Inspection on 25/04/06 for Greenacres

This inspection was carried out on 25th April 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Greenacres 27/11/07

Greenacres 24/09/05

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Greenacres Mill Lane South Chailey Lewes East Sussex BN8 4DY Lead Inspector Nigel Thompson Unannounced Inspection 25th April 2006 09:00 Greenacres DS0000063869.V288685.R01.S.doc Version 5.1 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 DS0000063869.V288685.R01.S.doc Version 5.1 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 Adults 18-65. 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 DS0000063869.V288685.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Greenacres Address Mill Lane South Chailey Lewes East Sussex BN8 4DY 01273 481238 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.eastsussex.gov.uk/socialcare East Sussex County Council John Reilly Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Greenacres DS0000063869.V288685.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated will be seven (7). Service users must be aged between eighteen (18) and sixty-five (65) years on admission. Service users with a learning disability only to be accommodated. Date of last inspection 24th September 2005 Brief Description of the Service: Greenacres is an established service that is registered to provide care for up to seven people who have learning disabilities and challenging behaviours. The home is a large bungalow in South Chailey, a village to the north of Lewes. It is in a quiet location, and has large gardens around the bungalow. The home includes seven single bedrooms, a lounge, a dining room, a kitchenette/dining area, a large kitchen, two bathrooms and a sensory room. There are two vehicles to enable people to access services and community facilities. Staff are employed by East Sussex County Council Social Services department, and are responsible for providing the care and day-to-day running of the home. Information about the service, including the Statement of Purpose and CSCI reports is made available to prospective service users, as part of the admission process. The range of weekly fees, as of 25 April 2006, is £61.35 - £63.93. Greenacres DS0000063869.V288685.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five and a half hours in April 2006. It found that the majority of the National Minimum Standards that were assessed had been met or partially met and the overall quality of care provided was good. Service users spoken with during the inspection expressed satisfaction with the home, the staff and the service provided. The purpose of this inspection was to assess compliance with the requirements of the previous inspection and to generally monitor care practices at the home. On the day of the inspection, the Registered Manager was not on duty and there were six service users living at the home. The inspection involved a tour of the premises, examination of the home’s records and discussion with the Resource Officer (RO). Three service users and three members of staff were also spoken with. The focus of the inspection was on the quality of life for people who live at the home. In order that a balanced and thorough view of the home is obtained, this report should be read in conjunction with previous inspection reports. What the service does well: The experienced manager and support staff in the home are clearly committed to meeting the complex needs of the service users, often in difficult and challenging circumstances. Through working closely and consistently with service users, they have developed a sound understanding of their individual care and support needs. Service users are encouraged and supported to make decisions about their lives. Where appropriate and practicable, they are involved and regularly consulted on many aspects of life in the home, including menu planning and activities. . Greenacres DS0000063869.V288685.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: 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 DS0000063869.V288685.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Greenacres DS0000063869.V288685.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 4 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The admission process is generally satisfactory, however there is a potential risk for service users and staff as the individual care and support needs of prospective service users are not always comprehensively assessed before they move into the home. EVIDENCE: Following a referral to the home, a member of a specialist Assessment Team visits the prospective service user and completes a pre-admission needs assessment, including all personal and emotional care needs, mobility issues, social and cultural needs and family involvement. During the case tracking of two service users, a full examination was carried out of all relevant documentation, including care plans. It was noted in one case that there was no recorded evidence of an initial preadmission assessment having been carried out, although comprehensive Social Care Assessments, completed following the individual’s admission to the home, were in place. Greenacres DS0000063869.V288685.R01.S.doc Version 5.1 Page 9 The Resource Officer (RO) confirmed that, as part of the home’s admission procedure, such an assessment would have been made, however, there was no documentary evidence to support this. Prospective service users are invited to visit the home to look around and meet with staff and existing clients. New service users move in to Greenacres for an initial three month trial period, during which time their suitability and compatibility are fully assessed and it is established whether their identified care and support needs are able to be met. Service users spoken with during the inspection confirmed being generally settled in the home, although one person did have concerns about the noise and unpredictable behaviour of other service users: ‘It’s alright here – I like it’. ‘Sometimes it’s noisy and I don’t like the banging and screaming. I go into my room’. Greenacres DS0000063869.V288685.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users’ care plans enable staff to meet their assessed needs in a structured and consistent manner. However individual care plans, including risk assessments do not always reflect current or changing support needs of service users. The systems for service user consultation and participation are good and service users are enabled and supported to take acceptable risks and encouraged to make decisions about their day-to-day living. EVIDENCE: The existing service user care plans are currently being improved. Key workers are working closely with individual service users to review, amend and develop ‘person centred’ Lifestyle plans. Plans that were examined were found to contain an informative ‘Pen profile’, behavioural guidelines and comprehensive information regarding the individual’s health, communication, personal and social care needs. Greenacres DS0000063869.V288685.R01.S.doc Version 5.1 Page 11 The effective use of pictures, photographs and diagrams in the revised plans ensure the assessment and ongoing care planning process is more clearly focused on and accessible to the individual service user. Lifestyle plans are now written in the first person and are clearly and directly linked to the individual’s assessed needs. Plans examined contained comprehensive details of their personal, psychological and emotional support needs. However, there was little evidence in place that Lifestyle Plans, including health and medication details, behavioural guidelines and personal risk assessments, are regularly reviewed and updated to reflect significant changes in needs or circumstances. Although guidelines and assessments have review date boxes, it was noted that the majority have not been completed. Extensive recording formats are in place and range from R1 (Annual Review working paper) to R6 (Interim service review). Formal ‘Interim service reviews’ are held six monthly, involving the service user, key worker and manager. The RO confirmed that service users’ relatives also have the opportunity to be involved, where appropriate. It was noted that, where they are able to do so, service users routinely sign their plan, to confirm agreement with any action points and issues discussed during the review meeting. Staff, spoken with during the inspection, confirmed that service users are consulted regarding many aspects of their day-to-day living, including choosing colour schemes for their room and communal areas, menu planning and recreational and leisure activities. Effective communication systems, including weekly staff meetings and monthly service users’ meetings are in place to ensure that all staff are aware of service users’ changing care and support needs. As with Lifestyle Plans, the minutes to service users’ meetings are also now recorded in a more accessible format, with the use of illustrations. Staff, including day care staff, were aware of the behavioural guidelines and individual support needs of service users and recognised the importance of a structured and consistent approach: ‘The manager is always going on about the need for consistency’. Greenacres DS0000063869.V288685.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Activities, although limited, are generally well managed and are age and culturally appropriate. Service users benefit from menus that are balanced and nutritious and reflect their individual likes and preferences. EVIDENCE: A structured weekly timetable, displayed around the home, indicates that service users have opportunities to take part in various activities, including day services, college courses, (Creative dancing and photography) and regular walks and drives out. The rural and relatively isolated location of the home clearly limits community participation and impacts on the social opportunities for service users. Consequently there is a dependence on reliable transport and support staff who are able to drive. Greenacres DS0000063869.V288685.R01.S.doc Version 5.1 Page 13 However it is evident from discussion with staff that service users continue to be supported to access a range of vocational and leisure activities and local facilities, reflecting their individual needs, preferences and abilities, including visiting garden centres and parks, arts and crafts, cooking, swimming and using the home’s sensory room. One service user was clearly very proud of her artwork, on display in her room: ‘ I do arts and craft – I like it. Do you like it?’ The RO confirmed that, where appropriate, service users’ family links are encouraged and supported, however not all service users have regular family contact. Menus are varied and balanced and are based on service users’ identified likes and preferences and an alternative to the main meal is always available. A member of staff confirmed that, for safety reasons, service users do not have access to the main kitchen and are not generally involved in meal preparation. Greenacres DS0000063869.V288685.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Staff have developed close and positive relationships with service users and demonstrate an awareness and sound understanding of their individual care and support needs. Service users receive dignified and sensitive support to meet their personal, emotional and health care needs and are protected by robust systems for the safe control and administration of medication. EVIDENCE: Service users’ personal care and support needs are clearly documented in their individual Lifestyle plan. As previously documented, the recently revised plans focus on a ‘person centred’ approach to care. Close and effective working relationships between service users and their key worker were evident, through discussion and direct observation, during the inspection. Staff spoken with confirmed that this enables any subtle change in an individual’s mood or behaviour to be identified and hopefully addressed at an early stage. Greenacres DS0000063869.V288685.R01.S.doc Version 5.1 Page 15 There was documentary evidence that service users are registered with a local GP and are supported to access a range of services and other health care professionals, including community psychiatric nurses and psychologist support, as required, to meet their assessed emotional, psychological and health care needs. During the inspection a psychologist arrived at the home, to discuss with staff the ongoing support needs of one service user and any necessary modifications to the behavioural guidelines. It was evident that staff work closely and effectively with service users and during the inspection were observed interacting individually with them in a sensitive and respectful manner. Staff were aware of and clearly knowledgeable about the personal care and support needs of each of the service users and were able to describe how those needs are effectively met in a consistent manner. Communication systems within the home were found to be effective and include daily progress sheets for each service user, a communication book and full handover between shifts. Weekly staff meetings ensure that any issues or concerns can be fully discussed. Staff spoken with during the inspection confirmed that the effective levels of communication: ‘We work as a team here and everyone knows what’s going on’. ‘It’s important that we all work together and respond to situations in the same way’. The home operates a ‘Monitored Dosage System’ (MDS) to ensure the safe control and administration of medication. Regular monitoring of procedures as well as guidance and advice is provided by a local pharmacist. During the inspection, staff were observed dispensing and recording medication, safely and professionally, in accordance with the service’s robust policy and procedures. All medication is stored securely and was found to have been recorded accurately. The RO confirmed that all staff who are directly involved in administering medicines have received appropriate training, however there was no documentary evidence to support this. Greenacres DS0000063869.V288685.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The open and inclusive atmosphere within the home enables service users, staff and visitors to feel able to express any concerns, confident that they will be listened to and acted upon. Service users are safeguarded from abuse through robust policies and procedures. EVIDENCE: A clear and accessible complaints procedure is in place. Service users and members of staff spoken to during the inspection confirmed that, should they have a concern or complaint, they would have no hesitation in speaking to the manager and each person was confident that they would be listened to: ‘Oh yes, I’d tell the manager – no problem’. It was noted that there have been no concerns or complaints recorded by the home since the last inspection. Policies and procedures relating to abuse, including whistle blowing are in place and were found to be up to date and well maintained. The RO confirmed that staff are made aware of these and other key policies and procedures as part of their induction and foundation training and they are also reinforced during supervision and staff meetings. Greenacres DS0000063869.V288685.R01.S.doc Version 5.1 Page 17 All newly appointed members of staff now undertake training under the Learning Disability Awards Framework (LDAF), which now includes specific modules regarding abuse awareness and the protection of vulnerable adults. Staff spoken with during the inspection confirmed the training provided: ‘The LDAF training is very good. We started off with ’Communication’ and how important effective communication is in this kind of work. Then we covered ‘Abuse’ – what it is and what to do if we suspect it is going on’. Greenacres DS0000063869.V288685.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 & 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users benefit from accommodation that is safe, comfortable, generally well maintained and decorated to a satisfactory standard. EVIDENCE: During my ‘guided tour’ of the premises, it was evident that there is an ongoing programme of redecoration and refurbishment. Several service users rooms had been recently repainted or, in one case, tastefully wallpapered and personalised to reflect individual tastes, interests and preferences. Significant environmental improvements have clearly been made since the previous inspection, consisting of the high quality refurbishment of the two bathrooms, shower room and toilets. However, the majority of environmental standards within the home remain largely unchanged. There are seven single bedrooms and a range of communal areas, including a sensory room and a kitchenette/dining area, where service Greenacres DS0000063869.V288685.R01.S.doc Version 5.1 Page 19 users are supported to make drinks and light snacks. A large comfortable lounge with patio windows opens onto an extensive rear garden with a barbeque area and a summer house. Service users spoken with during the inspection expressed general satisfaction with the home and particularly with their own rooms: ‘I ‘m very pleased with my room and like to come in here to listen to my music and look at my books’. In the kitchenette area, staff were observed providing support to two service users as they prepared breakfast and a hot drink. The RO confirmed that contractors are employed to maintain the garden and there is also a contract in place with a cleaning firm, who visit the home several times a week. At the time of the inspection, levels of cleanliness and hygiene were found to be generally satisfactory throughout. Greenacres DS0000063869.V288685.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 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, 32, 33, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. There are generally sufficient trained and competent staff on duty at all times to meet the assessed, often complex needs of the service users. Thorough recruitment procedures help to ensure the safety and protection of service users. EVIDENCE: Since the previous inspection six new support staff have been appointed and the duty rota indicates that staffing levels have increased and there are now sufficient numbers on each shift. However it was noted that two staff are currently on long term sick leave and, on occasions, the home continues to rely on relief staff and agency workers. The RO is responsible for recruitment within the home and confirmed that the manager is currently not routinely involved in staff interviews. However, it is evident that prior to her present role, the RO worked in the home for several years and has extensive experience of the service. She is aware of the complex needs of service users and understands the challenges faced by the staff. She confirmed that the majority of new staff had previously worked in Learning Disability services in other areas and have varying levels of relevant knowledge and experience. Greenacres DS0000063869.V288685.R01.S.doc Version 5.1 Page 21 As previously documented, all newly appointed members of staff now undertake training under the Learning Disability Awards Framework (LDAF). This is in addition to National Vocational Qualification (NVQ) in care and mandatory staff training, including basic food hygiene, fire safety and first aid. This was confirmed during discussions with members of staff, however there was no documentary evidence to support this, as training records were not made available at the time of the inspection. The current arrangements for the provision and recording of formal staff supervision was found to be unstructured and unsatisfactory. Members of staff spoken with during the inspection either had not received formal supervision or described it as being provided ‘as and when’. The RO confirmed that at present staff supervision is shared between herself and the manager. However there was again no documentary evidence to support this. A record of staff supervision dates, displayed in the office, contained many gaps and indicated that formal supervision for care staff is not currently being regularly provided and recorded, as required. Greenacres DS0000063869.V288685.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The service demonstrates a commitment to improving standards throughout, by regularly reviewing aspects of its performance, through an effective programme of self-monitoring and consultation. Service users benefit from effective record keeping and up to date policies and procedures relating to health and safety, which staff are aware of and adhere to. EVIDENCE: The experienced and competent manager is clearly working hard to improve and maintain standards and develop an open and inclusive atmosphere within the home. Staff and service users, spoken with during the inspection, confirmed how approachable and supportive he is. As previously documented, on the day of the unannounced inspection, the manager was not on duty. Greenacres DS0000063869.V288685.R01.S.doc Version 5.1 Page 23 Effective quality monitoring systems are in place, including the Periodic Service Review (PSR), carried out in the home by an independent member of care staff from another service and the monthly Service Monitoring, undertaken by a Resource Officer. The system for obtaining feedback from service users has been significantly improved by the development and recent implementation of the Annual Customer Satisfaction Feedback form. This impressive ‘user-friendly’ document makes use of illustration and symbols to establish whether an individual is satisfied with many aspects of daily living at the home. Service users are assisted, as necessary, to complete the forms. Areas covered include:- personal choices, activities, privacy, dignity and respect and the physical environment. The RO confirmed that the health, safety and welfare of service users and staff is of paramount importance within the home. COSHH assessments and guidelines are in place. Temperature regulators are fitted to all hot water outlets, accessible to service users. All accidents, incidents and injuries are recorded and reported, as required. Greenacres DS0000063869.V288685.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 2 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 X X 2 x Greenacres DS0000063869.V288685.R01.S.doc Version 5.1 Page 25 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 YA2 Regulation Requirement Timescale for action 31/05/06 2. YA6 3. YA9 4. YA35 5. YA36 14 (1) (a)(b) & (c) It is required that no service user is admitted to the home unless a full assessment of their care and support needs has been carried out. 15 (1) It is required that all service users’ care plans be regularly reviewed and updated, as necessary, to include clear support guidelines. (Previous timescale of 01/11/05 not met.) 13(14)(b) (c) It is required that all risk assessments be regularly reviewed and updated. (Previous timescale of 01/11/05 not met.) 18(1)(c)(i)16(2)(j) It is required that all staff receive up to date training in moving and handling and food hygiene. (Previous timescale of 01/11/06 not met.) 18 (2) It is required that all care staff receive regular and recorded formal supervision at least six times a year. DS0000063869.V288685.R01.S.doc 30/06/06 30/06/06 30/06/06 31/05/06 Greenacres Version 5.1 Page 26 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 YA35 Good Practice Recommendations It is recommended that all staff training be clearly recorded. Greenacres DS0000063869.V288685.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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