had been improvements. The main hall, stairs and lounge had new carpets. The bedroom ceiling, where there had been a leak had been painted. Some other bedrooms had also been decorated and new flooring put into the some bedrooms. Green Haven DS0000027707.V334836.R01.S.doc Version 5.2 Page 19 The Manager Designate is aware there are areas still needing attention, such as the dining room. One resident told the Inspector that the dining room needed painting as he could see marks on the walls. This was fedback to the Manager Designate. The Inspector noticed that in two bathrooms on the first floor, the baths were very marked by hard water and in need of re-enamelling. The top floor also had a bathroom that was not currently being used. A medical bath was due to be put in instead of an ordinary bath and this had been an outstanding job for some time. This bathroom is in need of updating and a requirement was made for the bathrooms to be addressed. The Manager Designate informed the Inspector that the maintenance person had been prioritising work in the home, along with the Manager Designate, to try and get the main jobs completed. Over the next few months the front and the back of the home were due for painting along with a number of resident’s bedrooms. The Inspector acknowledged the home is a large Victorian building that can prove difficult to continuously maintain. Overall the Inspector is aware that the home is looking more presentable and homely. Staff receive training on health and safety and infection control. The Inspector met with the domestic member of staff who cleans the home. She confirmed she has the opportunity to attend relevant courses, such as moving and handling. The laundry facilities are located in a separate room and the washing machines are able to wash soiled items. The home was clean and free from unpleasant odours at the time of the inspection. Residents commented positively on the environment of the home and said it was clean and warm for them to live in. Green Haven DS0000027707.V334836.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by suitable numbers of staff who can meet their needs. The staff employment files did not contain all that is required. In order to safeguard residents, robust recruitment procedures need to be in place. Staff had not received specialist training or refresher training on handling medication. To ensure residents are supported appropriately and safely, various training courses need to be available. EVIDENCE: As noted earlier, the Manager Designate had increased the number of staff working in the morning. This is a busy time in the home and the Deputy Manager confirmed the recent staff increase had a positive effect on the home. The rota demonstrated that the Manager Designate also works once or twice a week sleeping over at the home. This enables him to meet with the waking night member of staff and provide them with support and supervision. Senior members of staff also work at night sleeping in at the home. The home has two domestic members of staff working to keep the home clean and free from unpleasant odours. Green Haven DS0000027707.V334836.R01.S.doc Version 5.2 Page 21 The home has provided staff with the opportunity to study for an NVQ. The Deputy Manager is currently working towards obtaining an NVQ level 4. The Manager Designate stated that offering staff the chance to study is provided on a regular basis. Some staff due to retire in the near future have not commenced with the NVQ qualification. The home has employed casual members of staff and is no longer using agency staff. The Inspector viewed a sample of staff employment files. Two casual members of staff had originated from the same country and their application forms indicated they had worked for the same previous employer. Their staff files contained references from the same two people, who were not former employers. This was discussed with the Manager Designate who informed the Inspector that the two members of staff had not been able to provide work employer references. The Inspector advised the Manager Designate that when an applicant is not able to provide work references, then it must be recorded, with any relevant explanations as to the reasons for accepting personal references. One casual member of staff had a POVA first check returned to the home, but not a Criminal Record Bureau Check. The home has been checking on this so that it is returned as soon as possible. Other staff files contained Criminal Record Bureau Checks, completed application forms and health declarations. There were no up to date or recent photographs of the staff, this must be completed for all members of staff and a requirement was made for this to be addressed. The Inspector viewed the induction the home provides to new staff. There is a document that new members of staff work through during their first week. This covers a wide range of subjects, such as emergency procedures, routines of the home and working and supporting the residents. The new staff confirmed they had received an induction and had spent time shadowing existing members of staff. Recently the Manager Designate has been using an external organisation that provides most of the mandatory training needed for the staff team. Individual staff training records evidence training attended and are useful to view when staff are due for refresher training. Staff were up to date with mandatory training, such as fire safety and moving and handling was being provided in three days time. The Inspector discussed with the Manager Designate the need for staff to receive specialist training and information on relevant subjects when working with older residents, such as dementia, the Mental Capacity Act 2005 and other health related illnesses. In light of this need and the need for senior members of staff to receive medication refresher training a requirement was made for the Manager Designate to provide staff with the learning opportunity to gain additional and necessary skills. Green Haven DS0000027707.V334836.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ benefit from living in a home that is well managed and organised. The home reviews the care being provided and seeks the views of the residents and family. Systems are in place to protect residents’ finances. The home had not notified the CSCI of an allegation made. In order to safeguard residents’ clear procedures need to be in place for all relevant professionals to be notified of an incident or allegation. Green Haven DS0000027707.V334836.R01.S.doc Version 5.2 Page 23 The fire risk assessment was basic and did not fully record how the home had considered potential risks. To protect residents this document needs to be detailed, current and informative. EVIDENCE: The Manager Designate had been in post for just over a year. He is still in the process of applying to become the Registered Manager and is aware of the need to register with the CSCI as soon as possible. The Inspector was informed of the reasons for the delay and was satisfied that attempts had been made for this issue to be resolved. The Manager Designate is currently studying for the NVQ level 4 in care and the Registered Managers Award. He is also an NVQ assessor and attends the mandatory training provided for the staff team. The Manager Designate had developed a summary of the work the home had been doing to meet the National Minimum Standards. The Inspector advised the Manager Designate to include future aims and objectives for the home. The home also seeks the views of the residents and family members and will include any relevant contributions into the above report. Monthly Regulation 26 visits also take place and the CSCI receives the reports from these independent visits. The Manager Designate also completes a report for the Committee and meets with the Committee every two months. The Inspector was satisfied that systems are in place to review the quality of care provided in the home. Where possible the Manager Designate recognises the importance of obtaining the views of the residents and their family or friends so that the care provided is what the residents want and need. The Inspector viewed a sample of residents’ monies and found these to be kept in a locked safe away from the main area of the home. All financial transactions are recorded and the home receives a full annual audit via an external organisation. Each month residents’ monies are counted and recorded. Residents receive different amounts of money each week, depending on their individual circumstances. The samples of monies counted by the Inspector were correct. Resident pay for certain services, such as newspapers, clothes and the hairdresser. The Inspector viewed the maintenance records. The electrical mains test, Portable Appliance Test and Gas Safety Record were all up to date. The home sends samples of water off to an organisation and they test for Legionella. The home was free from this in October 2006. Green Haven DS0000027707.V334836.R01.S.doc Version 5.2 Page 24 The Inspector made a recommendation for the home to carry out routine checks and de-scaling on showerheads and taps in order to minimise the spread of Legionella. Water temperatures are taken on a regular basis and all taps have thermostatic controls fitted to prevent temperatures from exceeding a safe level. The fire officer had visited in 2005 and made no recommendations. The Manager Designate was aware that new fire Regulations were introduced in 2007 and the Inspector suggested for a fire officer to visit the home to ensure the home is meeting all of the new fire Regulations. The Inspector viewed the home’s current fire risk assessment, which was a checklist and did not detail potential fire risks in the home. A requirement was made for the Manager Designate to devise a more detailed form. A recommendation was made for individual fire risk assessments to be completed on those residents who might refuse to respond to the fire alarm being set off or those residents who might need additional support and assistance from staff. Fire drills had been held during the day and night with different members of staff. The fire equipment was due to be serviced and checked the following week after the inspection. As noted in Standard 18, there had been an allegation made three months earlier by a resident. The CSCI must be notified of any major incident, accident or allegation made by a resident. This was discussed with the Manager Designate who recognised that this had been an error. A requirement was made for the home to recognise and notify the CSCI of any significant events. Green Haven DS0000027707.V334836.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 8 2 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 x 18 3 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 2 Green Haven DS0000027707.V334836.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES 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 OP8 Regulation 13(1)(b) Requirement Timescale for action 16/07/07 2. OP9 13(2) 3. OP9 13(2) Health professionals, where necessary, must be involved in providing treatment and advice for any identified specialist health need. Medication systems must be 02/07/07 robust to ensure any errors are identified. (Previous timescale 07/12/06 not met) To safeguard residents, accurate 26/06/07 records must be kept regarding the quantities of the medication that is delivered to the home. Any additional medication carried over must be recorded on the Medication Administration Records. To provide a pleasant place to bathe in, the baths on the first floor need re-enamelling and the top floor bathroom needs updating. 01/10/07 4. OP19 23(2)(d) Green Haven DS0000027707.V334836.R01.S.doc Version 5.2 Page 27 5. 6. OP29 OP30 Schedule 2 18(1)(a) (c)(i) 7. 8. OP38 OP38 23(4) 37 To protect residents, staff employment files must contain all that is listed in Schedule 2. Residents need to be supported by a competent staff team. Staff must receive refresher training regarding the safe handling and recording of medication and any other specialist training for the work they are to perform. To protect residents a detailed fire risk assessment must be devised and completed. To safeguard residents, the CSCI must be notified, if there are any serious occurrences, events, accidents or incidents in the home. Any of the above must be clearly recorded, along with any action taken following on from an event. 09/07/07 03/09/07 31/08/07 26/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP9 OP18 OP38 Good Practice Recommendations It is strongly advised that information on all medications used in the home, along with their side effects, are obtained and available for staff. It is strongly recommended that all relevant professionals be notified when an allegation of abuse has been made. It is strongly recommended that individual fire risk capability assessments be completed on those residents who do not respond to the fire drills, or need assistance from staff. It is recommended that as part of the routine maintenance checks, showerheads and taps are regularly checked for lime scale and de-scaled. 4. OP38 Green Haven DS0000027707.V334836.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI - 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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