Inspection on 08/04/08 for Green Trees

This inspection was carried out on 8th April 2008.

CSCI found this care home to be providing an Poor service.

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 Trees 28/10/08

Green Trees 12/12/07

Green Trees 10/07/07

Green Trees 04/05/06

Green Trees 07/11/05

Green Trees 21/07/05

Green Trees 24/01/05

Green Trees 03/06/04

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Green Trees 21 Crescent East Hadley Wood Hertfordshire EN4 0EY Lead Inspector Jane Ray Unannounced Inspection 9:15 8th and 23rd April 2008 08/04/08 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 Trees DS0000010646.V361410.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 Trees DS0000010646.V361410.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Green Trees Address 21 Crescent East Hadley Wood Hertfordshire EN4 0EY 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) 020 8449 6381 020 8449 2008 admin@greentreescarehome.co.uk www.greentreescarehome.co.uk Mr Brian Colin Haydon Ms L June Haydon, Mr Simon John Kidsley Ms L June Haydon Care Home 16 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0) of places Green Trees DS0000010646.V361410.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th December 2007 Brief Description of the Service: Green Trees is a small family owned residential care home specialising in the holistic care of the frail elderly and those who suffer from dementia. Green Trees home is a detached Edwardian property located in a residential area of Hadley Wood registered to provide care and support for 16 older people. The home is near to local shops. The home has 12 single and 2 double rooms available on two floors. Ten of the single bedrooms have en-suite facilities. There are two bathrooms, both with hoists, a shower room with toilet and a ground floor toilet. The home has a lift. The home has a spacious lounge and dining room. The attractive rear garden is designed to be accessible for the residents. Mrs Haydon is one of three providers and she has managed the home for approximately fourteen years. The other two registered providers are Mr Haydon and Mr Kidsley. The home’s stated aims and objectives are to make the resident’s stay as happy and as comfortable as possible, giving high quality care to enable the highest level of independence, choice, privacy, dignity and fulfilment that individual abilities will allow. Inspection reports produced by the Commission of Social Care Inspection (CSCI) are available upon request from the registered manager/provider. The current scales of charges range from £500 to £575 per week. Green Trees DS0000010646.V361410.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. The inspection took place on the 8,10 and 23 April 2008 and was unannounced. The inspections took fifteen hours to complete. We looked around the home and spent time speaking individually or in groups to the people living in the service. We also interviewed two of the care staff who work in the home. After the inspection we spoke to two relatives to ask for their views on the service. A pharmacy inspector also carried out a separate inspection. We also looked at all the relevant records including service user records, staff files and health and safety information. The home also prepared a self–assessment (AQAA) and this was submitted to the Commission for Social Care Inspection in July 2007. This information was used as part of the inspection although some parts needed to be updated. We also used a method of observation over a one and a half-hour period in order to get a better understanding of the resident’s experience of living in this service. This is called the ‘Short Observational Framework for Inspection (SOFI). This involved observing 4 people who live in the home and recording their experiences at regular intervals. This included their state of well being, and how they interacted with staff members, other people who use services, and the environment. The quality of the staff interaction with the residents was also noted. The inspection is the annual key inspection and the aim is to look at how well the service is meeting the key National Minimum Standards for Older People. The inspector would like to thank the service users and staff for their assistance with the inspection process. What the service does well: Many of the service users and their relatives were full of praise about their lives at Green Trees and the care they receive from the staff. One resident said during the inspection “I am very pleased to have moved here. It certainly is a lovely home. I am well cared for”. The atmosphere in the home was friendly, with the residents enjoying each other’s company and chatting with the staff. One person said during the inspection “I feel I can talk to two of the carers and Green Trees DS0000010646.V361410.R01.S.doc Version 5.2 Page 6 they listen to me”. The home is a family run business and this provides continuity of care and a more informal approach. One relative said that the care provided by the home “is as near to family as you can get”. The individual staff were observed to be providing a high standard of personal care. The staff were very positive about their work and when they spoke to the residents they demonstrated a good knowledge of their individual needs and a caring approach. They take care to promote the residents privacy and dignity at all times. The home was tidy and homely and residents are encouraged to bring personal items with them to make their bedrooms familiar and comfortable. The home has an excellent cook and the lunch that was served during the inspection was tasty and nutritious. What has improved since the last inspection? What they could do better: A number of areas for improvement are identified at this inspection or are outstanding from the previous inspection. Whilst standards of care in the home have improved the care plans must reflect all the support required by residents in terms of their emotional needs. Residents must also be safeguarded, by ensuring the recording of drugs is accurate. Their dignity needs to be maintained by ensuring female residents are offered personal care by someone of the same gender. Ongoing dialogue with the local Primary Care Trust should take place to ensure that those residents who want dental care are able to access this service. More opportunities for people to go out or attend church Green Trees DS0000010646.V361410.R01.S.doc Version 5.2 Page 7 should be available for those who wish to do so. Odours in the home must be eliminated, by ensuring the carpets are steam cleaned as regularly as needed. The staff should continue to monitor their manner, language and approach to ensure their communication with the residents is of a high standard at all times. There needs to be adequate numbers of staff working at busy times to ensure the needs of all the residents are met and a cleaner must be employed to ensure care staff can concentrate on their role. Staff working at night must have an effective system for getting assistance from the sleep in staff in the event of this being needed. The Commission is considering taking enforcement action on both these staffing shortfalls. Staff must have access to an ongoing programme of training and the new system of supervision must be rolled out across the whole staff team to ensure consistent care practice. Staff require safeguarding vulnerable adult training that includes input from social services. Staff team meetings should take place to allow operational issues to be discussed. The manager must have the skills, experience and training to manage the home. The Commission is considering taking enforcement action. The home must correctly notify the Commission of serious incidents in the home and the Commission is now considering further enforcement action for this offence. The staff must receive the correct health and safety training to try to eliminate unnecessary risks for the residents. The Commission is considering taking enforcement action. 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 Trees DS0000010646.V361410.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 Trees DS0000010646.V361410.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,2,3,4 and 5 were inspected. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use this service can be assured that the home will consider their assessment as part of their admission process to the home. Information about the home is available to help them decide if the service is right for them. EVIDENCE: The statement of purpose and service user guide were inspected prior to the inspection. Both of these documents were in a user-friendly format and were clearly written, accurate and contained all the necessary information. We spoke to two relatives who said that they felt they had received enough information about the service before their relative moved in. They also confirmed that they had been offered a copy of the service user guide. They had also been able to visit the home as part of the decision making process. Green Trees DS0000010646.V361410.R01.S.doc Version 5.2 Page 10 Four case notes for people living in the homes were inspected and these all contained detailed assessments as part of the care plans prepared by the home. Three people had been admitted to the home since the last inspection. They had assessments prepared by appropriate care professionals if placed by social services. All the residents, including those placed privately had assessments prepared by the home. These contained all the necessary information. The manager and senior carer confirmed that they had met the residents prior to their admission to the home. One relative said that their mother “had been made to feel very welcome” by the staff in the home. We discussed the current needs of the people living in the home with the care staff and observed the care they were receiving. The staff felt confident that they were meeting the needs of the residents and this was reflected in the care that was observed. We looked at the contracts between the home and the residents for the three people who had moved to the service since the last inspection. They all had a contact in place that included all the necessary information and was correctly signed. Green Trees DS0000010646.V361410.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10 were inspected. People using this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people living in the home are supported to access the healthcare treatment they need. Their health is compromised by the lack of adequate recording of medication. The dignity of residents is affected by the lack of choice at night for female residents who are only offered care by a male member of staff. EVIDENCE: We looked at the care plans for four people living in the home. These documents had been developed further since the previous inspection and generally covered all the areas where care and support were needed. They provided guidance to staff on what action they needed to take to meet each persons needs. The care plans had all been reviewed on a monthly basis. Two of the residents whose care plans we looked at had complex emotional needs. The care plan contained very limited guidance on how staff might wish to Green Trees DS0000010646.V361410.R01.S.doc Version 5.2 Page 12 support the person with these needs. For example one care plan said to “give support and reassurance”. Only one of the four people whose care plan was viewed had any record of a review meeting with their social worker in the last year, although one person had not yet been in the home for a year. The registered provider was able to show the letters that had been sent to social workers inviting them to attend review meetings. We also spoke to a couple of members of care staff and they explained that at the moment the key worker system is not being implemented. One senior carer said “she key-works all the residents” and another said, “I do not key work anyone”. It is recommended that a key working system is implemented that enables staff to provide specific support to individual residents. This recommendation is outstanding from the previous two inspections. The case notes that we inspected showed that areas of risk were assessed. These included moving and handling, nutrition, infection control and pressure care. The home also keeps a record of each persons weight on a monthly basis. Only one person has bedrails. A risk assessment is in place signed by the relatives and healthcare professional to confirm this is an appropriate intervention. At the time of the inspection the manager explained that none of the residents had a pressure sore. It was observed that residents at high risk of developing pressure sores had a pressure-relieving mattress on their beds. The manager also explained that only one person was receiving input from the district nurse. Since the last inspection there has been an adult protection investigation in the home. Whilst the allegation of abuse was not substantiated it had raised issues of care staff performing care that was potentially nursing care input. The manager said that they were ensuring that referrals were being made to district nurses and not undertaking nursing tasks. The case notes showed that the home has a separate record of healthcare appointments for each resident. These showed that the residents were receiving primary healthcare input and being referred for specialist input as needed. The adult protection investigation had raised concerns about medical input being accessed in a timely manner. The healthcare records showed that medical input had been sought promptly for residents. One resident did say that she had an ongoing stomach complaint and would like to see the doctor. The manager said this is an ongoing issue and in the past she has declined offers to contact the GP. The manager explained that most of the residents can now only access a private dental service and that relatives have been informed of this. The manager explained that since the last inspection she has contacted the PCT about dental input. One resident said he really wanted a dental appointment Green Trees DS0000010646.V361410.R01.S.doc Version 5.2 Page 13 and is unable to leave the home. The manager explained that this has been discussed at his review meeting and the care manager is resolving funding issues. The manager explained that referrals have been made for residents to receive support with mental health issues. One resident has had input from a psychiatrist. We looked at the medication system in the home. The home uses a system of dossette boxes organised by the pharmacist. The home has medication administration charts. These include a photo of each resident apart from those who moved in very recently and these help to ensure the medication is administered correctly. The medication received in the home is recorded on the MAR sheet and there is a separate book for medication returned to the pharmacy. An audit trail for the medication is available. Three gaps were observed on one residents MAR sheets. The temperature in the medication trolley is recorded daily. One resident had PRN medication and guidelines had been put in place to say when this should be administered. Two residents were taking a controlled drug. The controlled drug records were inspected and a running total had not been maintained for one of the residents. When the manager tried to work out how many tablets should be in stock this did not reflect the tablets available in the medication cupboard. The manager acknowledged that she had not recorded when the medication had been delivered. Two days after the inspection we spoke to the manager who confirmed that she had corrected the controlled drug records and that all the medication was accounted for. The staff training records were inspected for seven staff and they had all received medication training from the home manager in the home. Throughout the inspection the staff were observed supporting the people living in the home with their personal care, meals and moving around the home. This was done in a manner that respected the residents’ privacy and dignity. It was however noted that at night there was only one waking night staff and this was a male member of staff on a few nights. This staff member when spoken to during the inspection explained the care he provides at night and this involves offering support with personal care. The manager explained that none of the female residents have expressed concerns about being supported by a male member of staff but a choice of staff is not available. It was observed that the staff were very aware of the mood and comfort of the residents and responded to any sign of distress, including non verbal indications. The SOFI exercise indicated that for most of the one and a half hour period the residents who were observed were generally in a positive mood state. The engagement of the residents was mainly with staff but some residents also had some contact with each other. The staff interaction was generally good and they showed warmth, respect and were also enabling the residents to be interested in current affairs. It was however noted that some of the staff spoke Green Trees DS0000010646.V361410.R01.S.doc Version 5.2 Page 14 very loudly to each other and laughed very loudly, which can be a bit overpowering. Staff on occasion used language that was over familiar. The staff also tended to relate more to the residents with stronger verbal communication skills and they need to ensure the quieter residents are included in the conversations. Standard 9 Evidence from inspection carried out by Lawrie Allum, Pharmacist Inspector on the 23 April 2008. On 23 April 2008 at 10:20 I conducted an unannounced pharmacists specialist inspection of the home when I was accompanied by June Haydon, the home’s manager. The service was currently having medicines prescribed 4-weekly and dispensed weekly in the Nomad monitored dosage system (MDS). As many medicines are unable to be included in the MDS the manager expressed concern in the increasing problem whereby medicines are dispensed in both the MDS, providing for one week at a time, and standard containers, providing supply for the full 4-weeks prescribed. The manager was considering discontinuing the MDS so that all medicines are dispensed in standard containers to enable each resident’s medicines be kept together within a dedicated tray within the locked medicines trolley. Medicines administration records (MAR) were recorded on a 13-week chart purchased by the home. Audits of medication indicated that 5 out of the 6 medicines selected at random did not agree with the quantities recorded. It was therefore not possible to confirm that these 5 medicines were being administered in accordance with the prescribers’ directions and consequently an immediate requirement notice was served with respect to addressing this issue. Controlled Drugs (CD) were stored in a locked CD cupboard located within the locked medicines cupboard. Owing to night staffing arrangements there were difficulties in terms of access and recording when a CD was required to be administered at night. Means of addressing these issues were discussed including the installation of a stand-alone CD cupboard, in order to meet the Misuse of Drugs Regulations. Staff at the home received medication training from the manager including ongoing assessment. In order to ensure that the professional pharmaceutical and clinical aspects were adequately included it was recommended to include the services of a registered pharmacist in the training. Available sources of access to a suitably qualified pharmacist were discussed. Green Trees DS0000010646.V361410.R01.S.doc Version 5.2 Page 15 It was necessary to bring to attention that a medicine, finasteride, prescribed for one of the home’s residents requires awareness of handling precautions to avoid any risk of causing foetal abnormalities. Although there were currently no medicines requiring cold storage, the current arrangements included placing medicines in a separate container at the bottom of the kitchen fridge. Under the circumstances of the low demand the kitchen fridge could be used, however, the dedicated container would need to be locked, marked for “medicines only” and only accessible by an authorised carer. To meet the requirements of medicines product license the temperature recording would require maximum and minimum (M/M) temperatures to be recorded daily using a M/M thermometer. To avoid the risk of cross-contamination of blood-borne infections e.g. Hepatitis, the home requires disinfection facilities and a documented procedure that includes granules containing sodium dichloroisocyanurate (Presept or equivalent) to deal effectively with any blood spillage. Further information is available from the Department of Health or from the local PCT. In order to provide access to a suitable broad range of medicines information it is recommended to provide a recent copy of the BNF. The tables at the end of this report include some of the above issues arising from the pharmacist inspector’s inspection, in requirements 9 to 12 and recommendations 6 to 8. From the findings it is concluded that the handling of medicines in this service is adequate. Green Trees DS0000010646.V361410.R01.S.doc Version 5.2 Page 16 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): Standards 12,13,14 and 15 were inspected. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are supported to make choices in all areas of their daily lives. People who use the service are able to enjoy a stimulating lifestyle and can enjoy the activities that are available. The meals are balanced and nutritional and form an important social event in the day. EVIDENCE: We were able to observe the staff supporting the people living in the home throughout the inspection. The residents are able to exercise choice in terms of when they want to get up and eat breakfast. One resident said “I like to get up early but I go to bed at the same time as some of the other people”. A member of staff talked about two residents who like to stay up late to watch films on the television. They can also ask for a drink whenever they want, although drinks are offered throughout the day. Residents are also encouraged to maintain or improve their independent living skills. One relative said, “my mother has regained skills and has started writing her diary again”. Another Green Trees DS0000010646.V361410.R01.S.doc Version 5.2 Page 17 resident said “I like to look after myself as much as possible and the staff help me if necessary”. Since the last inspection the home has made considerable progress in providing a range of activities for the residents. An entertainer visits the home on a fortnightly basis and once a week a physiotherapist comes to hold a gentle exercise class. The residents spoke very enthusiastically about both these activities. The staff in the home, also arrange additional activities including arts and crafts, bingo, quizzes, indoor gardening and music sessions. We looked at the records of these activities and also observed an activity session taking place. The residents also enjoy the fortnightly visits from the hairdresser and beautician. It was observed that residents who spend time in their rooms are encouraged and supported to participate in activities. Residents also choose to do activities independently. One resident had been given a tape recorder by the manager to listen to music and said he was “absolutely thrilled”. Another resident said how much she enjoyed doing puzzles and sitting in the garden. Since the last inspection a visiting social worker raised concerns about residents spending long periods of time in their rooms and possibly being restrained by tables being placed in front of their chairs. We found that most residents are supported to spend time out of their rooms and have chosen to be on their own. One resident was observed to have his table in front of his chair when not having a drink but we were able to see that he could push this table away if he wanted to stand up. We asked a few residents about whether they went to church. Two residents said they would like to go to church but were worried about whether the staff had time to take them. The manager explained that religious services are held in the home. It was apparent that some people who did not have regular visitors had very limited opportunities to leave the home and the two staff who arrange activities both felt that this was an area where further progress could be made. The staff and residents explained that visitors are made welcome in the home. One relative said, “we can visit at any time and are always welcomed by the staff and someone will offer us a drink”. The home has a cook and during the inspection lunch was prepared. All the food was home made and used fresh produce. The meal was healthy and nutritious and enjoyed by the residents. There was a choice of meals available and several of the residents commented on how much they enjoyed their meal. Green Trees DS0000010646.V361410.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 were inspected. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home are able to access an appropriate complaints procedure. The staff appear to understand the principles of safeguarding vulnerable adults but may benefit from additional training. EVIDENCE: The complaints procedure is available in the service user guide and includes details of who complainants can contact. Two residents spoken to during the inspection said they would speak to the manager if they had any complaints. One member of care staff who was interviewed during the inspection showed a good understanding of how to respond if he received a complaint. Since the last inspection there has been an adult protection investigation in the home. Whilst the abuse was not substantiated it was however noted that the home had not followed safeguarding vulnerable adult procedures by contacting social services to bring the allegation to their attention and ensure action is agreed through a strategy meeting. This failure to follow procedures resulted in enforcement action being taken against the home. At this inspection it was seen that the homes own safeguarding vulnerable adults procedure had been Green Trees DS0000010646.V361410.R01.S.doc Version 5.2 Page 19 updated to reflect the correct notification and investigation process. Two care staff were interviewed and demonstrated a good knowledge of how to recognise abuse and the need to report this appropriately. The investigation had also recommended that the home access training provided by Enfield Social Services. The manager said that Social Services had not provided the details of this training to the home, but there was no evidence that the home had tried to chase up this issue. The staff have already received internal training on safeguarding vulnerable adults, but this was provided by the manager who had not subsequently followed correct procedures. There was no evidence that the home has not reported a safeguarding vulnerable adult issue and the manager and registered provider now seem to have a good understanding of the importance of following correct procedures. The manager explained that the home does not hold any money or valuables on behalf of the people living in the home. Most of the residents have relatives who help them with their finances and one person has an appointed representative who acts on her behalf. Green Trees DS0000010646.V361410.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,20 and 26 were inspected. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live in the home have access to an environment that is generally clean and comfortable. EVIDENCE: We did a tour of the home. The building is very spacious and there is access through the lounge to an attractive rear garden. The home is well maintained and rooms are redecorated on a rolling programme. All the equipment was in working order. Green Trees DS0000010646.V361410.R01.S.doc Version 5.2 Page 21 There was a strong odour in one of the bedrooms, although the room appeared clean. The senior carer said that the carpet is steam cleaned every few days but this may need to take place more regularly. Green Trees DS0000010646.V361410.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 and 30 were inspected. People who use this service experience poor outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people living in the home are supported by a small stable team of staff, but staffing levels at busy times do not always meet the needs of the residents which may mean that residents do not get the support they need in a timely manner. EVIDENCE: The staff rota was inspected. This showed that during the day there were two care staff working in the home and at night there was one waking member of staff and a second staff member sleeping in. The manager may also be available but may not be working hands-on with the residents. There is also a full-time cook but the domestic post has been vacant for the past two inspections and the manager explained that no recruitment was taking place at the time of the inspection. The registered provider explained that there are also two part-time carer post vacancies. At the time of the inspection there were fourteen residents living in the home. It was observed that when we arrived at the home at 9.15am there were two staff working and it was hard for one of them to open the door as they could not leave the residents. One resident also told the provider during the inspection that he had been calling Green Trees DS0000010646.V361410.R01.S.doc Version 5.2 Page 23 for help for a long time that morning to get the assistance he needed to get out of bed. Another resident said “sometimes staff don’t come all that quickly as they have other people to see”. This indicates that there are not enough staff working in the home during busy times of the day. A requirement has been made at the previous two inspections for a cleaner to be recruited in order to ensure there are adequate numbers of staff available to meet the needs of the residents. At this inspection this post was still vacant and the care staff said that they were sharing the domestic duties between the team. The fact that one of the bedrooms had a strong odour and the carpet needed to be steam cleaned also reflected the absence of domestic input for the home. This inspection also includes evidence of inadequate numbers of care staff working at peak times. The recent adult protection procedure also raised concerns about how the waking night staff call for assistance from the sleeping in staff at night. At the moment the waking staff can phone the sleep in room or call for assistance, but that can be difficult if they are unable to leave the resident. The registered provider said they are still looking at the best way of addressing this issue. The Commission is now considering enforcement action due to the failure of the home to provide sufficient staff to meet the health and welfare needs of the residents. The previous key inspection and AQAA identify that over half the staff have completed an NVQ in care. Previous key inspections had checked that staff had completed all the recruitment checks and no new staff have come into post since the last inspection. This indicates that the service follows the correct recruitment procedures. The staff training records were inspected for all of the staff and show that all the staff have completed the Skills for Care core induction standards. Certificates are available to confirm what training staff have received, but no ongoing programme of training is in place to meet individual training needs. One of the suggestions of the recent adult protection investigation was for the home to hold a staff team meeting to discuss the recommendations of the report. The two staff spoken to during the inspection said that there had not been a staff meeting and one staff member said that they knew about the “criticisms the home had received”. We received the impression that the staff had no formal process to discuss issues and consider areas for improvements, which would enable them to provide consistent high quality care. Green Trees DS0000010646.V361410.R01.S.doc Version 5.2 Page 24 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): Standards 31,33,36 and 38 were inspected. People who use this service experience poor outcomes in this area. This judgement has been made using available evidence including a visit to this service. Whilst people living in this home benefit from stable management arrangements the manager does not have the appropriate skills to effectively manage the service. The safety of the residents is compromised by staff not having all the necessary health and safety training. EVIDENCE: The manager has been in post for fourteen years. She has a number of appropriate care qualifications but no management qualification and therefore needs to undertake an NVQ level 4 in management and care. At the previous Green Trees DS0000010646.V361410.R01.S.doc Version 5.2 Page 25 key inspection she was asked if she had started this qualification and said this had not been booked and she felt she would not be able to pass two of the units. The Registered Person since the last inspection has verbally proposed that the deputy manager will work towards becoming the manager and start the NVQ level 4. This proposal has not been put into writing to the Commission and no timescales have been given for this to be implemented. No evidence was available to show the deputy manager has started this training. The current registered manager also confirmed at this inspection that she has not started the management training. Whilst the manager demonstrates good skills in caring for the residents in the home, there is evidence that she struggles with managing the service as reflected in the recent adult protection investigation and in a number of shortfalls identified in this report. The Commission is now considering enforcement action due to the manager’s failure to undertake training to ensure she has the experience and skills necessary to manage the care home. At the previous key inspection the annual quality assurance exercise seeking the views of the service users, relatives and other care professionals associated with the home had taken place. A requirement was made at the last inspection for an action plan to be prepared in order to ensure that suggestions made as part of this exercise are implemented. The registered provider confirmed during the inspection that this has not taken place. The staff supervision records were inspected. The home has introduced a new format that has been implemented with three staff. Two staff confirmed that they had been supported to receive a more comprehensive supervision. This new system has not yet been implemented with all the staff. The safeguarding vulnerable adult investigation that took place since the last inspection showed that the home had failed to notify the Commission of the injury sustained by a resident in the home. This resulted in enforcement action taking place. At this key inspection the manager told the inspector about a resident who had to be taken by ambulance to hospital in the evening of the 1 April 2008. We looked at the resident’s records to confirm that this had happened. We asked the manager why she had not informed the Commission in line with regulation 37 and she said, “I was not sure how to complete the form”. She also explained that she was planning to attach copies of letters she had sent to the hospital about the resident’s treatment. She acknowledged that she had not notified the Commission without delay as over a week had elapsed since the incident had taken place. The Commission is now considering further enforcement action for this offence. The current certificates were available to confirm the maintenance for the portable electrical appliances, electrical appliances, gas appliances, fire alarm and extinguishers, lift, hoists, nurse call and water system. We looked at the work outstanding from the fire risk assessment and this has now been Green Trees DS0000010646.V361410.R01.S.doc Version 5.2 Page 26 completed which provides guidance to staff on maintaining fire safety in the home. The previous two key inspections have resulted in requirements being made for staff to complete necessary health and safety training in order to be able to support the residents safely. The training certificates were inspected for seven care staff and the cook. This includes four care staff who work on their own at night. In terms of moving and handling three care staff have no training, three have internal training and one has external training completed in 2002. The manager explained that she completed a correspondence course in risk assessing for patient handling in 1998 and the certificate was seen. Whilst the manager completed a certificate in training from the University of Greenwich in 1999 and this certificate was seen there is no evidence that she is appropriately qualified to train others in moving and handling. The residents are predominantly mobile but a few have limited mobility and one person needs two staff to assist with her moving and handling as stated in her care plan. In terms of first aid training, four staff have no training, two have internal training and one has external training. Three of the four staff who work on their own at night do not have evidence of first aid training. One member of staff who was interviewed during the inspection and who works at night twice a week said he had asked for first aid training. The registered provider said they had identified training at a college but this had not been booked. The manager had a certificate to confirm she had completed a course in health and safety at work in 2004 she did not have evidence that she was qualified to train other people in first aid. The cook had completed a certificate in food hygiene in 1984 and had completed internal training in 2005. The internal training had been provided by the home manager. The Commission is considering enforcement action due to the homes failure to ensure all staff have received the appropriate health and safety training. Green Trees DS0000010646.V361410.R01.S.doc Version 5.2 Page 27 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 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 3 x x x x x 2 STAFFING Standard No Score 27 1 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 2 x x 2 x 1 Green Trees DS0000010646.V361410.R01.S.doc Version 5.2 Page 28 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 OP7 Regulation 15(1) Requirement The registered person must ensure the residents have a care plan showing how each persons health and welfare needs will be met. This must address their emotional needs in adequate detail. The registered person must make arrangements for the recording and safe keeping of medication received in the home including the correct recording of control drugs. The registered person must respect the dignity of the residents by offering female residents access to same gender care. The registered person must make arrangements by training staff to prevent the residents being harmed. This training must be provided with advice from social services. The registered person must keep all parts of the home clean by steam cleaning the carpets on a regular basis. The registered person must DS0000010646.V361410.R01.S.doc Timescale for action 30/06/08 2. OP9 13(2) 30/04/08 3. OP10 12(4) 30/06/08 4. OP18 13(6) 31/05/08 5. OP26 23(2) 31/05/08 6. OP30 18(1)(c) 30/06/08 Page 29 Green Trees Version 5.2 7. OP33 24(1)-(3) 8. OP36 18(2) 9. OP9 13(2) 10. 11. 12. OP9 OP9 OP9 13(2) 13(2) 13(2) ensure staff receive training appropriate to the work they perform by the provision of an ongoing programme of training. The registered person must maintain a system for improving the quality of care provided by the home by collating the results of the annual quality assurance exercise and preparing an action plan. This requirement is restated from the previous inspection. Previous timescale of 28/02/08 was unmet. The registered person must ensure all the care staff are appropriately supervised by implementing the system of supervision for all the staff working in the home. This requirement is amended and restated from the previous two inspections. Previous timescales of the 31/08/07 and 28/02/08 were unmet. Medication records are required to be accurate to account for the administration of medicines to users of the service in accordance with prescribed directions. Immediate Requirement notice issued 30/04/08. Controlled Drugs (CD) are required to be stored in a CD cupboard at all times. A written policy/procedure is required for medicines with additional handling precautions. It is required to provide the necessary cold storage for medicines. 31/05/08 31/05/08 12/05/08 23/04/08 23/04/08 23/04/08 Green Trees DS0000010646.V361410.R01.S.doc Version 5.2 Page 30 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 OP7 OP8 OP10 Good Practice Recommendations The registered person should operate a key-working system to ensure the needs of each resident are fully met. This is restated from the previous two inspections. The registered person should continue to liaise with the local PCT to address dental input for residents living in the home. This is restated from the previous two inspections. The registered person should ensure staff continue to improve their approach with the residents by not speaking or laughing too loudly, not using over familiar language with each other and continuing to try and engage the less verbal residents. The registered person should try to offer opportunities for more activities in the local community and to facilitate residents who want to go to church. The registered person should hold regular staff meetings to allow operational issues relating to the home to be discussed with the staff team. It is recommended that a registered pharmacist is included in medication training for the home’s care staff to ensure the inclusion of up to date reference on pharmaceutical and clinical aspects. To avoid the risk of cross-contamination of blood-borne infections, disinfection facilities and a documented procedure that includes granules containing sodium dichloroisocyanurate should be provided for dealing effectively with any blood spillage. To meet the home’s access to medicines information it is recommended to keep a recent edition of the British National Formulary (BNF). 4. 5. 6. OP12 OP27 OP9 7. OP26 8. OP9 Green Trees DS0000010646.V361410.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Green Trees DS0000010646.V361410.R01.S.doc Version 5.2 Page 32 - 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. 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