Inspection on 17/10/05 for Greenacres Care Home

This inspection was carried out on 17th October 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 Care Home 10/09/07

Greenacres Care Home 21/08/06

Greenacres Care Home 07/07/05

Greenacres Care Home 21/02/05

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

CARE HOMES FOR OLDER PEOPLE Greenacres Care Home Greenacres 17-19 Grimsby Road Caistor Lincolnshire LN7 6QY Lead Inspector Mr Doug Tunmore Unannounced Inspection 17th October 2005 10:15 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 Care Home DS0000053788.V258725.R01.S.doc Version 5.0 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 Care Home DS0000053788.V258725.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Greenacres Care Home Address Greenacres 17-19 Grimsby Road Caistor Lincolnshire LN7 6QY 01472 851989 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) Mr Terence Alan Shepherdson Mrs Catherine Laverick Care Home 10 Category(ies) of Old age, not falling within any other category registration, with number (10) of places Greenacres Care Home DS0000053788.V258725.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7 July 2005 Brief Description of the Service: Greenacres is a care home which provides personal care to persons over the age of 65 years. It is situated at the top of a hill within the small town of Caistor. Local facilities include shops, library, church, chapel and public houses. The registered owner/manager provides transport at no extra charge for residents wishing to access these facilities. The home stands in its own gardens, with parking available at the front of the building. Communal and bedroom (eight single and one double) accommodation is provided on the ground floor. There are separate lounge, large reception area and dining room. Greenacres is a family run business. The previous owners currently occupy the floor of the building, whilst they await the completion of a new bungalow in the grounds of the home. The homes service users guide states that we encourage clients to remain independent as possible; the care staff will support a client to enable them to achieve this. Greenacres Care Home DS0000053788.V258725.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced. The main method of inspection used was called case tracking, which also involved looking at policies and procedures relating to maintaining the safety and general welfare of residents. Residents were spoken to, as well as one relative and one community nurse, the manager and care staff and observations were made of care practices. A partial tour of the home took place. What the service does well: What has improved since the last inspection? What they could do better: The home needs to ensure that the Commission is informed of any serious accidents to residents. The home’s rota must reflect those care workers who are on duty at any given time. Personnel files must evidence that care staff have submitted the required information for the protection of residents. Fifty percent of staff must have level two National Vocational qualifications by the end of 2005. Information relating to audits carried out in the home must be posted for the information of residents and visitors. Greenacres Care Home DS0000053788.V258725.R01.S.doc Version 5.0 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 Care Home DS0000053788.V258725.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Greenacres Care Home DS0000053788.V258725.R01.S.doc Version 5.0 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 the following standard(s): 3 The home undertakes a full care needs assessment and writes to prospective residents informing them whether the home can meet their needs or not. EVIDENCE: The home has a detailed admissions procedure, which identifies the needs of residents coming into the home. Two resident’s file showed that the home had visited and carried out a care assessment of their needs and in one case a hospital discharge sheet with a care assessment was carried out, which was available on this residents file. A relative was contacted who confirmed that she and her husband had visited the home prior to her mothers emergency admission. She also said that she was aware that the proprietor had visited the hospital to talk to health care professionals regarding her mothers care needs. Evidence was seen that the home now writes to residents confirming that the home could meet their needs. A draft letter was seen which was to be sent to a resident who was an emergency admission. Greenacres Care Home DS0000053788.V258725.R01.S.doc Version 5.0 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 the following standard(s): 7&8 There is good care planning in this home, which helps ensure that the general health and welfare of residents is addressed. The Commission has not been informed about accidents to residents. EVIDENCE: Files seen showed that care plans have been updated and are available in all residents files. Admission assessments and monthly reviews were seen and had been signed by residents, their representatives, or the manager and care workers charged with this task. The minutes of the staff meeting held on 03/10/05, noted that all but two care plans have now been updated. Individual care plans evidenced that accidents are recorded in the homes’ accident book, daily notes and body maps. However, the Commission has not been informed in writing about accidents to residents. A community nurse made positive comments about the home, stating that there was good communication between the home and themselves and that staff were welcoming and helpful and could follow instructions given to them regarding the care of residents. Greenacres Care Home DS0000053788.V258725.R01.S.doc Version 5.0 Page 10 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): The above standards were not inspected. EVIDENCE: Greenacres Care Home DS0000053788.V258725.R01.S.doc Version 5.0 Page 11 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): The above standards were not inspected. EVIDENCE: Greenacres Care Home DS0000053788.V258725.R01.S.doc Version 5.0 Page 12 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 & 26 The home is well maintained, the standard of the environment and its facilities are appropriate and safe for the needs of residents. The home is clean and tidy, with a pleasant smell throughout. EVIDENCE: The home has a rolling maintenance programme, which shows forthcoming maintenance and decoration to be carried out externally and internally at the home. A tour of the environment found that the home was decorated to a reasonable standard. The home is currently planning to re-fit the kitchen with stainless steel work tops/ovens. The home also carries out monthly risk assessments relating to all perceived areas of risk for residents. The home employs one cleaner who works eighteen hours in three days each week. The community nurse said that she has not detected any unpleasant odours in the home during her visits. A partial tour of the home by the inspector found it to be clean and it smelt fresh. Greenacres Care Home DS0000053788.V258725.R01.S.doc Version 5.0 Page 13 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 & 30 The numbers of staff on duty meets residents needs. The homes recruitment procedures are not implemented. The home rota does not reflect accurate staffing levels. Staff are trained to carryout their jobs. EVIDENCE: Two care workers personnel files did not have a photograph, identification or a record of their initial interview. None of the care workers have been given The General Social Care Council Codes of Practice, which sets out their responsibilities as care workers looking after vulnerable adults. The homes training plan was seen and found to be up to date. The training record identified those workers, one a senior care worker, who had undertaken statutory training in 2004 and 2005. The care manager has NVQ (National Vocational Qualifications) 2 & 3 and is awaiting her NVQ 4 qualification. One care worker has NVQ level 2 & 3, three workers are currently undertaking NVQ level 2 training and a further two workers have GNVQ (General National Vocational Qualifications). One carer stated that she had undertaken; fire procedures, manual handling, food hygiene, first aid and health and safety training. She also confirmed that she is undertaking NVQ training level two. She was able to demonstrate a clear understanding of her role and responsibilities. Greenacres Care Home DS0000053788.V258725.R01.S.doc Version 5.0 Page 14 The homes rota was seen and it was found that adequate staffing levels are maintained to meet the needs of residents. One carer stated that there are always enough staff on duty to cover shifts. There is one waking night staff and one sleeping night worker, who is on call. However, the on call worker is a family member and past care manager and lives in the home in separate accommodation. The rota does not show that she is on duty from 21.00 hrs to 07.00 hours in the morning. Comments received by the community nurse were ‘ hardly any staff turnover, the staff have been here for a while. I have often seen them doing training, with workers from other homes also visiting to train’. She also stated that there are enough staff on duty and residents are very well cared for,’you can’t fault them, caring and on the ball’. Greenacres Care Home DS0000053788.V258725.R01.S.doc Version 5.0 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 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 & 38 Records seen show that residents’ health and general welfare and safety are promoted. The home ensures that that the residents have the opportunity to voice their views and opinions. Accurate records are kept of residents’ monies. EVIDENCE: The registered manager is qualified and experienced in running this home for ten older people. Comments made by the visiting community nurse and staff showed that she is seen in a very positive light and is currently making changes in the home to meet current standards. The home conducts an in-house residential quality assurance audit. Questionnaires have been given to residents, relatives, pharmacist and the community nurses in 2005. The survey was seen by the inspector, which covers many aspects relating to the running of the home and the conduct of care workers. The returned questionnaires were seen to contain positive Greenacres Care Home DS0000053788.V258725.R01.S.doc Version 5.0 Page 16 comments from residents and relatives. The provider stated that the audit had not been posted on the notice board for the information of residents and relatives. The community nurse confirmed that the practice had received a questionnaire from the home. The minutes of the last residents meeting held in 03/10/05 showed that residents are encouraged to voice their views and are actively involved in issues relating to the running of the home. A care worker commented that residents meetings are held and they are encouraged to voice their opinions about the running of the home. Residents seen at lunchtime said that the staff are very kind and approachable. The home does not deal with residents monies but keeps a receipt book in which the hairdresser or chiropodist signs and dates for any service given. Any necessities are bought by the home and then relatives reimburse them, with receipts made available. All other monies relating to funding are paid into the homes bank account on a standing order by relatives. No other monies belonging to residents are paid into the homes account. There are a range of policies and procedures available in the home relating to fire safety and fire risk assessments. There was also evidence that fire alarm, fire drills and emergency lighting checks and fire alarm inspections have been undertaken. Care staff also receive fire training as part of the homes initial training and as a regular training event. Certificates were available showing that bath hoists had been serviced. All wheelchairs seen on the day of the inspection had footplates, which were in use. Greenacres Care Home DS0000053788.V258725.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 3 Greenacres Care Home DS0000053788.V258725.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? N0 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 OP8 Regulation 37 (c) Requirement The registered person must give notice to the Commission without delay of the occurrence of any serious injury to a resident. The registered person must ensure that the duty rota reflects the number of workers on duty at any given time. The registered person must not employ a person to work at the care home unless the person has the correct documentation including a recent photograph and identification. Timescale for action 15/12/05 2 OP27 18(a) 15/12/05 3 OP29 19 15/12/05 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 OP28 Good Practice Recommendations A minimum ratio of 50 trained staff members to NVQ level two excluding the registered manager should be DS0000053788.V258725.R01.S.doc Version 5.0 Page 19 Greenacres Care Home 2 3 4 OP29 OP33 OP29 available in the home by 2005. The home should furnish all staff with the General Social Care Councils Conduct of Practice for their information. The home should post all information relation to its internal audits on the notice board for the information of residents and visitors. The home should record all staff interviews and keep relevant notes in personnel files. Greenacres Care Home DS0000053788.V258725.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Care Home DS0000053788.V258725.R01.S.doc Version 5.0 Page 21 - 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!