Inspection on 17/05/06 for Greenacres

This inspection was carried out on 17th May 2006.

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

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

Other inspections for this house

Greenacres 06/11/07

Greenacres 01/03/07

Greenacres 12/09/05

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 Greenacres The Horseshoe Banstead Surrey SM7 2BQ Lead Inspector Joseph Croft Unannounced Inspection 17th May 2006 10:00 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 Greenacres DS0000059315.V295008.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. Greenacres DS0000059315.V295008.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greenacres Address Greenacres The Horseshoe Banstead Surrey SM7 2BQ 0207 759 9100 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) sharon.blackwell@anchor.org Anchor Trust Mrs Mary Elizabeth Painter Care Home 60 Category(ies) of Dementia - over 65 years of age (20), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (5), Old age, not falling within any other category (60), Physical disability over 65 years of age (20) Greenacres DS0000059315.V295008.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th September 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 accommodation for sixty (60) service users. The accommodation 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 DS0000059315.V295008.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection using the Inspection for Better Lives process for the year 2006/2007. This key inspection ensured that all the core standards of the National Minimum Standards for Older People were considered. This inspection was unannounced therefore staff and residents were not informed in advance of the inspection being carried out. At the time of the inspection, the home hosted a Surrey Adult Protection Conference. As a result of this, the inspection took over eleven hours over a two-day period with one inspector. The inspection process included a review of progress for compliance with statutory requirements made at the time of the last inspection. A tour of the premises was undertaken. Files sampled during this inspection included residents’ care plans, risk assessments, staff training records and staff recruitment files; other documents sampled included the pre-inspection questionnaire submitted by the acting manager, policies and procedures, staff duty rota, menu, medication and records of medicines. Discussions took place with the acting manager, staff, residents and relatives who were present at the time of the inspection. The home has an acting manager who commenced her duties in January 2006. To date the Commission For Social Care Inspection Surrey Local Office has not received an application for consideration to register her as manager for the home. This was discussed with the acting manager at the time of the inspection. During discussions residents stated they were happy living in the home, that the food was good and they liked the activities offered. Residents’ bedrooms had their personal belongings such as televisions, stereos, pictures, ornaments and family photographs. Residents stated that they knew the staff, and liked them. Residents are able to make choices regarding their daily lives. Discussions took place with staff on duty at the time of the inspection. Staff were knowledgeable about residents’ care plans, their likes and dislikes, and how to support residents with their personal care. Feedback was provided at the end of the inspection to the acting manager. The inspector would like to thank the staff and residents for their cooperation during the inspection. The home has been subject to one Protection of Vulnerable Adult enquiry. A copy of the report is held on file at the Commission For Social Care Inspection Surrey Local Office. Greenacres DS0000059315.V295008.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: All risk assessments must be reviewed on a regular basis. The Registered Provider must ensure arrangements for the recording, handling, safekeeping and safe administration of medicines are accurately maintained. Medication must be administered at the dose and frequency as prescribed by the doctor. Advice must be sought from the GP when omissions in medications have been identified. The acting manager and deputy manager must attend the Surrey Multi-Agency Training on the Protection of Vulnerable Adults. The register provider must ensure the member of staff identified obtains the necessary documentation from the Home Office in regard to that persons right to live and/or work in the UK. The registered provider must ensure all staff have two Greenacres DS0000059315.V295008.R01.S.doc Version 5.2 Page 7 written references. All staff files must contain individual evidence if induction, a training and development programme and records of supervision. A training schedule of how the home will work towards achieving 50 of staff with an NVQ qualification must be developed. The acting manager’s recruitment file must be available in the home at all times for inspection purposes. The registered provider must ensure the information submitted to the Commission For Social Care Inspection in regard to the home is accurate. 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 DS0000059315.V295008.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 Greenacres DS0000059315.V295008.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs are assessed prior to their moving into the home. EVIDENCE: The acting manager stated that the majority of residents have care managers who undertake pre-admission assessments. The home currently has sixteen residents who are self-funding. The acting manager and deputy manager undertake assessments on those who are self-funding, which includes a visit to the prospective resident’s present placement, and a one-day assessment undertaken at Greenacres. Pre-admission assessments were evidenced during the inspection. Residents are offered the opportunity of staying at the home for a week before deciding if they wish to move in. During discussions, residents stated they had made a visit to the home before moving in. Relatives spoken to confirm that this was the process their relative had followed. Greenacres DS0000059315.V295008.R01.S.doc Version 5.2 Page 10 Evidence of annual reviews of residents’ needs was viewed. The acting manager stated the home offers intermediate care to a maximum of four residents. Specific bedrooms are allocated for intermediate care. Residents undergo the same assessment of needs as permanent residents; this was evidenced during the sampling of files. A discussion took place with one resident who was receiving intermediate care, who stated that they enjoy coming to the home for short visits. Greenacres DS0000059315.V295008.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents are supported in a dignified and respectful manner. The management of medication administration is not satisfactory and requires further development. EVIDENCE: Senior care staff make a detailed assessment of each resident, from which their care plan is developed. The assessments covered all aspects of their lives including personal care and cultural needs. Evidence of monthly reviews was observed on the files sampled. Risk assessments were sampled, however, not all risk assessments sampled had been reviewed on a regular basis. A requirement has been made in regard to this. Records were held in several different locations. This was not seen to be helpful to staff as information concerning residents is not therefore easily and readily accessible. This could lead to information being missed and residents health needs not being met appropriately. A recommendation has been made that information about residents should be kept in one file. The acting Greenacres DS0000059315.V295008.R01.S.doc Version 5.2 Page 12 manager stated the care plans are currently being reviewed, which will incorporate all information being maintained one file. During discussions some residents were aware they had a care plan, others were not sure. Health care needs were recorded to ensure residents receive the health care services to meet their assessed needs. Files sampled included evidence that residents had been consulted on how they prefer personal care to be delivered. During discussions residents stated they were satisfied with how their personal care needs are attended to. The acting manager stated that no resident had pressure sores. If areas are identified then the district nurse, who visits on a daily basis, is immediately informed. Evidence was viewed that staff were to attend training on ‘Tissue Viability’ on the 18th May 2006. The home has regular contact with an incontinence advisor from Epsom hospital who is due to visit the home on the 22nd May 2006. Nutritional screening is undertaken, and monthly weight checks were evidenced on files sampled. Referrals are made to the GP if residents experience difficulty in eating, or are losing or gaining weight. During discussions, residents stated they are able to visit the GP, Dentist, Optician and Chiropodist as and when needed. Residents stated they can attend the doctors’ surgery, but if they are not able to, the GP will visit them in the privacy of their bedrooms. The home uses the Anchor Homes Medical Policy and Procedure that is followed by staff at the home. The acting manager stated that only one resident administers his or her own medication. The risk assessment for this was viewed, and it was evidenced that this had not been reviewed since July 2004; a requirement has been made under Standard 7 in regard that all risk assessments must be reviewed on a regular basis. Residents spoken to stated that they receive their medication at the appropriate times. The home uses Boots blister packs and medication administration record charts for recording medication. Medical records sampled provided evidence that records of medicines dispensed are not accurately maintained. Dispensed prescribed medication recorded on the Medical Administration Records sheets did not balance with the stock of prescribed medicines stored in the medical cabinet. An immediate requirement was issued in regard to this. It was also noted that several omissions had been recorded in the medical files, however, there was no evidence that the GP had been contacted to discuss the significance of these omissions. A requirement in regard to this has been made. As discussed with the acting manager at the time of the inspection, a referral has been made to the Commission For Social Care Inspection Pharmacist for an inspection in regard to medication practices at the home. Greenacres DS0000059315.V295008.R01.S.doc Version 5.2 Page 13 The Commission For Social Care Inspection Pharmacist inspection was undertaken on the 9th June 2006 with the following findings: Medication storage and records were sampled on three of the five units. This showed that: Whilst the majority of service users receive their medication as prescribed for them one person was not receiving their pain relief as regularly as their doctor had prescribed. One other service user was prescribed a sedative medication to be given ‘as needed’, with no clear instructions provided by the prescriber as to when to give this medication to the service user. Following consultation with the relevant General Practitioner, the registered person must have a clear care plan, giving detailed instructions to staff, of when to give sedative medications that are prescribe ‘as needed’ for service users. This will ensure that medication is administered in a clear and consistent way for the benefit of service users. Whilst the standard of record keeping was generally high there were a very small number of omissions in completing the records when medication was given to service users. There were systems in place to monitor this and action was being taken. When medication administration record charts were written by the care staff these were not checked for accuracy by a second member of staff, which is recommended as good practice to reduce the opportunity for errors occurring. When medication was prescribed to be given at a dose of one or two tablets the actual amount given was not consistently being recorded, though there had been some recent improvement in this. People are supported to safely look after and take their own medication, where this is appropriate. All medication was stored securely for the protection of the service users. An audit of medication usage is kept to monitor usage. The acting manager stated that only staff who have received the appropriate training are permitted to dispense medication. Training had been undertaken on the 22nd February and the 16th March 2006. Sampled evidence of this training was viewed. The next training is due on the 15th June 2006. During discussions residents stated staff always treat them with dignity and respect. Staff stated they call residents by their preferred names, treat them as individuals and respect the choices they make. Practice observed during the inspection was polite, friendly and respectful. Information in regard to personal care is recorded in residents’ care plans. Most residents have telephones in their bedrooms, and the home provides a mobile payphone. Greenacres DS0000059315.V295008.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers residents choice and opportunities in their daily life. EVIDENCE: The acting manager stated the home employs two activity co-ordinators, and is seeking to employ a third. The acting manager stated she is planning to have a three monthly rolling activity calendar. At the time of the inspection it was evidenced that three activities are offered to residents on a daily basis. Activities included aromatherapy, manicures, music and quizzes. Residents choose whether to join the activities provided within the home. Other residents attended a nearby day centre or are able to make their own way into town if they wish to go shopping or visit friends. During discussions, residents confirmed that they are able to choose activities they wish to partake in. Each unit in the home has the weekly activity sheet displayed on the notice board. It was evidenced that resident leisure and activity interests were recorded in care plans. During discussions residents and their relatives stated they are able to meet in the privacy of resident’s bedrooms and can visit at appropriate times throughout the day. Residents are able to go out with their relatives. Greenacres DS0000059315.V295008.R01.S.doc Version 5.2 Page 15 Residents’ religious needs are met through attending church services of their choice, and/or attending services conducted by religious denominations that visit the home. At the time of the inspection two ministers were visiting residents at the home. The home accommodates one resident who is from a different cultural background. The acting manager stated staff use picture cards and key phrases to communicate with this resident. Staff have daily contact with the relatives of this person. Discussions took place with the relatives of the resident concerned, who confirmed the home is meeting the cultural needs of their relative. The home uses a four-week rolling menu that was viewed during the inspection. The menu provided evidence that meals were balanced and included fresh vegetables and fruit. Daily records of cooking and fridge /freezer temperatures were evidenced. Residents are offered different foods if they do not like the meal prepared. During discussions, the chef stated that a recent consultation had taken place with residents to ascertain their views about the food provided. These were evidenced during the inspection. Comments were favourable about the food provided. The chef stated that individual consultations take place with residents when they move into the home to discuss their dietary needs. This was confirmed during discussions with residents and relatives present during the inspection. All residents spoken to were complimentary about the food provided by the chef. Residents stated they are offered alternative food if they do not like a particular meal. Residents stated that they could order what they wished, including a cooked breakfast if they wanted one. Residents can choose to eat in the dining area or in their own bedrooms. During discussions staff stated that, in their opinion, the food is of a good quality. Evidence of training in food handling and hygiene was observed in staff files sampled. Greenacres DS0000059315.V295008.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system to enable residents and their families to raise concerns. Residents are not protected by the homes Protection of Vulnerable Adults Procedures. EVIDENCE: The home has an appropriate complaints leaflet that is provided to each resident. This details the complaints procedure with timescales for resolving complaints, and provides details of the Commission For Social Care Inspection Surrey Local Office. During discussions, residents stated they would make a complaint to the senior care staff or manager of the home. Staff stated they would make complaints to the manager or, if not satisfied, would contact the area manager. On the day of the inspection the home hosted a Surrey Multi-Agency Protection of Vulnerable Adults conference. An assistant operations manager from the Epsom and Ewell Social Care Team chaired this meeting. However, it was evident that the home had not followed the Surrey Multi-Agency Protection of Vulnerable Adults Procedure. The acting manager had last attended the Surrey Multi-Agency Protection of Vulnerable Adults in 2001. A requirement has been made that the acting manager and deputy manager must attend the Surrey Multi – Agency training on the Protection of Vulnerable Adults, details of the Greenacres DS0000059315.V295008.R01.S.doc Version 5.2 Page 17 dates of attendance must be forwarded to the Commission For Social Care Inspection Surrey Local Office. During discussions, not all staff were able to give accurate details in responding to Protection of Vulnerable Adult issues. All staff stated they would report poor practice to the senior care staff and/or the manager. The acting manager stated that all staff are attending Protection of Vulnerable Adults training on the 24th and 25th May 2006. The inspector viewed the Protection of Vulnerable Adults Policy and Procedure produced by Anchor Homes. Further advice will be sought in regard to this document. Greenacres DS0000059315.V295008.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides adequate communal and individual living space making it a safe and comfortable place to live. EVIDENCE: The accommodation is divided into five units, each containing its own lounge, dining room, small kitchen, assisted bath, shower and toilets. On the day of the inspection the home was clean, tidy and free from offensive odours. Residents’ bedrooms had en-suite facilities; assisted baths were also available for use where required. Adequate bathing and toileting facilities were provided. A number of the residents’ bedrooms rooms were seen and each had been personalised with family photographs and other possessions. They were spacious, light and airy. Greenacres DS0000059315.V295008.R01.S.doc Version 5.2 Page 19 Communal parts of the units were accessible to residents and were tidy and free from obstructions. Fresh flowers were observed throughout the communal areas. Greenacres DS0000059315.V295008.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents are not fully protected by the home’s recruitment policy and practices. EVIDENCE: At the time of the inspection the duty rota evidenced that 11 staff are on duty during the early shift, and 10 staff during the afternoon/evening shift, plus an activity co-ordinator and a senior member of staff. The home uses four waking night staff, which includes a senior care officer. Four domestic staff attend to the domestic duties in the home. The acting manager stated she had reviewed the staffing ratios, which led to the increase from 8 to the minimum of 10 care staff on each shift. The home uses the Anchor Homes bank staff, however, the acting manager stated that Anchor homes have decided these will become permanent members of Greenacres staff team. Staff recruitment files were sampled. Two of the files sampled did not contain all as stated in Schedule 2 of The Care Homes Regulations 2001 as amended. It was observed that two written references had not been obtained in two identified files. These were staff who had been working at the home pre 2002. However, files of the most recently employed staff contained the necessary information. An immediate requirement has been made in regard to this. One staff file did not contain the necessary documentation from the Home Office in Greenacres DS0000059315.V295008.R01.S.doc Version 5.2 Page 21 regard to that persons right to live and/or work in the UK. A requirement in regard to this has been made. It was noted in the files sampled that not all staff had a record of induction, training and development plan or records of supervision. Requirements in regard to these have been made. Some staff files sampled evidenced they had undertaken mandatory training. A list of future training for staff was viewed, and includes training in the Protection of Vulnerable Adults, dementia care, food handling and hygiene, medication and moving and handling. During discussions staff were able to inform the inspector of the training they have received whilst working at the home. Staff stated they are provided with the training they need to ensure they continue to meet the assessed needs of the residents. The percentage of staff that hold an NVQ level 2 or above is 6 . The registered provider must forward to the Commission For Social Care Inspection Surrey Local Office a training schedule of how the home will work towards achieving 50 of staff with an NVQ qualification. The home has two NVQ assessors. New staff undergo one-week induction training, followed by shadow working for a further week. The induction training pack used by Anchor Homes was viewed at the time of the inspection, this provided a detailed and informative training week for staff new to the home. At the time of the inspection, several members, of staff were attending an on site induction-training day. Greenacres DS0000059315.V295008.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home’s management and administration do not adequately protect residents. EVIDENCE: The acting manager has been in post since January 2006, and therefore must submit an application to be considered for registration to the Commission For Social Care Inspection Surrey Local Office. The registered provider must ensure that when a new manager is appointed, an application to register with the Commission For Social Care Inspection Surrey Local Office is made promptly. The acting manager stated she has fifteen years experience working with older people, which includes the management of other care homes. This could not Greenacres DS0000059315.V295008.R01.S.doc Version 5.2 Page 23 be evidenced, as the acting manager’s recruitment file is not kept at the home. A requirement has been made that all recruitment files must be available in the home at all times for inspection purposes. The acting manager did have copies of training certificates she has undertaken, which included Registered Managers Award, NVQ assessor award, Internal Verifier, Health and Safety, nutritional screening, care for the elderly, pressure sores, first aid and medication. As stated under Standard 18, the acting manager must attend the Surrey Multi-Agency training in the Protection of Vulnerable Adults. The acting manager had submitted a pre-inspection questionnaire to the Commission For Social Care Inspection Surrey Local Office prior to the inspection. It was noted this document contained two pieces of information that were inaccurate with the findings on the day of the inspection. These were in regard to residents with pressure sores, and the number of residents with dementia living at the home. At the time of the inspection, the acting manager stated no residents currently have pressure sores, this did not concur with the information on the pre-inspection questionnaire. The home is registered to accommodate 20 residents diagnosed with dementia, however, the pre-inspection questionnaire states the home is currently catering for the needs of 24 residents diagnosed with dementia, which means the home is operating outside of the category of registration. These errors were discussed with the acting manager. Requirements have been made that the registered provider must forward evidence to the Commission For Social Care Inspection Surrey Local Office that the home does not have any resident with pressure sores, and the home is only accommodating 20 residents with dementia. The Commission for Social Care Inspection (CSCI) have previously been provided with a copy of one of the home’s internal quality audit documents. The home has devised a questionnaire for residents, their relatives and other associated professionals. The acting manager stated these are to be distributed during July 2006; these completed questionnaires will be viewed at the next key inspection of the home. The home conducts monthly meetings with the residents. The acting manager has recently commenced monthly meetings for relatives. This was confirmed during discussions with relatives. The acting manager has written an annual development plan for the year 2006 to 2007, a copy of which was provided to the inspector. Developments for the next year include training a third NVQ assessor; continue to provide training necessary for staff to meet the assessed needs of residents and a review of the accommodation for residents to be undertaken. The home use the Anchor Homes’ policies and Procedures that are available to all staff. The acting manager stated that residents and their families control their money. The home does hold small amounts of monies for residents under a Greenacres DS0000059315.V295008.R01.S.doc Version 5.2 Page 24 “Residents’ Personal Monies” (RPM). This is an interest free account with a national bank. Residents can make withdrawals in the home during office hours. Anchor Homes have issued an updated bulletin to residents, which provides information on how the RPM operates. During the inspection samples of account statements used by residents were viewed. Details of transactions are accurately recorded in these statements. Residents are able to keep sums of money locked in their bedroom lockers; however, residents must be advised as to the appropriate amounts of money to be kept. A recommendation in regard to this has been made. Residents spoken to stated they are able to access their money from the RPM accounts during office hours. One resident had been subject to a recent theft, which has been investigated under the Surrey Multi-Agency Protection of Vulnerable Adults procedure. As stated under Standard 30, evidence of ongoing mandatory training was viewed. Records of the following were evidenced at the time of the inspection; Annual servicing of the gas boiler, 8th October 2005, fire equipment manufactures check, 5th April 2006, Specialist equipment used at the home 29th April 2006, and portable electrical appliance check, 25th February 2006. The Environmental health officer inspection was on the 12th February 2005; the acting manager stated the next inspection is due on the in October 2006. The last fire drill conducted by the home was on the 29th March 2006. Daily records of fridge, freezer and cooking temperatures were viewed. Greenacres DS0000059315.V295008.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X 3 X X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X 3 X X 3 Greenacres DS0000059315.V295008.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP7 OP9 Regulation 13 (4) (c) 14 (2) 13(2) Requirement All risk assessments must be reviewed on a regular basis. The Registered Provider must ensure that arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home are accurately maintained. Medication must be administered at the dose and frequency as prescribed by the doctor. In the interest of the welfare of service users a request was made at the inspection for a General Practitioner to review and clarify the medication for one specific service user. When variable doses of medication are prescribed a record must be made of the actual dose administered to the service user. The registered provider must ensure advice is sought from the GP when omissions in medications have been identified and record the outcome. DS0000059315.V295008.R01.S.doc Timescale for action 17/06/06 17/05/06 3 OP9 12(1)(a) 09/06/06 4 OP9 13(2) 07/07/06 5 OP9 13 (1) (b) 18/05/06 Greenacres Version 5.2 Page 27 6 OP18 10 (3) 13 (6) 7 OP29 8 OP29 19 (1) (b) Sch 2 (3) Sch 4 (6) (c) 12 (1) (a) The registered provider must forward to the Commission For Social Care Inspection Surrey Local Office evidence of dates the acting manager and deputy manager are to attend the Surrey Multi-Agency Training on the Protection of Vulnerable Adults. The register provider must obtain two written references for the staff identified. 22/06/06 22/05/06 9 OP30 10 OP30 11 OP31 12 OP31 13 OP31 The register provider must ensure the member of staff identified obtains the necessary documentation from the Home Office in regard to that persons right to live and/or work in the UK. 18 (1) (c) The registered provider must Sch 4 (6) ensure all staff files contain (g) individual evidence if induction, a training and development programme and records of supervision. 18 (1) (c ) The registered provider must forward to the Commission For Social Care Inspection Surrey Local Office a training schedule of how the home will work towards achieving 50 of staff with an NVQ qualification. Sch 3 (3) The registered provider must (n) forward to the Commission For Social Care Inspection Surrey Local Office evidence of the number of residents living at the home who have pressure sores. 4 (3) (b) The registered provider must Section 24 forward to the Commission For CSA 2000 Social Care Inspection Surrey Local Office evidence of the number of residents living at the home who are diagnosed with dementia. 17 (2) The registered provider must Sch 4 (6) ensure the acting manager’s DS0000059315.V295008.R01.S.doc 22/06/06 25/06/06 29/06/06 02/06/06 02/06/06 06/06/06 Page 28 Greenacres Version 5.2 14 OP31 recruitment file is available in the home at all times for inspection purposes. 8 (1) (a) The registered provider must Section 11 submit an application to be of The considered for registration as Care manager to the Commission For Standards Social Care Inspection Surrey Act 2000 Local Office. Applications must be submitted promptly 01/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP7 OP9 Good Practice Recommendations Information about residents should be kept in one file. It is strongly recommended as good practice that when it is necessary to handwrite on a medication administration record chart in the home that the member of staff writing the chart signs and dates the chart and that a second carer checks the entry for accuracy and then initials the chart. In addition the entry should include a reference to where this information was sourced, such as the prescriber’s name. The registered person is strongly recommended to produce a clear care plan for each service user who is prescribed medication ‘to be given as needed’, to provide detailed instructions to staff as to when to give the medication. This will ensure that medication is administered in a clear and consistent way for the benefit of service users. Residents should be advised as to the appropriate amounts of money to be kept in their bedroom lockers. 3. OP9 4. OP35 Greenacres DS0000059315.V295008.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Surrey Area Office 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 DS0000059315.V295008.R01.S.doc Version 5.2 Page 30 - 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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