Inspection on 12/09/05 for Greenacres

This inspection was carried out on 12th September 2005.

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

Greenacres 06/11/07

Greenacres 01/03/07

Greenacres 17/05/06

Greenacres 10/05/05

Greenacres 22/11/04

Greenacres 26/07/04

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

CARE HOMES FOR OLDER PEOPLE Greenacres The Horseshoe Banstead Surrey SM7 2BQ Lead Inspector Mrs Susan McBriarty Unannouced 12 September 2005 th 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 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. Greenacres H58_s59315_Greenacres_v241436_120905_stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Greenacres Address The Horseshoe Banstead Surrey SM7 2BQ 0207 759 9100 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Anchor Trust Mr Gary Hall Care Home 60 Category(ies) of DE(E) - Dementia over 65 (20) registration, with number of places MD(E) - Mental Dissorder over 65 (5) OP - Old Age (60) PD(E) - Physical Dissorder over 65 (20) Greenacres H58_s59315_Greenacres_v241436_120905_stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Dementia - over 65 years of age (20), Mental Disorder, excluding learning disability or dementia - over 65 years of age (5), Old age, not falling into any category (60), Physical disability over 65 years of age (20). Date of last inspection 10th May 2005 Brief Description of the Service: Greenacres is an Anchor Trust care home for older people. The home is purpose built and offers well equipped accomodation for sixty (60) service users. The accomodation is divided into five units and all service users have single rooms with en-suite facilities. Communal facilities are arranged on each floor, these include dining rooms, lounges and small equipped kitchens. Each floor also has suitable toilets, assisted bathrooms and walk in shower rooms. The home is located in a residential area of Banstead, with easy access to community amenities. The home has a car park at the front of the building, and is surrounded by an enclosed garden. Greenacres H58_s59315_Greenacres_v241436_120905_stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, the second inspection for 2005 – 2006. Two staff and four residents were spoken to during the inspection. This inspection focussed on the remaining standards not assessed during the inspection of the 10th May 2005. A number of documents were sampled including, staff induction plans, the home’s financial plan and resident’s financial information. The home provided a number of documents to the Commission for Social Care Inspection (CSCI), these are noted within this report. What the service does well: What has improved since the last inspection? What they could do better: This inspection focussed on those standards not assessed during the inspection on the 10th May 2005. One requirement has been made regarding the home’s policies and procedures regarding the recording, storage and administration of medication following the finding of several errors by the staff team. The home’s policies and procedures were very clear and audit systems were in place, however evidence was found that staff were not following the home’s policies and procedures in all areas. Greenacres H58_s59315_Greenacres_v241436_120905_stage4.doc Version 1.30 Page 6 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. Greenacres H58_s59315_Greenacres_v241436_120905_stage4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Greenacres H58_s59315_Greenacres_v241436_120905_stage4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 Standards 1,3,4 and 5 were assessed during the inspection of the 10th May 2005. Standard 6 does not apply. The home provides a contract in the form of a licence to each resident of the home. EVIDENCE: A requirement was made at the last inspection, that the home updates the statement of purpose. This has been completed; Anchor Homes have provided an organisational document that is supported by information regarding Greenacres. The Inspector sampled a number of resident files and all those sampled contained a contract signed by the resident. Greenacres H58_s59315_Greenacres_v241436_120905_stage4.doc Version 1.30 Page 9 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 standard(s) 9,11 Standards 7,8 and 10 were assessed during the inspection of the 10th May. Further work is required to ensure that the home meets their own policies and procedures with regard to medication administration. The home has a policy and procedure in place regarding the care and support of those who are dying. EVIDENCE: The requirements made at the inspection held on the 10th May 2005 have been met. The risk assessments and care plans have been updated, the Inspector reviewed a small sample of the updated files. The home has a policy and procedure to support those who are dying. Further work is required to ensure that staff members are following the home’s policies and procedures in respect of medication administration. The home has a clear procedure for auditing the administration of medication including the investigation of gaps in the medication administration sheet. There were instances where gaps were found by the Inspector but had not been Greenacres H58_s59315_Greenacres_v241436_120905_stage4.doc Version 1.30 Page 10 investigated and documented by staff as required. The list of staff trained to administer medication was missing although the manager reported that an updated copy had recently been printed and placed in the main medication cupboard. In addition other errors that did not affect the health and well being of residents but indicated that staff were not following the policies and procedures were found. A requirement is made that the home reviews the policies and procedures and ensure that all staff are fully aware of their responsibilities. Greenacres H58_s59315_Greenacres_v241436_120905_stage4.doc Version 1.30 Page 11 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 standard(s) These standards were assessed during the inspection of the 10th May 2005. EVIDENCE: Greenacres H58_s59315_Greenacres_v241436_120905_stage4.doc Version 1.30 Page 12 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 standard(s) 17 Standards 16 and 18 were assessed during the inspection of the 10th May 2005. The residents legal rights are supported through training and the policies and procedures of the home. EVIDENCE: The manager has arranged training for all new staff to ensure that the staff team are fully aware of the legal rights and responsibilities of the residents. During the previous election the residents were offered the opportunity to be taken to polling station, those who wished to vote chose to use the postal voting system. Greenacres H58_s59315_Greenacres_v241436_120905_stage4.doc Version 1.30 Page 13 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 standard(s) These standards were assessed during the inspection of the 10th May 2005. EVIDENCE: A requirement was made to ensure that the home kept locked any areas where chemicals harmful to health were stored. The specified area was seen at the inspection held on the 12th September 2005 and was found to be locked. Greenacres H58_s59315_Greenacres_v241436_120905_stage4.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28 Standards 27,29 and 30 were assessed during the inspection on the 10th May 2005. The manager had plans in place to ensure that staff received qualifying training. EVIDENCE: The requirements made at the inspection on the 10th May have been met. However Anchor Trust does not keep the original Criminal Record Bureau (CRB) checks at the home. Those files sampled during the inspection contained an email from Anchor’s head office stating that the specified staff member has a clear CRB check and recording the disclosure number. Greenacres H58_s59315_Greenacres_v241436_120905_stage4.doc Version 1.30 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34,35 Standards 31,32,36,37 and 38 were assessed during the inspection on the 10th May 2005. The home has an internal system regarding quality assurance. The Inspector was provided with a copy of the home’s budget for the last financial year and for this year to July 2005. Anchor Homes have policies and procedure in place to assist residents with their own finances. EVIDENCE: The requirements made at the last inspection have been met. The Commission for Social Care Inspection (CSCI) have been given a copy of one of the home’s internal quality audit documents. The manager informed the Inspector that the audits were carried out twice yearly and seek to ensure that the home is complying with internal policies and procedures as well as the National Minimum Standards Older People. Greenacres H58_s59315_Greenacres_v241436_120905_stage4.doc Version 1.30 Page 16 THE CSCI received a copy of the budget report for the home for 2004 – 2005 and a copy of the budget report for the 2005 – 2006 year (to date). No issues have been raised by the CSCI regarding the information provided. Anchor Homes have a policy and procedure in place regarding resident’s finances. The home holds a pooled account into which specified residents monies is paid, the administrator withdraws money from the account on a regular basis and as residents request money to meet their needs the amount is recorded. The residents do have an individual statement, which reflects the amount held in the pooled account. The pooled account does not pay interest. The CSCI did not make a requirement to alter this process but did note that the system means that cash held at the home is not attributable to any one resident. Greenacres H58_s59315_Greenacres_v241436_120905_stage4.doc Version 1.30 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 2 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 x 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x 3 x x x 3 3 3 x x x Greenacres H58_s59315_Greenacres_v241436_120905_stage4.doc Version 1.30 Page 18 NO Are there any outstanding requirements from the last inspection? 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 9 Regulation 13(2) Requirement The registered person must ensure that the arrangements for the recording, handling, safekeeping, safe administration and disposal of medications are reviewed and that those staff trained with regard to medication follow the homes policies and procedures. Timescale for action 3rd October 2005. 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 Good Practice Recommendations Greenacres H58_s59315_Greenacres_v241436_120905_stage4.doc Version 1.30 Page 19 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Greenacres H58_s59315_Greenacres_v241436_120905_stage4.doc Version 1.30 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!