Inspection on 15/05/07 for Greenaways Rest Home

This inspection was carried out on 15th May 2007.

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

Greenaways Rest Home 08/06/06

Greenaways Rest Home 04/10/05

Greenaways Rest Home 04/05/05

Greenaways Rest Home 05/01/05

Greenaways Rest Home 17/08/04

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

CARE HOMES FOR OLDER PEOPLE Greenaways Rest Home 56 Collington Avenue Bexhill-on-sea East Sussex TN39 3RA Lead Inspector Caroline Johnson Unannounced Inspection 15th May 2007 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 Greenaways Rest Home DS0000021119.V337383.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Greenaways Rest Home DS0000021119.V337383.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greenaways Rest Home Address 56 Collington Avenue Bexhill-on-sea East Sussex TN39 3RA 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) 01424 210899 01424 732704 britheadoffice@hotmail.co.uk Mrs Jacqueline Brittain Mrs Jillian Lawrence Care Home 12 Category(ies) of Dementia (12) registration, with number of places Greenaways Rest Home DS0000021119.V337383.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of service users to be accommodated is twelve (12) Service users must be older people aged sixty five (65) years or over on admission Service users with a dementia type illness are to be accommodated Admit one named service user under the age of sixty-five (65) Date of last inspection 8th June 2006 Brief Description of the Service: Greenaways is a detached property situated approximately one mile from Bexhill town centre. Residents’ accommodation is provided on two floors; a stair lift is fitted to assist service users to access first floor rooms. The home shares a large pleasant rear garden with another care home next door owned by the same proprietors. Greenaways is registered to accommodate up to twelve older people with dementia. The registered providers are Britannia Care Homes Ltd who also own another three homes in the area. The home makes CSCI reports available to prospective residents and/or their relatives/representatives upon request. The fee charged as of May 2007 is £360 to £400 per week. Additional charges are made for chiropody and hairdressing. Greenaways Rest Home DS0000021119.V337383.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of the inspection process an unannounced site visit was carried out on 15th May. The visit lasted from 10.15am until 6.30pm. During the visit there were opportunities to meet with the owner, the registered manager and with one member of care staff. Time was spent speaking with residents in the lounge area and observing lunch and part of an activity in the afternoon. A full tour of the building was carried out. A wide range of documentation was examined including the preadmission documentation held in relation to one resident and three care plans. In addition records held in relation to staff recruitment and training, staff rotas, menus, complaints, quality assurance and health and safety were examined. At the time of inspection the manager was on duty with one other member of care staff. The staff member was not one of the permanent staff but had come from another home within the group to cover for sickness. Another staff member from another home also arrived to assist and free up the manager so that she could facilitate the inspection. Following the inspection four relatives were contacted to hear their views on the quality of the care provided in the home. Comments received are reflected below. What the service does well: Staff are provided with good training opportunities. A staff member spoken with felt well supported. The residents spoken with stated that they are looked after well. Bedrooms are well decorated and have been personalised with photos and ornaments. Some of the residents also have small items of furniture that they brought with them to the home. The care plans were up to date detailing the current needs and abilities of the residents. Comments from relatives included: `We can’t believe how lucky we are, finding Greenaways was the best thing ever’, ‘We are invited to activities and are always offered tea and cake or biscuits’, ‘When we visited initially, the owner asked the residents if they would mind her showing us their rooms, ‘The home keeps me informed. When my relative was in hospital a carer sat with me in the hospital all day’, ‘Couldn’t be happier’. ‘Staff are wonderful’ and they ‘are notified of any change and the home contacts the Doctor if there are any concerns’. Greenaways Rest Home DS0000021119.V337383.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can Greenaways Rest Home DS0000021119.V337383.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. Greenaways Rest Home DS0000021119.V337383.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Greenaways Rest Home DS0000021119.V337383.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Thorough pre admission assessments are carried out to determine if the home can or cannot meet prospective residents’ needs. EVIDENCE: There is a statement of purpose in each care plan. Pre admission documentation was seen in respect of one recently admitted resident. There was detailed information about the needs and abilities of this resident. There were also records present detailing a visit made by the resident to the home prior to admission and comments on how they had interacted with staff and other residents. In addition to information about needs and abilities there was also information included about the resident’s family, the residents past hobbies and interests, private arrangements for a chiropodist to visit and information about a befriender that would visit periodically. The home does not cater for intermediate care. Greenaways Rest Home DS0000021119.V337383.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are very good systems in place for detailed care planning. The quality of the record keeping particularly in relation to risk assessments does not currently safeguard the risk of accidents and incidents occurring. However, the home is aware of the work needed in this area and have already made strides to improve. EVIDENCE: Three care plans were examined on this occasion. Each of the residents’ abilities and needs are clearly documented. Records show that there is a monthly check of the care plan to ensure that it remains up to date and any changes are documented. A monthly summary report is also written. Within the past year the company has introduced care-planning meetings where the owner, manager, resident and family meet to discuss the care plan and to agree any changes. In two of the care plans seen there had been a careplanning meeting but the third resident was still relatively new to the home. Greenaways Rest Home DS0000021119.V337383.R01.S.doc Version 5.2 Page 11 Risk assessments seen were generally detailed but in some cases it was not clear what action needed to be taken to minimise the risk of accidents occurring. The owner advised that as this issue has been raised in other homes within the company, on previous inspections, all the managers attended a course the week prior to the inspection on compiling risk assessments. The manager was able to demonstrate that she understood what action needed to be taken to improve the quality of the risk assessments. Records show that a chiropodist visits the home on a regular basis. One resident is bed bound and receives daily visits from the district nurse. The manager advised that none of the residents are prescribed medication at nighttime. All of the day staff have received training on medication. Medication was seen to be stored securely. Records were in order but the home does not always record on the rear of the MAR (medication administered record) chart if medication has not been given for any reason. Records showed that unused medication is returned to the locally pharmacy on a regular basis. One resident does not like taking a tablet form of medication so most of their medication has been changed to liquid form. This resident is due to have their medication reviewed in the near future and their relative is also going to attend this review. As required at the last inspection staff have received training on epilepsy. A relative spoken with stated that the home ‘pulled out all the stops’ to care for their relative when they were ill. Staff were very caring, a specialist bed was obtained and with support from the District Nurse they helped her relative return to good health. Greenaways Rest Home DS0000021119.V337383.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The emphasis placed on developing the activities provided for residents has helped in ensuring that residents have regular stimulation and opportunities to take part in meaningful activities. Staff need to empathise with residents more and to be aware of the possible impact of their communication. EVIDENCE: Client forum meetings are held regularly to seek the views of the residents on a variety of issues. The last meeting was held in April 2007. There was evidence that residents were asked what time they would like to go to bed at and what time they would like to get up. Questions related to a number of topics including the food and activities in the home. All responses were individually documented. Records maintained by night staff showed that one resident likes to get up very early. Records also showed that the majority of the residents get up between 6am and 7am and that some of the residents are woken up during this time. The manager advised that she did not think that Greenaways Rest Home DS0000021119.V337383.R01.S.doc Version 5.2 Page 13 residents were woken and that this was more about how the record was written. She agreed to explore this issue in more detail with the night staff and advised that she did not think it was acceptable to wake residents up in the morning unless there was a reason to. Since the last inspection the home has worked hard to improve and increase the range of activities provided in the home. Photographs are taken of all activities and staff advised that relatives have appreciated seeing the photos. One resident advised that she loves to spend time in the garden. The manager stated that this resident would be growing tomatoes in the near future. A book club has recently been introduced and residents from the sister home next door join residents for this activity. One of the residents also enjoys reading prayers at this time. On the day of inspection there was a knitting group and two of the residents participated. This was a new activity. Other activities include regular music and movement, painting, flower arranging and craft sessions. External entertainers are also brought in periodically. There were details on the residents’ notice board of upcoming activities. This includes a party for the football cup final. It was reported that a volunteer from the local church visits the home on a weekly basis. The manager advised that they are continually trying out different activities and that some are more successful than others. The owner advised that arrangements would be made for residents to go strawberry picking in the summer months. One relative stated ‘we can’t believe how lucky we were finding Greenaways.’ Relatives spoken with stated that they ‘are invited to activities run in the home’. One relative stated that the food is lovely, there are parties for birthdays and the home go to great efforts to make them special. When they visit relatives they are always asked if they would like tea and cake/biscuits and this can also be taken in the garden. Another relative stated that ‘the food is varied’ and attention is given to ensuring that the consistency is appropriate to the needs of their relative. Staff observed in the course of their duties were gentle and caring in their approach. They gave residents time to respond and listened to what was being said. However, it was noted that at times staff spoke with residents in what could be perceived as an inappropriate manner. An example of this was to ask a resident to whistle and then to say that ‘she is the only one in the home that can do this, the rest have lost the ability’. In addition a resident was asked the times tables and when they didn’t know the response to one question the staff member said that she only remembers the two times tables and has forgotten the rest. It was clear that the staff member would not intentionally try to upset or belittle the resident but it was acknowledged that this could have been the result. It should be noted that the resident showed no distress or upset. Greenaways Rest Home DS0000021119.V337383.R01.S.doc Version 5.2 Page 14 There is a four-week menu in place. The manager advised that following the last inspection they introduced a cooked breakfast for a period of time but this did not work well. Instead they now have a greater variety of cereals available. A roast meal is served twice a week. Suppers include a choice of hot meal or a selection of sandwiches. Records of the actual meals served show that there is a variety of meals served including, fish, chicken and red meats. The manager advised that rather than buying joints of meat they now buy diced meat, as the residents are able to cope better with this. Records showed that there are three residents that have diabetes and alternatives to the main desserts served were recorded. In the kitchen area it was noted that there was a list of the type of plates and cutlery used by individual residents. Sausage casserole was served for the main meal. One resident is fed her meals in her bedroom. Two of the residents were fed in the dining room and another resident required close observation and monitoring. Other residents required occasional monitoring and prompting. The designated cook was in the kitchen and that left two carers in the dining room. However, one carer had to leave the area to provide personal care to a resident, which left one carer with the remaining residents. The carer advised that she did not feel under pressure and that she knew that she could call on assistance quickly if necessary. However, a less experienced carer might have struggled with the task. In relation to one of the residents who received occasional monitoring and prompting, their care plan stated that they are at high risk of choking and should be fully supervised. Greenaways Rest Home DS0000021119.V337383.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are clear procedures in place enabling anyone wishing to make a complaint to do so. EVIDENCE: Records showed that one complaint had been received by the home since the last inspection. However as the complainant contacted the owner with the complaint it was the owner that dealt with the concern. There was a letter on file detailing the action taken as a result of the complaint. The manager advised that since then the complaint procedure has been amended to state that all complaints should be taken up in the first instance with the manager of the home and if the concern cannot be resolved the complainant should then refer their concern to the owner. Since the last inspection the Commission has received one complaint about the home. Issues raised as part of the complaint have been investigated as part of this inspection, some areas have been founded some unfounded. The manager has also been asked to investigate some areas further. There were no adult protection alerts made in the past year. Six of the staff team have received training on the protection of vulnerable adults and Greenaways Rest Home DS0000021119.V337383.R01.S.doc Version 5.2 Page 16 arrangements will be made for the remaining staff to attend a relevant course. There is a detailed policy and procedure on the subject. Greenaways Rest Home DS0000021119.V337383.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Work undertaken in the past year has improved the quality of the environment for the residents. The additional work planned should enhance this even further. In order to improve fire safety in the home additional work is required to address the recommendations of the recent fire risk assessment. EVIDENCE: A tour of the building was undertaken. All of the bedrooms seen had been personalised with photos, ornaments and personal belongings. A full interior decoration programme has been implemented. The wall coating by one of the bedrooms has been plastered over so there is no longer a risk of bumps and bruises. The carpet in the entrance hall has been replaced. The downstairs bathroom has been redecorated and the floor covering replaced. Greenaways Rest Home DS0000021119.V337383.R01.S.doc Version 5.2 Page 18 It was noted that in one of the bedrooms the shower facility, which is in the main room, was filled with toilet rolls. The manager advised that these could be moved. Door wedges were placed by at least four doors. The manager advised that following the recently fire risk assessment, where it has been assessed as necessary, door guards will be fitted. The kitchen area will be refurbished in the coming year. In one of the bedrooms a new window has been fitted. It was noted that the windows were locked as birds had been coming into the room. There were no restrictors fitted. In another bedroom there were cracks noted above the window area. The manager advised that the window in this room and all rooms to the front of the property are due to be replaced in the summer. The cause of the cracks in this bedroom will be investigated. There was a maintenance list in place detailing all the works that are due to be implemented in the coming year. Plans for the year also include replacement of the chairs in the lounge. In addition there are plans to improve the garden to make it more easily accessible and make repairs to the path. Four of the rooms will also be turned into en-suite rooms. A dishwasher will be installed in the kitchen. A relative spoken with was very pleased that when they visited the home initially and was being taken around the owner asked the other residents if they would mind her seeing their rooms. She described the rooms as homely. The manager confirmed that work has been carried out in relation to the two fire doors identified at the last inspection to ensure that they are compliant with fire regulations. Records held in relation to fire safety showed that all equipment is tested and recorded at regular intervals. In February 2007 there were four separate training instruction sessions for staff. The manager advised that the fourth instruction session was designed to test out a new format for carrying out fire drills. A system for carrying out unannounced fire drills now needs to be put in place. In January 2007 a company was contracted to carry out a fire risk assessment of the home. A list of recommendations were made to the home as a result some of which have already been addressed. An action plan has yet to be put in place to detail all action taken and to be taken along with timescales. At the time of the last inspection a recommendation was made to review the temperature in the laundry area. Since then an extractor fan has been fitted but this has only given limited ventilation. It is the intention to fit a better system for ventilation, but in the interim, staff use a fan whilst working in the area. Greenaways Rest Home DS0000021119.V337383.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The increased training opportunities available to staff will ensure that there is a staff team well equipped to meet the needs of the residents accommodated. The areas highlighted as part of the home’s internal audit system now need to be addressed to ensure that recruitment procedures are more thorough and that all staff receive thorough induction and training. Staffing levels are minimal and need to be continually reviewed to ensure that residents’ changing needs continue to be met. EVIDENCE: Throughout the day there are two care staff. At nighttime there is a waking and a sleeping-in member of staff. The company recently recruited a part-time cook who has since left their employment. The owner advised that this position has been advertised again. Care staff currently cook the meal and carry out laundry duties. A cleaner works six days a week from 9am until 12.30. Between 12noon and 12.30 the cleaner assists in the kitchen with washing up. The company are also in the process of employing a person to work between the hours of 4pm to 6pm to assist with the tea arrangements. The manager works two six-hour management shifts. Greenaways Rest Home DS0000021119.V337383.R01.S.doc Version 5.2 Page 20 The manager advised that movement between the homes within the company to assist as and when necessary continues. The company continues to review this practice and tries to keep disruption down to a minimum. Where possible it is always a staff member that knows the home well. One relative spoken with stated that they have concerns about staffing levels at key times of the day. Records for the three previous rotas were examined and it was evident that staff on occasions work an eleven-hour day. Staff advised that whilst they do not leave the building during this time they are able to take breaks in the dining area. The manager advised that on very rare occasions due to staff sickness she has worked a day shift and then a sleep-in shift. However, on these occasions she would always take the following day off. At the time of inspection the home was advertising for a couple of night shifts. The manager reported that one of the part-time night staff was covering the vacant hours. Staff records are stored securely and are only made available to those with a right to see them. Three staff files were examined but only two of these in detail. It was reported that CRB checks have been carried out on all staff and pova first checks had also been carried out. Disclosure numbers were recorded on staff files. Records showed that in relation to one staff member there were two character references and the one professional reference that was in place had been brought with the staff member on application. There were no induction records for this individual and no training and development records. In relation to the second staff member neither reference supplied was from an employer and in relation to one referee it was not clear how the referee knew the applicant or if they had worked together. There was evidence that this staff member had received an induction and that they had attended training and development courses. A staff appraisal had also been carried out recently. In relation to the third staff member there was evidence that they had attended numerous training courses since they started working in the home. The home’s induction package had been started but there were a few areas still to be completed. A staff appraisal had been started but not completed. There was evidence that the owner and administrator had been through the staff files a week prior to the inspection to carry out an audit and that they had highlighted a number of similar issues that need to be addressed. A record of the issues picked up via this audit was seen. In relation to staff, training records showed that all of the staff team are trained in infection control and in epilepsy and that three staff have yet to receive training in moving and handling but a course had been arranged for the week following the inspection. Of the eleven staff employed, 6 have completed training in dementia, fire safety, medication and the protection of vulnerable adults, 3 have completed training in continence, 8 have completed training in food hygiene and 3 have completed a course in pressure care. The manager has also recently completed a team leadership course. Three staff Greenaways Rest Home DS0000021119.V337383.R01.S.doc Version 5.2 Page 21 have completed NVQ at level 2 or above and another three staff are currently working towards the qualification. In addition the manager advised that another staff member has expressed a wish to complete the course. The owner advised that the company would be putting together a central training matrix to identify current gaps in training and, with the involvement of the manager, establish what further training is required specific to the clients in the home. Greenaways Rest Home DS0000021119.V337383.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good measures in place to protect the health, safety and welfare of residents and staff. Whilst staff feel well supported a system for ensuring that all staff receive regular formal supervision would be beneficial. EVIDENCE: The manager has worked in the home for several years and has a wealth of experience in caring for people with a dementia type illness. She completed NVQ level four in management and care, last year and is continuing to attend short courses to keep up to date with changes in care practices. She confirmed that staff meetings have not been held for some time. A staff member spoken with confirmed that she feels well supported in her role in the Greenaways Rest Home DS0000021119.V337383.R01.S.doc Version 5.2 Page 23 home. Of the three staff files seen one staff member had received regular supervision, one had received one supervision session and one staff member had no supervision records. This had been highlighted at a recent audit and arrangements were being made to address this. Since the last inspection the home has worked hard to improve their quality assurance systems. Nine responses were received from a relatives’ questionnaire. Responses were collated and a plan of the action to be taken as a result was distributed. Overall the responses were very positive. Some concern had been expressed about staffing levels and as a result the owner decided to employ a cook and a member of staff to assist at teatime. The response to relatives also stated that residents’ laundry is being done individually. However, when this was discussed with staff it was evident that this is not the case. The owner, or a representative on her behalf, visits the home on a monthly basis unannounced and a report is written of the findings. The report for May 07 was on file but the previous report was for January 07. The manager advised that the visits had been carried out but stated that the reports must still be at the head office. She agreed to locate the relevant copies. Regular audits are also carried out in relation to care plans and medication. The manager advised that the home has no involvement in residents’ finances. Fees for hairdressing etc are generally paid via the head office and the relevant people are then invoiced for the costs incurred by the company. There are a wide range of policies and procedures in place that are reviewed and updated periodically. It was noted that the home does not have a ‘bullying’ policy. In relation to health and safety the home is thorough in ensuring that all equipment is tested and serviced on a regular basis. Records showed that hot water temperatures are tested and recorded on a monthly basis. Hot water tested at one outlet on the day of inspection showed a satisfactory reading. A risk assessment for legionella was carried out in January 2007. Greenaways Rest Home DS0000021119.V337383.R01.S.doc Version 5.2 Page 24 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 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 X 3 3 2 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 X 3 Greenaways Rest Home DS0000021119.V337383.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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 OP19 Regulation 23(4a) Requirement Timescale for action 30/06/07 2. OP19 18(1)(c)(i ) In relation to fire safety the home must detail the action taken in relation to the home’s fire risk assessment. This will include reference to fire drills and the use of door wedges. That all staff are trained in fire 31/07/07 protection matters. [This requirement was made at the previous inspection and is partly met in that six of the eleven staff have completed training]. Timescale given was 4/11/06. One of the bedrooms must have adequate ventilation. Staffing levels must be kept under review to ensure that residents’ needs continue to be met. The registered person must ensure that in relation to staff recruitment they are more thorough in respect of checking the authenticity of references obtained for staff. All staff must receive regular supervision. 30/06/07 30/06/07 3. 4. OP25 OP27 23(2p) 18(1a) 5. OP29 19(1c) 31/07/07 6. OP36 18(2) 31/07/07 Greenaways Rest Home DS0000021119.V337383.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP14 OP19 OP26 OP33 Good Practice Recommendations The registered person should clarify with the night staff the arrangements for getting residents up in the mornings. The temperature of the laundry should continue to be monitored to ensure that it is safe to work in and also to store cleaning products. Arrangements for laundry should be clarified with the relatives of residents. A policy on bullying should be put in place. Greenaways Rest Home DS0000021119.V337383.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Greenaways Rest Home DS0000021119.V337383.R01.S.doc Version 5.2 Page 28 - 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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