Inspection on 31/08/06 for Green Haven

This inspection was carried out on 31st August 2006.

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

Green Haven 25/06/07

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 31st August 2006 09:05 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 Green Haven DS0000027707.V303841.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.V303841.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 *** Post Vacant *** 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.V303841.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd January 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. The majority of the service user group are frail elderly. However, the home aims to support service users in maintaining links with the community as far as is practical and in accordance with service users 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, one has en-suite facilities. The home has a large lounge and separate dining room. Smoking is only permitted in a part of the dining room. Fees vary from £425 per week for private and Social Services funded service users. Fees for service users staying for a short respite period are £440 week and fees for those service users living in larger double bedrooms are approximately £500 per week. Green Haven DS0000027707.V303841.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. The Registered Manager had left the home four months earlier and a new Manager has been in post for almost three months. This Manager will apply to become the Registered Manager and will be referred to as the Manager Designate in this inspection report. The Manager Designate assisted the Inspector with the inspection. Two members of staff, one visitor and four service users were spoken with as part of the inspection process. The home had eighteen permanent service users and one service user living in the home for short-term respite. There were no staff vacancies at the time of the inspection. All of the previous requirements were met and ten new requirements were made at this inspection. All of the Key Standards were assessed at this inspection. What the service does well: The home offers service users a homely and welcoming place to live in. The staff, many of whom have been in post for several years, are committed and enthusiastic in meeting the diverse needs of the service users. Service users and the visitor spoken with commented on the staff’s friendly and approachable manner. Green Haven DS0000027707.V303841.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Risk assessments that are completed must record all identified and potential risks regarding service users and note any risks that could be posed towards others. Daily records and occurrence sheets must be written in language that is professional and respects the dignity and choice of the service users. Medication must be counted and recorded when it is delivered to the home to ensure spot checks, when counting loose medication, can take place. Thus identifying easily if there have been any errors in administration. Social activities must be considered by all members of staff and developed to meet individual preferences and capabilities. Evidence must be available to demonstrate how the home offers stimulation and occupation to service users. The maintenance of bedrooms and the entrance hall must be well maintained. There must be a clear plan of action to address those rooms affected by the water leak that had come from the roof. All staff must be aware of the expectation there is for staff to obtain an up to date qualification, such as an NVQ. The home must ensure they have a staff team who have up to date knowledge and information to fully support the service users. Green Haven DS0000027707.V303841.R01.S.doc Version 5.2 Page 7 Training records must clearly evidence the courses members of staff have attended. Mandatory training must be provided within the required legal timescales and additional specialist training must also be explored to ensure staff have the necessary skills and information to care for the service users. An overall report that summarises the work and the reviews that have taken place in the home must be developed and produced for inspection and for service users. This must include obtaining service users and their representatives views on the home on a regular basis and include any relevant opinions into the report. The home must be able to show areas where there have been improvements and alterations and areas that still need attention. The home must ensure it is has an up to date certificate for the testing of Legionella. Any incidents or accidents affecting the welfare of the service users must be reported to the CSCI, preferably using a Regulation 37 form to clearly record the event and action taken after the event. Accidents/incidents must be clearly recorded in the home along the action taken following on from the accident/incident. 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. Green Haven DS0000027707.V303841.R01.S.doc Version 5.2 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 Green Haven DS0000027707.V303841.R01.S.doc Version 5.2 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 (Standard 6 is not applicable to this home). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are assessed prior to moving into the home to ensure the home can meet their needs. EVIDENCE: The Inspector viewed a pre-admission assessment completed by a senior member of staff from the home. This assessment was completed regarding a service user who is currently staying in the home on respite. The assessment recorded the prospective service user’s health, social and personal care needs, such as their mental health, any eating or drinking issues and any history of falls. In addition, the referrer, Social Services, had forwarded on to the home an assessment of the prospective service users needs. A questionnaire was also seen that recorded the service users likes and dislikes, thus evidencing the home includes the direct views of the service users and considers their individual preferences. Green Haven DS0000027707.V303841.R01.S.doc Version 5.2 Page 10 The Inspector discussed with the Manager Designate the possibility of reviewing the current pre-admission assessment form used and consider incorporating more detailed questions that will enable the home to gain further information about a service user wanting or needing to move into the home. The Manager Designate is keen to review all of the documents used in the home, as noted throughout the report and will look at altering the form in the near future. Green Haven DS0000027707.V303841.R01.S.doc Version 5.2 Page 11 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 outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall care plans outlined the personal and social needs of the service user. The risk assessments need to fully record all potential risks posed to both the service user and others in order to safeguard all concerned. The language and contents written in daily records and occurrence sheets need to improve be respectful of the service users. The health needs had been identified and were being met. The medication systems need to be robust to ensure the health and safety of all service users is upheld. Feedback from service users indicated that staff are respectful and ensure their privacy is upheld. Green Haven DS0000027707.V303841.R01.S.doc Version 5.2 Page 12 EVIDENCE: The Inspector viewed a sample of care plans, risk assessments and daily records/occurrence sheets. The care plans covered a wide range of topics such as daily living skills, physical health, mobility and social activities and those viewed were up to date. However the layout was basic and did not enable the assessor to record in any great detail the needs of the individual service user. This was discussed with the Manager Designate who informed the Inspector the care plans are to be reviewed and a new format would be introduced over the forthcoming months. The Inspector made a recommendation for the care plan format to be reviewed to ensure the home clearly records in detail service users needs and how these needs are to be met. Risk assessments had been completed and were up to date. The Inspector noted that for one service user, currently on respite at the home, their risk assessment did not include details regarding the fact they self-medicate and like to keep their medication in their bedroom. A requirement was made as omitting to complete a risk assessment regarding this task could pose a risk to both the service user and to others. See further on in this report for additional details relating to this particular service user and their medication. The Manager Designate acknowledged the need to ensure that risk assessments incorporate all potential hazards and risks for each service user and towards other service users or members of staff. Occurrence sheets were viewed at random. These are used to record any particular important piece of information. The Manager Designate is considering incorporating the daily records with the occurrence sheets, so that daily information is just written in one place. The Inspector read an occurrence sheet that implied that a member of staff had tried to offer choice to the service user, providing breakfast in their bedroom. However the record contradicted this by recording how choice had been taken away from the service user, by not providing lunch in the bedroom for the service user who wanted to remain in their room. This record indicated that the member of staff had tried to encourage the service user to eat down in the main dining room but then it was not clear if the service user ate lunch at all. The Inspector was concerned regarding the contents of the record and the language used, as some of the words were derogatory. This was brought to the attention of the Manager Designate and a requirement was made for any records relating to a service user must be written professionally and demonstrate clearly that the member of staff has respected the rights of the service user to make decisions and choices. The Inspector stressed the importance of staff being conscious of the phrases used when writing information regarding a service user and that staff need to be aware of writing the full details of an incident or occurrence as leaving any piece of information out of the record could give cause for concern. Green Haven DS0000027707.V303841.R01.S.doc Version 5.2 Page 13 Health needs were recorded on care plans and the Inspector was informed that staff accompany service users to health appointments, if family members cannot carry out this task. All service users have access to a GP, Chiropodist and Optician. A Dentist can and does visit the home where necessary. The Manager Designate informed the Inspector of their plans to introduce a medical/health form to show easily when a service user has seen a health professional and any outcome of the appointment so that staff can monitor any particular health needs. The weight of service users is recorded to enable staff to review any changes and act accordingly. Staff are aware of those service users at risk of falling and assist these service users where necessary. Samples of Medication Administration Records were viewed and these were found to be completed correctly. Liquid medicines had dates of opening written on them. The Inspector was unable to count the loose Paracetemol for one service user, as the when it had been delivered, the quantity had not been recorded. A requirement was made for all loose tablets to be counted with quantities recorded onto Medication Administration Records to ensure spot checks and audits can be carried out effectively. Spot checks are important to ensure there are no medication errors with loose medication. The medication from next week will be in the form of sealed blister packs to minimise the contact members of staff have with medication. The Inspector was informed that all members of staff would then receive training regarding the new medication systems to ensure they are aware of how to administer correctly. Currently only senior members of staff administer medication, the Manager Designate is looking to change this arrangement and encourage all members of staff, who are trained, to carry out this task. The Inspector was informed about a service user who is staying in the home for three weeks, who self medicates. The Inspector viewed this medication in the service users bedroom and found it was not locked in appropriate storage and neither was their bedroom locked. The Inspector discussed the urgency for this matter to be addressed whilst the inspection was taking place. The Manager Designate stated they would discuss with the service user either storing the medication along with the other service users medicines, which is in a secure locked cupboard or that a lockable container will be provided for them to then hold their own medication in their room. The Inspector acknowledged that it is very rare for a service user to self medicate, but that systems need to be robust to safeguard all service users. The Inspector was satisfied that this matter would be addressed immediately and a requirement was not made relating to this specific issue. Green Haven DS0000027707.V303841.R01.S.doc Version 5.2 Page 14 Overall the privacy and dignity of service users in relation to personal care was respected and upheld by the members of staff. Personal care is provided in private and it is noted on service users care plans if they are able to carry out personal care tasks independently. There is a telephone in the main hall for service users to use, although this is not in a private area. Service users confirmed they receive their personal mail unopened. The service users informed the Inspector that they always wear their own clothes and the visitor also confirmed this. The Inspector observed interactions between staff and service users and found these to be positive and caring throughout the inspection. Green Haven DS0000027707.V303841.R01.S.doc Version 5.2 Page 15 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 outcome area is good. This judgement has been made using available evidence including a visit to this service. The shortfalls in providing regular social activities and stimulation need to be addressed by the home in order to meet service users expectations and enrich their lives. Visiting is encouraged by the home to maintain social contacts and relationships. Service users are assisted to have control and autonomy over their lives. Meal provision and meal times are well managed and provide a healthy and nutritious diet for the service users. Green Haven DS0000027707.V303841.R01.S.doc Version 5.2 Page 16 EVIDENCE: Some social activities are in place, such as entertainers, who occasionally visit the home and provide various types of entertainment such as playing the piano. On the day of the inspection, a religious service was taking place for those service users with a particular faith. One service user spoken with attend Age Concern three times a week and is picked up via Dial-A-Ride. They spoke positively of this social group. One member of staff and some service users who were spoken with, commented on how there could be more activities provided in and outside of the home. In the past group outings had been planned, but often service users then decline attending. The scale and type of engagement and activity will vary depending on the needs and interests of the service user. Members of staff should discuss with service users their likes and interests and this should be documented clearly on individual service user care plans. The Inspector is aware of the difficulty that although there is one member of staff in charge of co-ordinating activities they along with other members of staff work directly hands on with the service users and activities are provided if there is time and sufficient staff working on any one shift. Training is to be offered for the staff member in charge of organising activities with the hope that any ideas and new information will be cascaded down to other members of staff. A requirement was made for the home to consider how to best use the staffing resources available to provide stimulation and occupation on a regular daily basis. Evidence must be available for inspection to demonstrate that staff have offered activities to service users. The Inspector spoke with a visitor who said they could see the service user in the main communal areas of the home or in private. Service users spoken with also informed the Inspector that visiting times are flexible in the home and that staff make visitors welcome. The Manager Designate is planning to hold service user and family meetings on a regular basis to ensure communication and developing positive relationships takes place. The Inspector viewed a care plan that highlighted where the service user was able to carry out certain tasks independently. The Inspector spoke with this service user who confirmed that staff promote their independence as much as possible. Those service users who can manage some of their personal finances are encouraged to do so. A service user showed the Inspector their bedroom where they had been able to bring some of their personal possessions. Green Haven DS0000027707.V303841.R01.S.doc Version 5.2 Page 17 The Inspector viewed the kitchen and met with the assistant cook. The kitchen, although small, was tidy and clean at the time of the inspection. Menus were viewed and showed that various meals were provided to suit the preferences of the service users. There are often two choices available and each day the kitchen staff speak with the service users to ascertain what they would like to eat. The Inspector observed lunchtime and sat with the service users. The Inspector saw that alternatives were provided for those service users who request a different meal. The lunch was not sampled but the pie was home cooked and all the service users spoken with spoke highly of the food provided in the home. Fresh produce is used as much as possible and special diets, such as Diabetes is catered for. The assistant cook then prepares the evening meal, often including homemade cakes. The assistant cook has obtained an NVQ level 2. Fridge and freezer temperatures are taken on a daily basis and were within an appropriate range. Staff were seen to offer additional food to service users to ensure they had received a sufficient amount of food. Overall lunchtime was unhurried with members of staff, where necessary, supporting service users. Meals are recorded on individual service users to enable the home to monitor service users diet and food intake. Green Haven DS0000027707.V303841.R01.S.doc Version 5.2 Page 18 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 outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are aware of how to make a complaint and feel their complaints or concerns would be listened to. Systems are in place to safeguard the service users. EVIDENCE: The complaints procedure is freely available and was viewed by the Inspector in the entrance hall. Those service users asked stated they would speak to the Manager Designate if they had a concern or complaint. The Inspector viewed the complaints book. There had been no complaints for several years. The home had a Protection of Vulnerable Adults, (POVA) allegation made by a service user regarding a member of staff earlier in the year. The CSCI and the local authority’s safeguarding adults co-ordinator was informed of the allegation and this had been investigated by Social Services. The allegation was not upheld and the Inspector, who liaised with Social Services during this investigation was satisfied that it had been managed appropriately. Staff are due to receive training on POVA the following week after the inspection. The Inspector discussed POVA issues with those staff spoken with and was satisfied that staff knew how to respond if they had POVA concerns. Green Haven DS0000027707.V303841.R01.S.doc Version 5.2 Page 19 The Inspector spoke with the Manager Designate to ensure all staff are aware of the policies and procedures of both the home and the local authority so that all staff know who to contact, if the Manager Designate is not available, any POVA concerns. Green Haven DS0000027707.V303841.R01.S.doc Version 5.2 Page 20 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, 24 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The shortfalls outlined below need addressing to ensure the home offers a welcoming and safe environment to live in. Service users bedrooms offer them the privacy and space to be with their personal belongings. Overall the home was clean and offered pleasant surroundings to live and work in. EVIDENCE: The Inspector carried out a tour of the home and inspected all floors and viewed a sample of rooms. Overall the home is well maintained and offers a homely environment to live in. There are photographs of service users and members of staff located in the hall that offer a personal feel to the home. Green Haven DS0000027707.V303841.R01.S.doc Version 5.2 Page 21 There had been a leak from the roof and this had recently been dealt with and fixed. However two bedrooms, number 20 and 16 had been affected by the leak and were in need of decoration once the ceiling was dry. In addition the main entrance hall carpet was looking frayed and worn in certain places, therefore a requirement was made for the rooms to be decorated and the carpet to be replaced as soon as possible. The Manager Designate informed the Inspector that four bedrooms would be decorated and updated each year. The garden is kept tidy and there is a maintenance man available to ensure the general up keep of the home is maintained. The Inspector viewed the book used to record when there is a maintenance issue and this work is then ticked off when completed. A service user showed the Inspector their bedroom. They stated they were happy with the room and that they had been able to bring a few personal possessions when they moved in. They also confirmed they can lock their bedroom if they require privacy. The home was clean, tidy and free from any offensive odours at the time of the inspection. The home has two domestic members of staff who maintain the day-to-day cleanliness of the home. The Manager Designate confirmed that the domestic staff attend mandatory training and any other training relevant to the work they are to perform. The laundry room is located in a separate room where a member of staff informed the Inspector they soak and wash any soiled items of clothing separately. The washing machine has a sluice cycle and the Manager Designate is to introduce the use of plastic red bags for soiled items. These bags can go straight into the washing machine, as they dissolve. Members of staff receive infection control training on a regular basis. Green Haven DS0000027707.V303841.R01.S.doc Version 5.2 Page 22 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 outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users needs are met by sufficient numbers of staff. NVQ, or equivalent, needs to be promoted and encouraged for all members of staff, to ensure they have reflected on their practice and have obtained new skills. Recruitment procedures are robust and aim to protect the health and welfare of the service users. The shortfalls in providing ongoing mandatory and specialist training needs to be addressed to ensure all members of staff are protected and that they have all the required knowledge to meet individual needs. EVIDENCE: The home currently does not have any staff vacancies. One waking night member of staff has left, but existing members of staff are currently covering these hours. The Secretary is leaving the home, having been in post for several years. The Inspector met with them and the new Secretary, who was being inducted into the post, to ensure there would be a smooth transition. Green Haven DS0000027707.V303841.R01.S.doc Version 5.2 Page 23 The rota was viewed and the Manager Designate explained they had changed the rota so that it was now a monthly rota where staff work alternate weekends. One staff member stated it was now more helpful as they could plan ahead and they could also request a swap and this was assisted wherever possible. Three members of staff work on the morning and three staff work on the afternoon shifts. During the night there is one waking night member of staff and a member of staff who sleeps in. The Manager Designate, who is still familiarising themselves with the running of the home has slept in at the home. Usually sleep in’s are only carried out by seniors, the Deputy Manager and the Manager Designate. Staff told the Inspector that there were sufficient numbers of staff working in the home at any one time. The Manager Designate intends to hold staff meetings once a month and separate senior meetings to maintain good communication and to share the new approaches and systems that will be introduced over the next few months. Currently the home does not meet the minimum ratio of having 50 of staff that have either obtained or are in the process of gaining an up to date qualification, such as an NVQ. There are plans in place to address this shortfall, however a requirement was made to ensure this action takes place. The Manager Designate is aware of the need for all members of staff to keep up to date with theories and skills. However he is also conscious of the members of staff who are near to retiring who do not wish to undertake a qualification. The Inspector stressed the importance of staff to undertake training and courses relevant to the work they are to perform in order to ensure they have the necessary skills and information to meet the demands of their job and the needs of the service users. Samples of staff employment files were viewed. The Inspector viewed completed application forms, including employment history, Criminal Record Bureau Checks, a health question answered by the applicants and two references. On one file the employment history was sparse and there was only one reference. This member of staff had worked in the home for many years and so a requirement was not made relating to this shortfall as the more recent staff employment files had provided all the necessary documentation. Discussions took place with the Manager Designate regarding the health question. The Inspector recognised that it asked if the applicants were well but did not ask for specific details. The Inspector made a strong recommendation for this to be addressed and for the Manager Designate to consider devising a detailed health questionnaire where the applicant has to complete, sign and date when applying for a position in the home. This document is important as it can inform the home of any conditions they would need to be aware of. The Inspector was informed that members of staff are often asked to attend a medical once they have completed their probation period. Green Haven DS0000027707.V303841.R01.S.doc Version 5.2 Page 24 The Manager Designate informed the Inspector they had been made aware when they took up their role that several members of staff were not up to date with the mandatory training that is required. This was being addressed and some courses had already taken place, such as moving and handling and infection control. A requirement was made for all members of staff to receive up to date mandatory training. Discussions took place with the Manager Designate in ensuring that individual staff training records are kept up to date, with information regarding the training they have received and include copies of certificates, if these have been issued. The Inspector reminded the Manager Designate of the need to also explore additional, specialist training on subjects such as dementia. This will be particularly crucial, if the home is to include the admission of service users who have a diagnosis of dementia. One member of staff spoken with commented that they would benefit from training on this subject as some of the current service users were developing short-term memory loss and early dementia symptoms. The Manager Designate was aware of the need to draw on various sources, both externally and internally to ensure staff gain the knowledge and information needed to work in the home. Green Haven DS0000027707.V303841.R01.S.doc Version 5.2 Page 25 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 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is managed by a new Manager Designate and so a period of adjustment is occurring. They are competent to manage the home for the benefit of the service users. The shortfalls in providing a report regarding the review of the home needs to be addressed in order to evidence how the home monitors what is good practice and works in the home and what needs further attention. A robust quality assurance system benefits the loves of the service users. Systems for protecting service users finances are robust. The shortfalls in the health and safety records need to be monitored more closely and reviewed in order to safeguard service users health and safety. Green Haven DS0000027707.V303841.R01.S.doc Version 5.2 Page 26 EVIDENCE: The Manager Designate is in the process of applying to be the Registered Manager. They have obtained NVQ level 4 and are currently studying, thorough the Open University, a degree in Psychology. This is his first managerial position and he has several years experience as a senior and Team Leader in various establishments. He has been in post almost three months and has spent this time observing and becoming familiar with the home and how it operates. The Inspector discussed the systems the home has in place to review the running of the home. Service user questionnaires had not been obtained since 2004 and so were out of date. The Manager Designate has a two monthly report he completes for the committee members. This covers a range of subjects relevant to the home, such as maintenance, staffing and training. The Inspector made a requirement for the home to have an overall quality assurance report available for inspection and service users. This should include service users and their representative’s views and action that will be taken to address any comments, along with any improvements and alterations the home has made over the past year. This report should also demonstrate areas that still need attention. As noted earlier in the report, the Manager Designate is keen to make alterations and improvements regarding documents used in the home. He has introduced a new system for medication and will be reviewing all the policies and procedures over the forthcoming months. Regulation 26 visits also take place, although the CSCI had not been forwarded copies of these reports for several months. The Manager Designate stated they would address this with the relevant committee member. The Inspector met with the Secretary who manages service users finances. She carries out a monthly check on all service users finances to ensure no errors have occurred. In addition, the Housing Corporation audits the home and the Secretary completes a monthly management account for the committee members. A sample of service users finances were viewed and checked by the Inspector. Receipts were obtained and recorded along with any expenditure. All service users finances checked were correct at the time of the inspection. Servicing records were viewed at random. The Gas Safety Record and Portable Appliance Testing was up to date. Fire drills had been held more frequently both day and night. There was no certificate available for the testing of Legionella and the Inspector made a requirement for this to be carried out. The Inspector viewed the accident book for service users. The Inspector viewed some accounts where service users had fallen or received bruises. Green Haven DS0000027707.V303841.R01.S.doc Version 5.2 Page 27 The CSCI had not received Regulation 37 forms notifying them of any incidents or accidents over the past year. The Inspector discussed with the Manager Designate the importance for staff to know that the CSCI must be notified if there is an event or accident that could affect the health and welfare of the service users. Accidents and incidents are recorded in a book that is not an official accident book. These records did not show how the home responded once the event had occurred, such as updating risk assessments and/or liaising with health professionals. A requirement was made for all incidents and accidents to be clearly recorded and for the CSCI to be notified of any untoward event, such as a fall or incident. This information is crucial, as the CSCI needs to be kept informed of any important events and to ensure that all professionals have been notified, in particular if an incident could require further investigation, such as a Protection of Vulnerable Adults investigation. The Manager Designate must ensure that all staff are aware of when to report an incident to the CSCI and how to clearly record any event. The Manager Designate acknowledged this shortfall and informed the Inspector that this would be addressed immediately. Green Haven DS0000027707.V303841.R01.S.doc Version 5.2 Page 28 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x 3 x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 2 Green Haven DS0000027707.V303841.R01.S.doc Version 5.2 Page 29 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 OP7 Regulation 12(4)(a) (5) Requirement Daily records/occurrence sheets must be written in a professional way. These must clearly outline the care provided and any other relevant information regarding a service user. Risk assessments must be completed on all potential risks to service users and others. Medication systems must be robust and record quantities of the medication that is delivered to the home. Activities must be devised, taking into account service users preferences and abilities. The shortfalls noted in the report regarding the maintenance of the home must be addressed. At least 50 of staff must be studying, or have obtained an NVQ or equivalent qualification. Training, in particular mandatory training must be available for all members of staff. Timescale for action 31/08/06 2. 3. OP7 OP9 13(4)(a) (c) 13(2) 04/09/06 01/09/06 4. 5. 6. 7. OP12 OP19 OP28 OP30 16(2)(m) (n) 23(2)(b) (d) 18(1)(a) (c) 18(1)(a) (c)(i) 31/10/06 30/11/06 31/01/07 30/11/06 Green Haven DS0000027707.V303841.R01.S.doc Version 5.2 Page 30 8. OP33 24 9. 10. OP38 OP38 13(4)(a) 37 A system for reviewing the quality of care offered in the home must be devised. A report must then be provided and be made available for inspection and service users. The testing for Legionella must be up to date and a certificate must be available for inspection. The CSCI must be notified, using a Regulation 37 form, 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. 03/01/07 29/09/06 01/09/06 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. 2. Refer to Standard OP7 OP29 Good Practice Recommendations The care plan format should be reviewed and developed in order for service users needs to be described in detail. A detailed health declaration should be developed in order to clearly evidence the applicants’ full health/medical history. Green Haven DS0000027707.V303841.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection West London Area Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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. 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