CARE HOMES FOR OLDER PEOPLE
Green Heys Park Road Waterloo Liverpool Merseyside L22 3XG Lead Inspector
Mrs Joanne Revie Key Unannounced Inspection 29th November 2007 9:30 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 Heys DS0000017237.V349179.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 Heys DS0000017237.V349179.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Green Heys Address Park Road Waterloo Liverpool Merseyside L22 3XG 0151 9490828 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) www.c-i-c.co.uk. Community Integrated Care Mrs Helen Cook Care Home 47 Category(ies) of Dementia (10), Dementia - over 65 years of age registration, with number (47), Mental disorder, excluding learning of places disability or dementia (10) Green Heys DS0000017237.V349179.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Service Users to include up to a maximum of 47 DE(E), of which up to a maximum 10 DE, and up to a maximum 10 MD. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Date of last inspection Brief Description of the Service: Green Heys is a purpose built Care Home, which provides nursing care to people who have dementia. The Home provides care for 47 service users over retirement age and care to ten people from the age of fifty upwards. Green Heys is situated close to Crosby village. There is a local library within walking distance and a number of shops. Public transport is approximately 5 minutes walk away. Green Heys is a privately owned establishment; the owners are a charitable organisation with a number of establishments in the North West. There are 34 single rooms, and 4 double rooms. All have en-suite facilities. There are gardens to the side and rear of the Home. There is 1 main dining room and 3-day rooms one of which is for residents who smoke. The home is built around a central courtyard, which is accessible to all. Green Heys DS0000017237.V349179.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Prior to the site visit taking place the service was asked to complete a document called an AQAA. This is a document, which gives information about the services strengths and weakness, and future plans for the service to develop further. Once the AQAA was received, surveys were sent out to the relatives of the people who live at the home and the staff who work there. Four of these were returned completed to CSCI. During the site visit, discussions were held with people who live at the home, their visitors and members of the staff team. Their views have been included within the report. The site visit was unannounced and was carried out by two inspectors. A variety of records were viewed which refer to the health and welfare and care received by the people who live at the home. This review also included viewing staff records. Observations were carried out to assess how well staff interact with the people who live at the home and how staff deliver care. The home has a manager who is registered to manage with CSCI. During the site visit an acting manager was in charge of the home as the registered manager was on secondment. A registered manager from another registered CSCI service came and supported the acting manager during the visit. This person is referred to as the supporting manager in this report. The cost of living at the home ranges from £521.00 to £ 603.00 per week. What the service does well:
The service ensures that everybody who moves into the home meets with a senior member of staff to have their needs assessed. This means that a decision can be reached about whether the service can provide the care that the person needs and the person has an opportunity to ask any questions face to face to help them make a decision about moving into the home. The staff team are good at identifying any risks to the person’s health and monitor people carefully in case deterioration occurs. Medications are managed safely so the risk of a person receiving the wrong medication is greatly reduced. Green Heys DS0000017237.V349179.R01.S.doc Version 5.2 Page 6 Family input is welcomed by the home. A visitor to Greenheys said, “We arrive at different times of the day and there are plenty of staff and they are glad to help. There is plenty of contact by nursing staff and we are involved in decisions about (name’s) care here.” Activities are provided inside and outside the home according to demand and are enjoyed by the people who live there. A person who lived at the home said, “I went out and had a good time. I was singing”. The home provides a variety of home cooked meals, which are enjoyed by the people who live there. In particular staff respond well to individual needs and wishes by quickly providing drinks and enabling meals times to be flexible. The home has a robust complaints system and provides a number of ways for people to voice their concerns. Management of the home respond and act on concerns There is a strong staff culture of whistle blowing and staff spoken with showed that they understood how to activate this and also how to protect vulnerable adults from abuse. One member of staff said” I wouldn’t care if it was a senior manager who had abused someone- Id still blow the whistle- Its not rightAbuse is abuse”. The acting manager stated that she always asks prospective employees what they would do if they suspected abuse had occurred as part of the interview process. This attitude has produced a zero tolerance to abuse and helps to ensure that the people who live at the home have their rights maintained and live in a safe environment. The organisation provides a variety of flexible training, which helps to ensure that the staff have the skills to meet the needs of the people who live at the home. The training is available” on line” so staff can complete this at home if desired whist being paid for their time. Management are able to access their work to assess progress. The service seeks people views and opinions through meetings and surveys, which shows that families and representatives have a voice on how the home is managed. The home presents as a warm comfortable clean place to live with good quality furnishings and fixtures. It has been adapted to meet the needs of the people who live there. The home has robust procedures in place to enable people to access their money safely and take a responsible attitude towards maintaining the health and safety of the people who live at the home as well as the staff. .” What has improved since the last inspection?
Green Heys DS0000017237.V349179.R01.S.doc Version 5.2 Page 7 The care plans have been greatly developed so that staff have access to up to date records about a persons needs .The service has also provided staff with good guidance, which reflects current good practise within the templates so that staff have clear guidelines of how to complete these records. Records showed that when writing a daily report staff refer to each of the indivual needs of the person as written in the plan. This shows that staff are using the plans and are considering each of the persons needs on a daily basis. The home has developed a staff member to become a “ Learning and training coordinator”. This role involves monitoring staff training to ensure it is up to date and organising available training so that staff are provided with the skills to meet the needs of the people who live at the home. The home has implemented a suggestion box as recommended by relatives, which gives people another way of raising suggestions. This also shows that peoples opinions are listened to and acted on. Many areas of the home have been redecorated and the courtyard garden has been landscaped with specialist flooring to reduce injury if a person should fall. These are significant improvements and help to promote a comfortable, homely atmosphere. What they could do better:
Despite new care plans being developed and staff being provided with written guidance, communication amongst the nursing team needs to be improved. Staff need to ensure that they act on the information provided before a person moves into the home so that the persons needs are met. During the acting managers annual leave staff had not informed CSCI of a death which had occurred. This would also suggest weak communication. Care homes by law (Care Home Regulations 2001) have to inform CSCI of all untoward/significant events which occur within the home. People equality and diversity needs have been considered but in some cases this should be explored further. Clear records should be kept of how people are receiving support and this should include the activities they are undertaking to maintain their beliefs and culture. Some of the plans viewed contained clear details of the persons wish following their death. However information in this area in other plans was incomplete. Although medicines are managed safely this system could be improved further by ensuring that the temperature of the medications fridge is tested daily to ensure it is working correctly. Green Heys DS0000017237.V349179.R01.S.doc Version 5.2 Page 8 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 Heys DS0000017237.V349179.R01.S.doc Version 5.2 Page 9 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 Heys DS0000017237.V349179.R01.S.doc Version 5.2 Page 10 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 does not apply to this service, as it does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs are fully assessed before they move into the home and they are provided with written information so they know what to expect. EVIDENCE: 3 care plans were viewed which contained assessment information and a discussion was held with the acting manager. The AQAA was considered which the registered manager had completed. The homes own assessments records have been improved since the last inspection. The records viewed covered all areas expected (i.e. psychological and physical needs) but also included the persons social needs, wishes, likes and dislikes.
Green Heys DS0000017237.V349179.R01.S.doc Version 5.2 Page 11 The acting manager who is also qualified as a registered mental health nurse confirmed that she undertakes all assessments and the records viewed reflected this. On the day of the visit the acting manager was attending a multidisciplinary team meeting to plan the admission of another person who wishes to move into the home. Two surveys, which had been completed by relatives, stated that they had received contracts, which explained the terms and conditions of residency at the home. Green Heys DS0000017237.V349179.R01.S.doc Version 5.2 Page 12 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. The service aims to care for people well and staff are quick to respond if their needs change. EVIDENCE: Three care plans were viewed. The service has introduced a new care plan template since the last inspection. The information recorded within these was clear and detailed and considered the person’s privacy and dignity and also past and present social interests. Some consideration had been given to the person’s equality and diversity needs but in some instances this could have been explored further and recorded clearer.
Green Heys DS0000017237.V349179.R01.S.doc Version 5.2 Page 13 Staff receive written guidelines also within the plan explaining how the records should be completed. This reflects good practise. Two of the plans viewed contained details of the person’s wishes following death but one did not. Each of the plans viewed showed that relatives had been consulted about each of the needs identified within the plan and relatives had signed to say that they had been involved. The plans also contained photographs of the people who they belonged to. Each plan contained daily records and staff were recording comments, which referred to each of the person’s individual needs on the plan. This reflects good practise and shows that staff are reading and referring to the plan. A carer commented that all staff are encouraged to read the plans (rather than just nurses), which also reflects good practise. Each plan viewed contained specific records of the person’s health care needs. Records were available which showed that staff consult with a variety of other health care professionals as the need arises. Daily records showed that staff respond quickly to changes in peoples needs by contacting the appropriate specialist for advice. All people who live at the home who were seen during the visit appeared well cared for i.e. wearing coordinated clothing, having tidy clean hair and clean nails. Each plan also contained risk assessments and identified whether the person was at risk of having falls, developing pressure sores or malnutrition. Records showed that people who live at the home are weighed regularly to monitor weight loss and weight increase and also showed that action is taken (usually by providing supplementary Fortified drinks) if weight loss does occur. The homes medications systems were viewed. This included receipt, administration, storage and disposal. The records clearly showed that a safe system is in place so that the people who live at the home are receiving their medication as prescribed. A dedicated locked air-conditioned room is available for storage, which also contained a medication fridge as well as trolleys and lockable cupboards. Staff were recording the temperature of the fridge but this was not always happening daily. Green Heys DS0000017237.V349179.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. Activities are provided inside and outside the home on demand for the people who live there. Meal times are flexible and enjoyed by all. EVIDENCE: Greenheys employs a designated activities co-ordinator who supervises inhouse leisure events, and outings for residents. On the day of the visit, some of the residents were listening to music in the garden-room during the morning, and others were watching a video in the main lounge during the afternoon. The member of staff responsible for activities said that due to differing abilities, concentration levels and preferences of residents, events are provided for small groups of people who would benefit most. To help residents to enjoy places of interest and community facilities, Greenheys has use of a mini bus and trained and vetted drivers are available,
Green Heys DS0000017237.V349179.R01.S.doc Version 5.2 Page 15 one being a resident’s relative. Recent outings referred to during the visit, were three trips to Blackpool (due to demand), a day out in New Brighton and a bowling trip. The activities co-ordinator said that participation in leisure activities is recorded in each individual’s care plan. It was not possible to assess levels of support, both social and spiritual, for individual residents, as some records were not written in sufficient detail. To ensure that each person receives the social and spiritual support they need, it is recommended that up to date and accurate records of activities, outings and religious observance, be maintained for each resident and are monitored. The reception area of Greenheys provides a welcoming environment for visitors. There is seating, a suggestion box, notice board giving relevant service details, and an information folder, containing details about Alzheimers disease, with a named contact person who will discuss any queries they may have about their relative’s condition. For residents who have no family, arrangements are made for support from local advocacy services to ensure they have independent representation. Residents were spending time in various areas of the building, some were in the lounges, quiet area and dining room, or in their bedrooms. One resident came to the dining room after the others had finished their meal and was served promptly by staff and was eating undisturbed and at leisure. She said that she gets up and goes to bed at times of her choosing and is always given her meal when she feels like eating. A resident seated in a quiet area was reading the paper and said he had no complaints and that staff are, “Very good, they help out.” There is a well-presented dining room and the tables are nicely laid with freshly laundered cloths, place settings and flower arrangements, condiments and cutlery. Mealtimes are flexible and during the morning, residents were seen coming in for breakfast at different times depending when they got up. They were served their choice of cereal, toast and a drink, without delay by a designated breakfast assistant. The main meal is served in two sittings, residents who need assistance with their meal being served at the second sitting. The mealtime was relaxed, and residents were served a drink as they sat down and on demand. Residents were promptly served their dinner, which was eaten at leisure. There was a cook and kitchen assistant supervising the serving of the meal and six members of care/nursing staff assisting/prompting residents. Nutritional assessments are in place for residents, their weight is monitored and their food intake is recorded after each meal, to ensure they are well nourished. Menus have been recently reviewed and provide variety and choice for residents which meet their special dietary needs, and their stated meal preferences. A chef is on duty every day and kitchen management and catering records were in good order.
Green Heys DS0000017237.V349179.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. Peoples concerns are listened to and acted on. EVIDENCE: During a tour of the environment it was noted that a complaint procedure is displayed within the foyer of the home, which gives people clear instructions of how to raise concerns. A suggestion box is also in close proximity. Records showed that the registered manager continues to investigate all complaints and concerns thoroughly within timescales. The two surveys received stated that they knew how to complain if they needed to. The home has copy of the Local councils Adult Protection procedures. The registered manager has taken appropriate action in the past when allegations have been made. Staff training records showed that staff have received abuse awareness training and further training around Protection of Vulnerable Adults from the local council. Green Heys DS0000017237.V349179.R01.S.doc Version 5.2 Page 17 During discussions with staff it became apparent that they understood the term “ whistle blowing” and the acting manager confirmed that she always asks prospective employees during interview what they would do if they suspected abuse had occurred. Green Heys DS0000017237.V349179.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): 19,22,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is a warm comfortable, clean place to live. EVIDENCE: Greenheys is a one storey, purpose-built care home, which is well maintained and is decorated and furnished in domestic style, to provide a homely environment for residents. There is an enclosed courtyard, which has planters and seating, and where they may enjoy being outside in safety. This area has been fitted with a soft ground surface to avoid injury to people in case of trips or falls. There is an ongoing decoration and replacement programme in place and floor coverings in a number of bedrooms have been replaced since the last visit.
Green Heys DS0000017237.V349179.R01.S.doc Version 5.2 Page 19 There are two lounges and a dining room for communal use and peoples’ bedrooms are personalised with the occupant’s belongings, and are generally in good decorative order. There are bathrooms and toilets throughout the building for peoples’ convenience, and a range of disability equipment including specialist seating, assisted baths, raised toilets and hoists to support those who are physically frail. Greenheys employs a maintenance person who carries out ongoing repairs. There is a system for reporting remedial work identified in regular checks of the building, and the maintenance record was read. This is signed as the work is carried out to ensure that repairs are done promptly and that the building is in good condition for residents. Areas of the building, which were seen, were clean and odour free, the cleaning schedules were read and were in good order. The housekeeper confirmed that that domestic staff receive relevant training. Cleaning materials are managed in accordance with COSHH regulations to ensure safe management and avoid risks to residents and staff. She also confirmed that there are systems in place for infection control and waste collection. There is a lockable store for cleaning materials, equipment and protective clothing. The housekeeper said that the carpet on the main corridor is steam cleaned regularly to avoid build up of odours. The laundry was well ventilated, organised and all equipment was in working order at the time of the visit. Designated laundry assistants are employed to ensure that laundering is carried out promptly, infection control procedures are followed and laundered clothing is returned to the owner’s bedroom without delay. Green Heys DS0000017237.V349179.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): 27,28,29,20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff have the skills to care for the people who live at the home and are provided in sufficient numbers to deliver that care. Communication issues are preventing some people being cared for as well as they could be. EVIDENCE: Off duty rotas were viewed which showed that the home is consistently staffed with 10 staff on duty from 8 am to 8pm (3 of whom are nurses) and five waking staff overnight (two of whom are nurses). Staff were observed to interact well with the people who live at the home and did not appear pressurised or hurried. This promoted a relaxing atmosphere. A care plan was viewed which revealed that a person who moved into the home had developed a wound prior to admission taking place, which required dressing. The acting manager had clearly recorded that this information must be developed into a care plan and that the wound must be redressed 3 days following admission. Nursing staff had not acted on these instructions and were unaware of the presence of the wound. Observation showed that the dressing was in place as detailed by the acting manager.
Green Heys DS0000017237.V349179.R01.S.doc Version 5.2 Page 21 Staff are offered the opportunity of undertaking NVQ qualifications through the companies training department. The AQAA stated that above 50 of staff have achieved NVQ qualifications. Seven staff files were viewed. All contained information to show that the necessary checks required had been carried out to make sure that the employee is suitable to work with vulnerable people. The services on line computer learning system was also viewed. A programme called “CIC academy” is available for all new staff. This meets good practise guidelines and ensures that staff receive a thorough induction to care. This learning method is flexible and the manager can monitor staff’s progress also. The service has developed a role for a training and learning co coordinator. This person organises training and monitors staff accomplishment. This information was available to view in the form of a training matrix. The matrix showed that staff had undertaken mandatory training to help ensure that the people who live at the home are safe but also specialist’s subjects such as Dementia training and the forthcoming changes in the Mental Health Act. No records were available to show that staff have undertaken training in Equality and diversity however the acting manager and the supporting manager stated that this topic is covered during staff induction. Discussions were held with staff during the visit. All were enthusiastic about their role and had compassion for the people who live at the home. Green Heys DS0000017237.V349179.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 service is managed in the best interests of the people who live there. EVIDENCE: A discussion with the acting manager and viewing her staff file showed that she is suitably qualified and experienced to manage the home in the absence of the registered manager. The organisation arranged for the acting manager to undertake a training induction to management, which she stated, was very useful. The registered manager continues to support the home.
Green Heys DS0000017237.V349179.R01.S.doc Version 5.2 Page 23 During the visit the acting manager was supported by a registered manager from another service (described as the supporting manager within the report). Incident forms have been received by CSCI from the home as required by law, however a death had occurred which CSCI had not been made aware of. This had occurred during the acting managers annual leave and procedures should be explored to ensure that this is not repeated in future absences. The home has recently achieved a five star RDB rating. Minutes of meetings with staff, carers and relatives were also viewed which showed these groups are consulted. Previous visits showed that home sends out surveys to relatives annually and the supporting manager confirmed that this practice continues .A suggestion box has been implemented following a request from relatives to enable more consultation and involvement. Records were viewed electronically and discussions held with the administrator and supporting manager. These showed that the service ensures any money that is kept on behalf of the people who live at the home is managed safely. An account has been set up with a different bank (other than the companies), which is ring fenced and yields high interest. Robust procedures are in place to manage any monies and protect the person’s best interest. A variety of certificates and contracts were viewed which showed that the service acts responsibly towards maintaining Health and Safety. These included fire records, electricity and Gas safety and water testing. Staff have had training in mandatory aspects of Health and safety to help keep people safe. No health and safety issues were identified during the visit. Green Heys DS0000017237.V349179.R01.S.doc Version 5.2 Page 24 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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 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 3 X X 3 X X x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Green Heys DS0000017237.V349179.R01.S.doc Version 5.2 Page 25 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 OP30 Regulation 13.2,37. Requirement Communication between nursing staff must be explored and rectified so that people receive the care that they need and to also ensure that the home works with in the regulatory framework of the Care Home Regulations 2001. (i.e. lack of notification following death) Timescale for action 31/01/08 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 OP7 Good Practice Recommendations Although plans are greatly improved consideration should be given to recording the equality and diversity needs of each person and how they will be supported to achieve these. Staff should ensure that they record everyone’s wishes in the event of their death. Staff should be reminded to ensure that the temperature of the medications fridge is tested and recorded daily.
DS0000017237.V349179.R01.S.doc Version 5.2 Page 26 2. 3. OP7 OP9 Green Heys 4. OP12 To ensure that each person receives the social and spiritual support they need, it is recommended that up to date and accurate records of activities, outings and religious observance, be maintained and monitored Green Heys DS0000017237.V349179.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Regional Contact Team Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2TQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries.northwest@csci.gsi.gov.uk Web: www.csci.org.uk
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