Inspection on 21/06/05 for Greenacres Cheshire Home

This inspection was carried out on 21st June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 30 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Greenacres Cheshire Home 21/05/09

Greenacres Cheshire Home 28/06/07

Greenacres Cheshire Home 14/11/06

Greenacres Cheshire Home 15/06/06

Greenacres Cheshire Home 23/01/06

Greenacres Cheshire Home 25/11/04

Greenacres Cheshire Home 10/06/04

Greenacres Cheshire Home 13/01/04

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

CARE HOME ADULTS 18-65 12 Greenacres 39 Vesey Road Sutton Coldfield Birmingham B73 5NR Lead Inspector Donna Ahern Announced 21 June 2005 st The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. 12Greenacres E54 S24843 Greenacres V227174 210605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Leonard Cheshire Address 39 Vesey Road, Sutton Coldfiield, Birmingham, B73 5NR Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 354 7753 0121 354 6065 Leonard Cheshire Charles Turner Care home 32 Category(ies) of Physical Disabilities (32) registration, with number of places 12Greenacres E54 S24843 Greenacres V227174 210605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years 2. 15 beds must be nursing 3. 17 beds must be residential care Date of last inspection 25th November 2004 Brief Description of the Service: The home is registerd to provide care and accommadation to 32 adults who have a physical disability. Greenacres is located in a quiet residential area, close to the centre of Sutton Coldfield. There is a range of shopping and leisure facilities nearby, and public transport links to the home by bus and rail are good. There are plans in place to reprovide the service in a newbuild home so that it meets the needs of its client group. The home has a bar,a large dining area, kitchen, physiothrapy facilities. Residents all have their own bedroom. There is a bungalow in the grounds which accomodates four residents and is a more domestic style environment. The home has a pleasant courtyard garden. To the front of the home there is a parking area for several cars. 12Greenacres E54 S24843 Greenacres V227174 210605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and involved two inspectors and took place over one day. The CSCI pharmacist inspector undertook a full audit of the homes systems on the day after the announced inspection, her findings are incorporated in this report. Both inspectors spent time talking with people who live at the home and observed interactions between residents and staff. One of the inspectors undertook a tour of the home and one inspector joined residents for lunch and observed mealtime practice. Residents care plans and risk assessments were inspected. Staff records were examined, and a number of Health and Safety records were inspected. The inspector had the opportunity to talk to the manager, care co-ordinator, three relatives and four staff. What the service does well: What has improved since the last inspection? The bungalow had been decorated and residents in this part of the home were really pleased with the new door opening system to their bedrooms, which are suitable for people who use a wheelchair. Residents said that there were less agency staff working at the home since the previous inspection and that staff are now working in two teams, which they said, was better. An activity co-ordinator had been appointed. 12Greenacres E54 S24843 Greenacres V227174 210605 Stage 4.doc Version 1.30 Page 6 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. 12Greenacres E54 S24843 Greenacres V227174 210605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection 12Greenacres E54 S24843 Greenacres V227174 210605 Stage 4.doc Version 1.30 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 standard(s) EVIDENCE: Not assessed at this inspection. 12Greenacres E54 S24843 Greenacres V227174 210605 Stage 4.doc Version 1.30 Page 9 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 standard(s) 6,7 and 9 Care plans and risk assessments required development and had not been kept under review. These shortfalls are of concern and have the potential to cause inconsistencies in the care and support given to residents. EVIDENCE: Two care plans were examined in detail one of a resident who had lived at Greenacres for a few years and a care plan for a resident who had recently moved into the home. The Profile sheet for the resident who had recently moved into the home had not been fully completed the medication details had not been recorded and some sections of the sheet had been left blank. The goal plan section of the care plan had not been completed. Evaluation sections throughout the care plans were generally poor in detail and were nondescriptive with “no new issues” recorded on many sections. This is not acceptable and a full evaluation must be completed. The social/activity section of the care plan had not been reviewed for over twelve months (review date recorded as 9/6/04). The care plan gave details of 12Greenacres E54 S24843 Greenacres V227174 210605 Stage 4.doc Version 1.30 Page 10 the residents interest however it did not give clear information regarding the support the resident would require to access the activities. Two additional care plans of residents who had lived at the home for a while were sampled for specific information pertinent to their care that arose at the time of the inspection. One resident was upset, tearful and agitated. Their care plan was examined. There was no plan in place for behaviour management or depression. Another residents stated that they were supported to access the community independently, which is really positive. However, there were no risk assessments in place to support this. The overall reviewing of resident’s care plans was found to be poor. One of the sampled care plans had not been reviewed since February 2004. The care plans must be kept under review. Daily records were examined and it was positive that some of the daily reports were very detailed and specific in there content. It was advised that historical daily records are achieved to assist with accessing current information and the organisation of resident’s files. The manager and the care supervisor stated that a new care plan format referred to as “ Individual Service Planning” was in the process of being implemented. The shortfalls highlighted above must be addressed immediately and incorporated into the new format. 12Greenacres E54 S24843 Greenacres V227174 210605 Stage 4.doc Version 1.30 Page 11 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 standard(s) 12,13 and 14 Some residents live very independent lifestyles and engage in a range of leisure activities. The home must improve opportunities for residents who require staff support to access leisure activities and they must keep adequate records in relation to these. EVIDENCE: Residents who live at Greenacres have the opportunity to attend day centres, colleges and universities. Some of the residents live very independent lives and stated that they make their own arrangements for social activities. The home has the facilities of a computer room and a craft room. One resident is an artist and they had their own room for use as an art studio. Some of the residents who live at Greenacres require significant staff support to engage in activities. The previous inspection report highlighted that residents said that the home needed an activities co-ordinator. It was positive to hear that there was an activity co-ordinator in post who also had the role of training officer. This staff member was not available at the time of the inspection as they were on leave. 12Greenacres E54 S24843 Greenacres V227174 210605 Stage 4.doc Version 1.30 Page 12 Residents spoken to said that social activities “could be improved upon” and that they would like the opportunity to “go out more”. The home had its own bar facililty, however the Bar nights were not taking place due to some problems renewing the license. Residents said that there was also a lack of people who could drive the homes transport, which had an impact on trips out. Resident’s care plans required further development regarding social activities. The care co-ordinator felt that the home should develop a system for the monitoring of activities. This was clearly needed so that evidence how they consult with residents regarding activities and the programme of activities arranged by or on behalf of the home can be monitored. These standards and the outcome for residents will be explored in more detail at the next inspection. 12Greenacres E54 S24843 Greenacres V227174 210605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 18,19 and 20 The health and personal care needs of residents are not fully documented on care plans and failed to provide sufficient detail on how best to support residents and were not kept under review. Further systems need to be installed to ensure all the residents medication needs are met EVIDENCE: Greenacres provides both residential and nursing care. The home has its own Physiotherapist who undertakes moving and handling assessments. Sampled moving and handling risk assessments were found to be comprehensive. However one of the moving and handling assessments did not have action to be taken should the resident fall. The personal hygiene and dressing plan on sampled care plans had no details regarding resident’s preference for a bath or shower. Bed safety rail disclaimers on resident’s files still had “cot sides” documented this must be reviewed and have the right terminology documented. The previous inspection raised concern about several bedroom doors on the nursing corridor which had been left open and people walking past could see right into the rooms of residents who were being cared for in bed. Some improvements to residents privacy had been made and the door leading through this area is now not a general walk way. However doors were still observed to be open to individual bedrooms, if this is residents choice, it must be clearly documented on their care plans. 12Greenacres E54 S24843 Greenacres V227174 210605 Stage 4.doc Version 1.30 Page 14 Sampled care plans and conversations with residents confirmed that they are supported to access a range of health professionals including optician, dentist, G.P, Consultants and other health professionals as required. Specific care plans sampled identified shortfalls in health care monitoring. It was positive that weight charts included action to be taken in the event of weight loss or gain. However on one of the sampled care plans it stated that the residents must be weighed monthly, the records stated that they had only be weighed on four out of the last seven months. There were combined care plans for bowel and urine care. It was advised that separate care plans are implemented for the bowels and urine, as there were specific health matters requiring monitoring for both. A continence assessment was dated 25 June 2003 with no evidence of a review. Bowel monitoring for one resident had not been completed since November 2004. A waterlow assessment had not been reviewed since 12 September 2004. Upon inspection of this resident’s room it identified that the appropriate pressure relief equipment was in place. A resident care plan identified that they are prone to chest infections. Their care plan had not been reviewed since 17/9/04. Examination of the daily records indicated that they had a chest infection the week prior to the inspection. There was no evidence of the care plan being reviewed inlight of their recent health care needs. Specific care plans must be implemented for acute healthcare needs such as infections. Residents who receive residential care indicated that they were generally satisfied with the health care support they receive or are enabled to receive. One of the residents raised a very specific concern. This matter was brought to the attention of the manager at the time of the inspection. The majority of medicines audited had been administered as prescribed and recorded accurately. A few discrepancies were found. Some medicines were available for administration but not recorded on the Medicine Administration Record (MAR) chart. There were no or inadequate written protocols detailing administration of occasional use medicines. The systems installed to check the medicines received were not robust and must be improved. Quantities of medicines received or balances carried over had not been routinely recorded making auditing difficult in some instances. There was no evidence of staff drug audits to confirm staff competence in medicine management. Residents were encouraged to self-administer some of their medication and this is commended. However no risk assessments or compliance checks were found during the inspection to confirm administration. Many of the residents have complex needs and some medicines are administered via PEG tubes. No evidence was found to check these medicines for suitability of administration via this route. Prescription creams must be discarded twenty-eight days after opening and must be stored securely. 12Greenacres E54 S24843 Greenacres V227174 210605 Stage 4.doc Version 1.30 Page 15 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 standard(s) 22 The complaints procedure is not effective. Resident’s confidence in the complaint procedure must be re-established so that they feel listened to and that complaints are acted upon promptly. EVIDENCE: There was a complaint policy and procedure in place, which must be updated to include CSCI details. The provider had received 11 complaints in the last twelve months. A number of complaints were received between January and April 2005. The complaints related to standards of care and levels of cleanliness. The organisation commissioned an independent investigating officer to look into the common issues of the complaints. A full report on the findings of the investigation was made available to the CSCI on 04 July 2005. All the complaints were up held. The Organisation has advised CSCI that the general manager will forward a detailed action plan to address the findings of the report. The complaints log was examined and found to be very confusing as the format in place was a “complaints return form” which is completed every three months and forwarded to the organisations head office for monitoring. Information was continually transferred from one three month period to another. It was difficult to track complaints that were still outstanding. This process required review. The home must have a log of complaint with received and completion dates and outcomes of all investigations. It must also indicate if the complaint was resolved to the complainant’s satisfaction. Some of the residents spoken to said that they knew how to make a complaint. Some residents indicated that if they make a complaint “they will get in trouble”. The organisations own investigation into complaints report also raised 12Greenacres E54 S24843 Greenacres V227174 210605 Stage 4.doc Version 1.30 Page 16 issues about residents confidence in the complaint process. This matter has been raised in previous inspection reports. The adult protection procedure was not examined at this inspection and will be examined in full at the next inspection. 12Greenacres E54 S24843 Greenacres V227174 210605 Stage 4.doc Version 1.30 Page 17 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 standard(s) 24,25,27,28 and 30 There are plans in place to reprovide this service so that it meets resident’s needs. In the interim some maintenance matters must be addressed so that the home is safe and comfortable for all residents. EVIDENCE: Greenacres is a large home and it has a bungalow sited adjacent to the main home. The home has had many parts of the main building refurbished over the years. There was a distinct difference in décor between the old and new areas. The organisation plans to reprovide the service in a new build home. At the time of this inspection a consultation process was in place with residents. There was also work in process regarding securing suitable land. The organisation has agreed to keep all interested parties up to date with developments. All residents have a single bedroom some have ensuite facilities. Bedrooms seen were personalised. One bedroom carpet had become very worn and required replacing. One room had an offensive odour which required addressing. The bathrooms and toilets are located near to resident’s bedrooms, 12Greenacres E54 S24843 Greenacres V227174 210605 Stage 4.doc Version 1.30 Page 18 are large in size and contain hoists and technical aids. Bathrooms were clean but some were very old and worn. It was positive that work had taken place to the bungalow including decoration of the lounge and new curtains. Residents said they were involved in picking the colour scheme and were really pleased with the push button doors that had been installed and happily demonstrated the ease with which they can now enter their bedrooms. Previous report raised the need for a covered walkway between the bungalow and the main building. Residents have to go outside and around the front of the building. The front of the home was very uneven and residents are required to negotiate their wheelchairs around the uneven parts. Residents said that this is the only route of access in all weather conditions and on some days they carry their laundry bags. One resident said that sometimes the school children passing by the home have made rude remarks. All residents spoken to in the bungalow felt strongly about a covered walk way being provided and said that it had been a concern of theirs for a long time. There is a good range of communal space including a choice of lounges, a large dining room, bar area, television and video lounge, computer room and activities room. The lift required refurbishment the manager said that quotes have been obtained. It had been anticipated that the work would take four days to complete. The manager said that consultation would take place with residents regarding the work and risk assessments will be undertaken. CSCI must be kept informed of developments. 12Greenacres E54 S24843 Greenacres V227174 210605 Stage 4.doc Version 1.30 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34 and 35 Staffing levels required review to ensure that they are adequate for resident’s complex needs. The home must have an effective staff team in sufficient numbers to meet residents needs at all times. Staff have not been adequately supervised by their manager they must receive support and supervision so that they can carry out their job effectively. EVIDENCE: Previous inspection reports highlighted the need to review staffing levels. The inspection report of November 2004 stated that there was evidence that the organisation was “trying to address the issue” of staffing levels. The manager stated at this inspection that staffing had been revised again. The staff work in two teams. The staffing consists of 8 carers in the morning (07.30-14.15) and 6 carers in the afternoon /evening (14.15-21.00). There are two qualified Nurses on each shift. At night the staffing consists of three carers (21.0007.30) and a night nurse (20.45-07.45). There remained a need to review staffing levels. The staff rota provides a handover period of fifteen minutes. Considering that many of the people who live at Greenacres have complex and changing needs, there was a need to review the length of the handover as it was felt that this was not an adequate amount of time. There was also concern that only one 12Greenacres E54 S24843 Greenacres V227174 210605 Stage 4.doc Version 1.30 Page 20 Nurse was part of the handover and the information to the second Nurse was handed over third party. There was concern about the level of staff input into the bungalow. Systems were in place for staff to record when they have given support to the residents in the bungalow, as required at the previous inspection. However when examined the records were not in sufficient detail to determine how long staff were in the bungalow and the records were not completed for some days which would indicate no staff support. Moving and Handling assessment identified that 18 of the 32 residents required two staff for manual handling. Many positive comments were received from residents about particular staff and that it was better since staff worked in teams, however residents also raised concern about staffing levels and the availability of staff. There were a number of staff vacancies. Four full time and one part time member of staff were due to commence employment on the 6 July 2005. Agency staff were still being used to support the rota. The manager stated that staffing levels are reviewed weekly and monthly. CSCI required that a full review of the staff arrangements must be undertaken. The Training Officer post was vacant. The manager stated that a staff member was overseeing training and activities as an interim arrangement. Staff training records were not examined at this inspection. These will be examined at the next inspection. However, it was requested the manager forwarded details of staff training on Manual Handling to CSCI. When examined it indicated that whilst regular training sessions are held staff had not received six monthly updates as recommended at the previous inspection (this was due to the number of staff with back related injuries). Staff were not even receiving annual updates. The training records on manual handling training were poor. These must be improved so that dates of training and updates are easy to establish without going through different pieces of paper and trying to track who did what when and who is still working at the home. Staff files were sampled and had the required information. Profiles were required in respect of all agency staff. These must include CRB number/date and details of the persons training and experience. Supervision records sampled indicated that staff supervision was inconsistent. One staff members record of supervision stated that they had supervision in May 2004 the next recorded supervision was June 2005. Another staff member’s records indicated eight months between supervision session and on another staff members there was over twelve months. This is not acceptable staff must receive regular supervision a minimum of six sessions per annum with records kept. 12Greenacres E54 S24843 Greenacres V227174 210605 Stage 4.doc Version 1.30 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 and42 The management approach was not fully open and inclusive with a clear sense of direction, which is effective for residents. Health and Safety matters required attention so that residents are not put at risk. EVIDENCE: The registered manager had been in post since 2001. He has significant management experience. Throughout the inspection process the manager and care co-ordinator were open to the inspection process. Feedback from residents was variable regarding the style of management. Whilst some residents made very positive comments there were also residents who felt that there were problems with the management style. Resident’s apparent lack of confidence in making complaints as highlighted in the complaint section of this report was of concern and required action by the manager and organisation to resolve the issues. 12Greenacres E54 S24843 Greenacres V227174 210605 Stage 4.doc Version 1.30 Page 22 A number of health and safety records were examined. The following matters required attention The date of the service of the call system was required the paper work on file indicated that the last service was undertaken on in May 2003. The lifting equipment was serviced in January 2005, CSCI required evidence that the defaults identified have been rectified. CSCI was provided with information following the inspection however the information did not detail what faults had been rectified following the service in January 2005. The COSHH file required review. The risk assessment for the general Health and Safety of the building were not on file. These must be available for inspection. There must be evidence that the matters of concern raised in the Work Place Fire Risk assessment have been actioned and when. The Health and Safety committee agenda minutes stated that when a fire drill and evacuation was undertaken on the 22nd December 2004 the conclusion was that “Greenacres staff appear confused and complacent in the event of a fire and urgent attention was required, it was recommended that Greenacres has more than two fire drills per year”. There was no evidence that any action was taken on this matter over the last six months and an immediate requirement was raised to address this. The manager contacted CSCI the following day and agreed that a fire drill would take place within one week. The previous Announced inspection report stated that given that several staff had reported back injuries/strains it was recommended that the organisation provide manual handling updates every six months. Records of Manual handling training forwarded to CSCI indicate that the Physiotherapist holds training session on a regular basis however staff are not receiving the training on a six monthly or annual basis. On the tour of the building COSHH items including general surface cleaner and hard surface cleaner were seen left out on work surfaces these items must be secured when not in use. A review of the security of the building was required. Residents and a relative raised concern about the lack of security lighting to the front of the building. A relative also raised concern about security and that there had been several occasions when they and other visitors had been let into the home and there were no systems in place for checking who they are, and their purpose for being there. A few days after the inspection a theft had taken place from within the home, which again raised security issues. 12Greenacres E54 S24843 Greenacres V227174 210605 Stage 4.doc Version 1.30 Page 23 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 1 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 x 1 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 2 2 x x 2 Standard No 11 12 13 14 15 16 17 x 3 2 2 x x x Standard No 31 32 33 34 35 36 Score x x 2 3 2 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 12Greenacres Score 2 1 2 x Standard No 37 38 39 40 41 42 43 Score 3 x x x x 1 x E54 S24843 Greenacres V227174 210605 Stage 4.doc Version 1.30 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 12 (1) (a) 15 Requirement Care plans must be kept under review. They must be reviewed six monthly or more frequently if needs change. The shortfalls identified in standard six must be encompassed within the care plan document. (previous requirement 28/2/05 ) Risk assessments required further development.( Previous requirement 28/2/05) The Registered Person must be able to evidence how they consult with all residents regarding activities and can monitor the programme of activities arranged by or on their behalf. (previous requirement 28/2/05) Further development of moving and handling risk assessments were required The recording and evidence of monitoring residents health care needs required significant development. Residents weight must be monitored. Separate care plans must be implemented for specific health matters. These records must be kept under review. Timescale for action 21/9/05 2. 3. YA9 YA13 13 (4) (a,b c) 16 (m,n) 21/8/05 21/8/05 4. 5. YA18 YA19 13 (5) 12 (1) (a,b) 15 (2) (b) 21/8/05 21/8/05 12Greenacres E54 S24843 Greenacres V227174 210605 Stage 4.doc Version 1.30 Page 25 6. 7. YA19 YA20 12 (1) (a,b ) 13 (2) 8. YA20 9. YA20 13 (2) 17 3 Schedule 3 (3) (i) 13 (2) 10. YA20 13 (2) 11. YA20 13 (2) 12. 13. YA22 YA22 22 (1) 22 (1) 14. 15. YA24 YA24 23 (2) (b) 16 (2) (k) Specific care plans must be implemented for acute health care matters. All service users wishing to self administer their medicines must be regularly risk assessed as able and compliance checks undertaken to ensure they take their medication as prescribed. All medicines available for administration must be recorded on the Medicine Administration Record (MAR) chart or destroyed Protocols must be written for all occasional use medicines including the dose, time between doses, maximum daily dose, recording details including outcome and review date. A robust system must be implemented and adhered to, to check the prescribed medication and the dispensed medication received. Prescription creams must be discarded twenty-eight days after opening and must be stored securely. The complaint procedure must be updated to include CSCI details. The system for logging complaints required review. The Registered Person must explore and resolve residents lack of confidence in the complaints procedure. (previous requirement 30/3/05) The organisation agreed to forward an action plan to address the recommendations of its own investigation into the complaint process. A residents bedroom carpet required replacing. The offensive odour in one bedroom required addressing. 21/8/05 29/6/05 29/6/05 29/6/05 22/7/05 22/7/05 21/8/05 31/8/05 21/8/05 29/6/05 12Greenacres E54 S24843 Greenacres V227174 210605 Stage 4.doc Version 1.30 Page 26 16. 17. 18. 19. 20. YA24 YA33 YA33 YA33 YA35 21. 22. 23. YA36 YA42 YA42 24. YA42 25. 26. 27. 28. YA42 YA42 YA42 YA42 CSCI must be informed of the propals and timescales to provide a covered walkway. 18 (1) (a) A review of the homes staffing levels was required. 12 (1) (a) The handover time between shift change must be reviewed and CSCI informed of the outcome. 18 (1) (a) The systems in place for 13 (a, c) monitoring staff in put in the bungalow must be developed. 18 (1) (a) Staff training records on Manual Handling must be developed. Staff must receive updates/refresher training on moving and handling. 18 (2) Staff must have regular,recorded supervision meetings at least six per year with their manager. 23 (2) (c ) The date of the service of the call system was required. 23 (2) (c ) CSCI required evidence that the defaults identified in the homes lifting equipment have been rectified. 23 (4) The Registered Person must be able to evidence that the matters of concern raised in the Work Place Fire Risk assessment have been actioned and when. 23 (4) (c ) A fire drill must take place. (iii) 13 (4) The COSHH file required review. 13 (4) COSHH items must be stored securly. 13 (4) (a)23 (2) (b) 13 (4) (a,b c) 13 (4) (a,b, c) The drive to the front of the home was uneven and a potential hazard to residents and required levelling. Risk assessments for the general Health and Safety of the building must be available for inspection. The Registered person must review its security arrangements internal and external. 23 (2) (b) 31/8/05 21/8/05 21/8/05 21/8/05 21/9/05 21/9/05 and ongoing. 30/6/05 21/8/05 31/7/05 30/6/05 31/7/05 21/6/05 and ongoing 21/9/05 29. 30. YA42 YA42 21/8/05 31/8/05 12Greenacres E54 S24843 Greenacres V227174 210605 Stage 4.doc Version 1.30 Page 27 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 YA22 Good Practice Recommendations The Registered person should consider introducing a grumbles book to record the comments of residents of the small complaints where they do not want to go down the formal route. It was advised that a log of regulation 37 reported incidents are kept. 2. YA37 12Greenacres E54 S24843 Greenacres V227174 210605 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ 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 12Greenacres E54 S24843 Greenacres V227174 210605 Stage 4.doc Version 1.30 Page 29 - 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!