Inspection on 23/01/06 for Greenacres Cheshire Home

This inspection was carried out on 23rd January 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 29 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 21/06/05

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 Greenacres Cheshire Home 39 Vesey Road Sutton Coldfield West Midlands B73 5NR Lead Inspector Donna Ahern Unannounced Inspection 23rd January 2006 10:40 Greenacres Cheshire Home DS0000024843.V279866.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 Cheshire Home DS0000024843.V279866.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 Cheshire Home DS0000024843.V279866.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Greenacres Cheshire Home Address 39 Vesey Road Sutton Coldfield West Midlands B73 5NR 0121 354 7753 0121 354 6065 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) Leonard Cheshire Charles Turner Care Home 32 Category(ies) of Physical disability (32) registration, with number of places Greenacres Cheshire Home DS0000024843.V279866.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Residents must be aged under 65 years 15 beds must be nursing 17 beds must be residential care Date of last inspection 21st June 2005 Brief Description of the Service: The home is registered to provide care and accommodation 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 new build home so that it meets the needs of its client group. The home has a bar, a large dining area, kitchen and physiotherapy facilities. Residents all have their own bedroom. There is a bungalow in the grounds, which accommodates 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. Greenacres Cheshire Home DS0000024843.V279866.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and involved two inspectors and took place over one day. Returning the second day to complete the inspection and give feedback to the manager and care coordinator. Inspectors spent time talking with the people who live in the home and observed interactions between residents and staff. One of the inspectors undertook a tour of the home not all bedrooms were inspected. 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, the housekeeper and two staff. This report should be read in conjunction with the inspection report June 21st 2005. What the service does well: What has improved since the last inspection? The staff handover time has been increased from fifteen minutes to thirty minutes so that there is additional time for staff to carry out a comprehensive hand over. There has been an increase of one care staff on the morning shift to meet resident’s needs. Painting and decorating throughout the ground floor corridor and first floor landing area has taken place and new carpets have been fitted on the ground floor corridor. Some resident’s rooms have been painted and new carpets fitted. Some improvements had been made to the range and choice of activities available to residents. Greenacres Cheshire Home DS0000024843.V279866.R01.S.doc Version 5.1 Page 6 The managers logging and tracking of complaints had improved. 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 Cheshire Home DS0000024843.V279866.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 Cheshire Home DS0000024843.V279866.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 The pre assessment process requires some further development so that the manager can evidence that residents need have been assessed in full prior to admission. EVIDENCE: The homes admission policy was assessed this was dated 24 June 2002 and the manager stated that it was due to be reviewed. The pre assessment information for the most recently admitted person was assessed. Some sections of the documentation had not been completed in full and some areas required further exploration and more detailed information. The manager said that the documentation was new and it was the first time it had been used and is due to be reviewed at the forthcoming area managers meeting. The manager said that a Nurse and the homes physiotherapists will be involved in future pre assessments so that the process is more comprehensive. Greenacres Cheshire Home DS0000024843.V279866.R01.S.doc Version 5.1 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 the following standard(s): 6, 9 Care plans and risk assessments required further development. The shortfalls are of concern and have the potential to cause inconsistencies in the care and support given to residents. EVIDENCE: The previous inspection report raised a number of concerns and shortfalls with residents care plans. 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. Progress on the implementation of the new format was monitored. There was evidence of some progress on developing residents care plans however a number of shortfalls were identified and required addressing so that the staff can demonstrate that residents needs are clearly documented and monitored. (See also healthcare standards 18 and 19) The emotional, spiritual and social interaction of the care plan had not been completed and the activities programme had not been completed. On another care plan of a recently admitted resident the persons personal support and goal plan had not been completed. In feedback to the managers they stated that this was incomplete due to some difficulties getting the required information prior to the persons admission. Greenacres Cheshire Home DS0000024843.V279866.R01.S.doc Version 5.1 Page 10 Information recorded in the persons daily notes had not been transferred to the care plan. There were no short-term care plans for occasions when residents developed complications such as chest infections. There was no risk assessment on file for a resident with hepatitis B, C and MRSA and no detail where the MRSA was. Greenacres Cheshire Home DS0000024843.V279866.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 15, 16, 17 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 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 craft room. One resident is an artist and they have their own room for use as an art studio. An Internet café was in the process of being developed off the activity room. The building work had been completed to accommodate the equipment. Some minor maintenance work was required before the equipment could be put in place. Residents spoken to were looking forward to the new development. Residents said “the Christmas meal was wonderful” and staff and volunteers had given up their free time to make the lunch a special occasion. Trips out to Greenacres Cheshire Home DS0000024843.V279866.R01.S.doc Version 5.1 Page 12 the theatre and pantomime had been organised. At the time of the inspection some residents were taking part in an organised trip to Millennium Point. Some of the residents who live at Greenacres require significant staff support to engage in activities and some said that they would like it if more in house activities could be organised. Residents said there is a core team of staff who treat them well however the changes in staff was of a concern to them and they felt that they were not always treated well by some agency staff. (See also standard 33). Residents were pleased that the bar facility had reopened providing a service once a week. The monitoring of activities required further development so that there is evidence of how staff consults with residents regarding the programme of activities arranged by or on behalf of the home. Residents said their friends and relatives are free to visit them at the home. Relatives were seen visiting and were actively involved in their relatives care. Meals are served in the main dining room. Residents said that there are two choices at each mealtime. One resident who is vegetarian said that their catering needs were well provided for. Currently the main meal is served at midday. Residents who go out during the day have the option of a reheated meal on their return or the teatime choice. Consideration should be given to reviewing with residents when the main meal is served. The food diaries kept for residents whose food intake is monitored required attention. The records were not effective as the recordings were not specific enough regarding quantities. Greenacres Cheshire Home DS0000024843.V279866.R01.S.doc Version 5.1 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 the following standard(s): 18, 19, 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 and gave details of size and type of sling and type of hoist. They had been reviewed annually. One of the sampled care plans did not have action to be taken should the resident fall the other one sampled did have this information. The risk assessment for bedrails was dated 10/02/04 and date of the review was 10/02/05 there was no evidence that the reviewed had been actioned. The decision not to use bumpers on the bedsides for the person who leans to the right must be reviewed. The person’s representative had not agreed the assessment. Catheter records gave good detail of the type of catheter, expiry date and lot number. The person’s catheter had been changed a number of times (ten) in Greenacres Cheshire Home DS0000024843.V279866.R01.S.doc Version 5.1 Page 14 close succession there was no rationale for the change in size. This information must be documented on the persons care plan. On one care plan there was good information about skin and pressure care and the type of mattress to be used. The other care plan did not contain this detail. Improvements were required to staff monitoring the person’s skin and reporting any redness. The wound care plan contained too many different wounds and instructions on the one chart. It was recommended that a separate chart be used for each wound. There was evidence of the dressing types being changed frequently with no explanation for this recorded on the care plan. The sleeping and night care plan was not completed. The personal hygiene and dressing plan required more details. There was no detail regarding how oral hygiene should be maintained. An error was found with the calculation of the waterlow score. A calculation had been made that put the person at high risk. The persons had broken areas and their age had not been allowed for which changed the score from 18 to 22 which made the person high risk. It is essential that calculations are accurate and appropriate action taken. The monthly weight charts are comprehensive and the layout of the form allows for weight loss or gain to be documented. The sampled care plan indicated that the person should be weighed monthly. However, this could not be evidenced from the chart, which indicated that the person had been weighed in January 2005, May 2005, July 2005 and October 2005. 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. A log of professional contacts was seen. Cross-referencing of this information identified that the log was not filled in every time a visit by a professional was made. There were no short-term care plans for occasions when residents developed complications such as chest infections. A letter on a residents file from a professional addressed to the manager, raised concern about how staff in the home had received training on peg tube replacement. Training had been offered but only taken up by a couple of individuals which raised concern by the professional about the lack of consistency and the potential for the likelihood of the resident being inappropriately admitted to hospital. The letter went on to raise concern about the difficulties in locating staff upon arrival for prearranged visits to the home and advice given had not always been followed up. The manager and care coordinator stated that they were not aware of the letter and its contents. Greenacres Cheshire Home DS0000024843.V279866.R01.S.doc Version 5.1 Page 15 They agreed to follow up on the matters raised as a matter of urgency. It is of concern that such a letter could be received by the home and the contents not brought to the attention of the management team. The manager must review the procedure for reviewing letters from professionals. Many of the residents have complex needs and some medicines are administered via PEG tubes. A full audit of medication administration was carried out at the previous inspection June 2005 by the CSCI pharmacist inspector. Progress on previous requirements was monitored. It was not possible to do an audit trail on Warfrain and this required addressing. The arrangements in place for the dispensing of controlled medication for a resident who stays with their family at the weekend required immediate review. It was unclear how the medication is dispensed there were no evidence of a protocol in place regarding this. It was positive that Staff was in the process of ensuring that the self-medication compliance forms had been completed as required at the previous inspection. Greenacres Cheshire Home DS0000024843.V279866.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 Some improvements had been made to the complaints procedure. The adult protection policy required review. Staff training must be provided in adult protection matters and complaints procedure so that residents are supported by an informed staff team who can safeguard residents from abuse. EVIDENCE: There was a complaint policy and procedure in place, which had been updated so that it includes CSCI contact details. The previous inspection report raised concern about the arrangements in place for the logging and tracking of complaints. It was positive to see that improvements had been made to the system. The outcome of complaints could be tracked on recently received complaints. One of the three complaints looked at raised some concern about the providers response times when investigating complaints. On the whole improvements were seen regarding how complaints are managed and documented. A number of staff must complete their training on complaints and adult protection training. The Protection of Vulnerable Adults from Abuse policy was assessed (dated 17th August 2001) and required review so that it embraces the Birmingham Multi Agency Guidelines. It must make it explicit that Social Care and Health are the lead agency on all protection matters. Greenacres Cheshire Home DS0000024843.V279866.R01.S.doc Version 5.1 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 the following standard(s): 24, 30 There are plans in place to reprovide this service so that it meets resident’s needs. Progress had been made on maintenance matters so that the home is safe and comfortable for 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. It was positive that much work had taken place to improve the internal standards of décor. Painting and decorating had taken place throughout the ground and first floor communal areas, passageways and stairway areas. New Greenacres Cheshire Home DS0000024843.V279866.R01.S.doc Version 5.1 Page 18 carpet had been fitted on the ground floor. Some bedrooms had also been painted and some bedroom carpets and furniture had been replaced. Bedrooms seen were lovely and comfortable and were full of personal items and very individual in layout and style. 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. An update on developments was given. Plans have been drawn up and the provider is in the process of forwarding an application to Birmingham city council planning Department. 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. Greenacres Cheshire Home DS0000024843.V279866.R01.S.doc Version 5.1 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 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): 32, 33, 34, 35, 36 Staffing levels required further 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 does not receive supervision so that they can carry out their job effectively. EVIDENCE: Previous inspection reports highlighted the need to review staffing levels. The manager stated that staffing had been increased. The staffing consists of 9 carers in the morning (07.30-14.15) which is an increase of one staff member 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). The nighttime staffing levels were still under review. CSCI must be informed of the outcome. The previous inspection report also raised concern about the length of the handover period, which was fifteen minutes. It was positive that this had been increased to thirty minutes so that there is sufficient time for a comprehensive handover to take place. The previous report raised 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. When examined the records were not in sufficient detail to determine how long staff were in the bungalow and the Greenacres Cheshire Home DS0000024843.V279866.R01.S.doc Version 5.1 Page 20 records were not completed for some days which would indicate no staff support. Examination of the records indicated that improvements had been made to the recordings of when staff support the people living in the bungalow. Residents who live in the bungalow confirmed this. Almost all the residents spoken to raised concern about the use of agency staff in the home. Residents said that whilst some of the agency staff are good many in their opinion are not. They don’t like to receive support from staff that they don’t know. They also said that some of the agency staff “don’t talk to them” or give care in a “rushed way” and “don’t consider their feelings and wishes”. The manager and care coordinator acknowledge theses concerns from residents and said that they are actively trying to recruit to vacant posts in an attempt to limit the use of agency staff and aim for greater consistency for residents. Four staff had been appointed and were due to start on the 13th February 2006. Three applications were being processed and the manager was hoping to confirm start dates for 1st March 2006. Two files for care staff that work on night duty were examined. It was difficult to locate information and the files would benefit from organising. The personal detail section, and the checklist of required information had not been completed on both sampled files. CRB information sent from the provider’s headquarters was not on file although this was actioned immediately by the manager. Profiles were available on agency staff. These included CRB number/date and details of the persons training and experience. The manager provided computer printouts of staff training. Two staff out of sixty-three staff required Manual-handling updates, which indicate good progress on addressing this essential training. Nine staff required Adult Protection training, eleven required Care Plan training, thirty four staff must do Complaint Training, ten must do First Aid, twenty three must do Food Hygiene, thirty nine must do Infection Control, eighteen must do Fire Protection, and 27 must do care of medicines. Supervision records sampled indicated that staff supervision was inconsistent. One staff member’s record of supervision stated that they had supervision in September 2004 and May 2004. Another staff member’s records indicated that supervision took place in December 2005, October 2005 and November 2004. As raised at the previous inspection staff must receive regular supervision a minimum of six sessions per annum is required with records kept. Greenacres Cheshire Home DS0000024843.V279866.R01.S.doc Version 5.1 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 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, 42 A number of key areas of service delivery required development so that residents can benefit from a well run home. Health and Safety matters required attention so that residents are not put at risk. EVIDENCE: The registered manager has been in post since 2001. He has significant management experience. There was evidence of some progress on previously raised requirements. However considerable work is still required in a number of key areas. The manager must ensure that if specific areas of work are delegated to other staff members such as maintaining staff files, undertaking staff supervision and care planning, there must be systems in place for ensuring these delegated task have been actioned to the required standard. A number of health and safety records were examined. The following matters required attention. Greenacres Cheshire Home DS0000024843.V279866.R01.S.doc Version 5.1 Page 22 Evidence of the test and outcomes of the electrical hardcore test, the PAT test and the legionella test which the manager stated had taken place recently must be confirmed with CSCI. The Work Place Fire Risk assessment required review (dated 08/12/04). The manager stated that this was scheduled to take place on 30 January 2006. A fire evacuation took place on the 29th June 2005 as a follow up to the previous drill in December 2004 when significant shortfalls were evidenced. Further concerns were raised at the time of the drill in June 2005. Some staff were confused about the required procedure and a full evacuation plan must be in place. The manager stated that the issues raised in June 2005 were addressed at the time of the fire safety training that took place on the 11th October 2005. There must be documented evidence on file of the shortfalls being addressed and a full evacuation plan must be available. A fire drill was required. Thermometers and recording books were available in each of the communal bathrooms for staff to use when assisting residents. These were examined and had not been filled in for several months. The periodic testing of water outlets takes place once a month these must indicate what action has been taken when high temperature recordings have been evidenced. The frequency of these tests must be reviewed Greenacres Cheshire Home DS0000024843.V279866.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 1 2 X 2 X X X X 2 X Greenacres Cheshire Home DS0000024843.V279866.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 3 4 5. Standard YA2 YA2 YA6 YA9 YA13 Regulation 14 (1) Requirement Timescale for action 31/03/06 28/02/06 31/03/06 31/03/06 30/04/06 6 7 8 YA17 YA18 YA18 The admission policy required review. 14 (1) The pre assessment documentation must be completed in full. 12 (1)(a) Care required further 15 development. Previous requirement 28/2/05. 13(4a,l,b, Risk assessments required c) further development. Previous requirement 28/2/05. 16 (m,n) 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. Some progress made further developments required. Previous requirement 28/2/05. 16 (2) i The food diaries kept for residents whose food intake is monitored required attention 13 (5) Further development of moving and handling risk assessments were required 12(1)(a,b) Personal care needs and how they must be met must be documented on the care plan. DS0000024843.V279866.R01.S.doc 28/02/06 31/03/06 31/03/06 Greenacres Cheshire Home Version 5.1 Page 25 and kept under review. 9 10 YA18 YA19 12(1)(a,b) Resident’s nighttime support needs must be documented on the care plan. 12(1a,l,b) The recording and evidence of 15(2)(b) monitoring resident’s health care needs required significant development. Acute care plans must be implemented for specific health matters. These records must be kept under review. 12(1)(a,b) Specific care plans must be implemented for acute health care matters. 12(1)(a,b) Waterlow assessments must be accurately completed. 13 (2) 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. 13 (2) A robust system must be implemented and adhered to, to check the prescribed medication and the dispensed medication received. 13 (2) The manager must review the 17 (1)a(i) arrangements in place for controlled medication dispensed for home leave. 22 (1) The Adult protection policy required review and must embrace the Multi Agency Guidelines. 23 (2) (b) CSCI must be informed of the propals and timescales to provide a covered walkway. Some progress work remains outstanding. 18 (1) (a) A review of the homes staffing levels was required. Some progress made night staffing levels must be reviewed. 7,9,19 Staff files required considerable Sch 2 organising and must contain all of the information as stated in DS0000024843.V279866.R01.S.doc 31/03/06 31/03/06 11 12 13 YA19 YA19 YA20 28/02/06 28/02/06 31/03/06 14 YA20 28/02/06 15 YA20 28/02/06 16 YA22 30/04/06 17 YA24 30/04/06 18 YA33 31/03/06 19 YA34 31/03/06 Greenacres Cheshire Home Version 5.1 Page 26 Schedule 2 20 21. YA35 YA36 Staff training must be provided in mandatory areas. 18 (2) Staff must have regular, recorded supervision meetings at least six per year with their manager. 23 (4) The Registered Person must review the Work Place Fire Risk Assessment. 23(4c)(iii) A fire drill must take place. 23 (4) There must be documented evidence on file of the shortfalls being addressed of the previous fire drill and a full evacuation plan must be available. 13 (4) Temperatures of the showers and bath must be recorded. 13(4)(a) The drive to the front of the 23(2)(b) home was uneven and a potential hazard to residents and required levelling. 13(4a,b,c) The periodic testing of water outlets takes place once a month these must indicate what action has been taken when high temperature recordings have been evidenced. The frequency of these tests must be reviewed. 13(4a,b,c) The Registered person must review its security arrangements internal and external. 13 (4) Evidence of the test and 23 (2)(b) outcomes of the electrical hardcore test, the PAT test and the legionella test which the manager stated had taken place recently must be confirmed with CSCI. 18 (1) c 31/05/06 28/02/06 22. 23. 24. YA42 YA42 YA42 30/01/06 28/02/06 28/02/06 25. 26. YA42 YA42 28/02/06 21/09/05 27. YA42 21/08/05 28. 29 YA42 YA42 31/03/06 28/02/06 Greenacres Cheshire Home DS0000024843.V279866.R01.S.doc Version 5.1 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. To review the time that the main meal is served. 2. 3 YA37 YA17 Greenacres Cheshire Home DS0000024843.V279866.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Birmingham 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 Greenacres Cheshire Home DS0000024843.V279866.R01.S.doc Version 5.1 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. 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