Inspection on 04/10/05 for Greenaways Rest Home

This inspection was carried out on 4th October 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Greenaways Rest Home 15/05/07

Greenaways Rest Home 08/06/06

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 56 Collington Avenue Bexhill-on-sea East Sussex TN39 3RA Lead Inspector Andy Denness Announced Inspection 4th October 2005 02:00 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 DS0000021119.V252183.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Greenaways DS0000021119.V252183.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Greenaways 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 philrit45.freeserve.co.uk Mrs Jacqueline Brittain Mrs Jillian Lawrence Care Home 12 Category(ies) of Dementia (12) registration, with number of places Greenaways DS0000021119.V252183.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 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 Date of last inspection 4th May 2005 Brief Description of the Service: Greenaways is a detached property situated on the outskirts of Bexhill on Sea. The town centre with its shops and access to bus and rail services is approximately one mile away. Accommodation is provided on two floors and a stair lift is fitted to assist those service users with mobility problems. The home has large gardens to the rear and parking at the front of the building. Greenaways is registered to accommodate up to 12 older people who have a dementia type illness and the registered owner is Mrs J Brittain. Greenaways DS0000021119.V252183.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over an afternoon and evening in October and lasted five hours. To help gather evidence on how the home is performing the Inspector sat and ate an evening meal with service users, met with staff and the home’s manager, examined a range of records and written information and undertook a tour of the premises. In depth discussions took place with several service users and two relatives of service users who were visiting at the time of the inspection. Written feedback regarding the home was received from several relatives of service users and some health professionals. What the service does well: 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. Greenaways DS0000021119.V252183.R01.S.doc Version 5.0 Page 6 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 DS0000021119.V252183.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, & 5. Pre admission procedures are satisfactory and help ensure that service users are admitted to a home that is suitable to meet their assessed needs. EVIDENCE: A service user guide and a statement of purpose have been produced for the home, these documents provide guidance for prospective service users and their relatives about the home, the service provided and how it is performing. Both documents were examined; it has been required that the statement of purpose is individualised to include more information specifically about Greenaways. The manager and owner of the home undertake assessments of new service users, a selection were examined; they were of a satisfactory quality. These assessments are supported by assessments undertaken by Social Services if they fund the service user. The home has a contract for issuing to service users and their relatives, a copy of the document was examined, it was of a satisfactory quality and contained all required details. The home does not provide rehabilitative care. Greenaways DS0000021119.V252183.R01.S.doc Version 5.0 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 & 11. Considerable improvements have been made to the policies, procedures and practices in the home regarding health, personal and social care needs; these are now good and help ensure that identified service user needs in these areas are appropriately met by staff. EVIDENCE: Using the initial assessment of need as a starting point individual plans of care are compiled for each service user; these identify amongst other things what support service users require from staff to meet their day to day needs in relation to health, personal and social care needs. Since the last inspection the manager has worked hard to make improvements to the care planning process, and plans examined were of a good standard. From observations made, records examined and information obtained from comment cards from health professionals it was evident that needs identified in the plans were being appropriately met by staff. Observations made during inspection confirmed that staff treat service users with respect and dignity. Because of their mental health needs, service users do not manage their own medication, staff do this for them; an easily monitored medication system is used, storage and records were examined and found to be in order. A written procedure is in place, which clearly gives guidance to staff on what to do in the event of the Greenaways DS0000021119.V252183.R01.S.doc Version 5.0 Page 9 death of a service user. The Inspector was told that if possible a service user would be supported to spend their last days in the home, in familiar surroundings with people that they know. The manager said that she is about to complete a bereavement training course. Greenaways DS0000021119.V252183.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Arrangements in the home regarding social and recreational needs, visitors and meals are good and ensure service users choice and variety in all of these areas. EVIDENCE: From discussions with service users, relatives and staff and from observations it was evident that service users have choices in all areas of their daily living. A range of leisure activities are included, these not only include group activities and entertainment but also staff spending time with individuals talking to them about their interests and past lives. The home has a well-tended large garden, service users spoke very positively of this, the garden is secure and those service users that are able can spend time in it unaccompanied. Records examined confirmed that a varied menu is provided; the Inspector sat and ate an evening meal with service users, it was well prepared and obviously enjoyed by them. Some service users needed help with eating this was provided sensitively by staff. Two relatives were visiting the home during the inspection, they were made welcome and spoke positively of the manager and staff and the service provided. Greenaways DS0000021119.V252183.R01.S.doc Version 5.0 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 & 18 Current arrangements regarding complaints and adult protection matters are satisfactory and ensure that these matters are managed appropriately. EVIDENCE: The home has detailed complaints and adult protection procedures in place, both procedures were examined; they were of a satisfactory quality. Records examined confirmed that the manager handles complaints in line with the written procedures. Staff training in adult protection matters is planned. The manager said that she has just received details for registering service users on the electoral roll and will be doing this. Greenaways DS0000021119.V252183.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 26. Physical standards and accommodation throughout the home were generally good and ensure that service users live in a comfortable, safe and well maintained environment. EVIDENCE: An inspection of all areas of the environment took place, this confirmed that physical standards were generally good, however it has been required that the holes in two doors are repaired to ensure privacy for service users, that some radiator guards are painted or varnished and that one bedroom is refurbished. Bedroom accommodation is provided in eight single and two double rooms, with the exception of the one room previously referred to all rooms were decorated and furnished to a satisfactory standard. The Inspector was told that service users are able to bring their own furniture with them if they so wish, some have done this, which has resulted in pleasant personalised rooms. Communal accommodation consists of a lounge and dining room both of which are furnished and decorated in a comfortable homely style. Emergency call points are fitted throughout the home. Heating is provided by a gas central Greenaways DS0000021119.V252183.R01.S.doc Version 5.0 Page 13 heating system with radiators in all rooms, all of which are guarded. Tests confirmed that hot water is delivered to wash hand basins and baths at a safe temperature. The home is fitted with a stair lift to assist service users access first floor accommodation. Two baths are fitted with a special seat/hoist to assist access and handrails and other adaptations are fitted in key areas to assist those with mobility problems. Since the last inspection improvements have been made to standards of cleanliness and hygiene in the home, which are now satisfactory. Written policies are in place regarding infection control and training plans examined confirmed that staff are trained in infection control. The laundry is suitably equipped and is now fitted with an extractor fan. The home has large well-tended gardens. Greenaways DS0000021119.V252183.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Staffing arrangements were generally satisfactory with sufficient numbers of staff employed to meet service users’ needs; some training has been required. EVIDENCE: Staffing levels consist of two care staff on duty at all times during the day, a cleaner two night staff, one waking and one sleeping. Care staff also undertake all catering duties. From records examined and discussions with relatives and service users it was evident that these levels are satisfactory ensuring that service users’ needs are appropriately met. Staff were observed to work in a caring and respectful way with service users; comments from service users and relatives regarding staff included “ they are wonderful, “I couldn’t fault them” and “staff are always helpful and caring”. Records examined confirmed that most staff are trained in food hygiene, moving and handling and first aid. At the last inspection it was required that fire prevention training be provided, this has not yet happened; it has been required that this now happens as a matter of urgency. Records examined confirmed that 50 of staff are not yet trained to the required level, however the Inspector was told that staff are now registered to start the appropriate course. Records examined confirmed that satisfactory recruitment procedures are followed when new staff are employed. The manager currently provides induction training for new staff. Greenaways DS0000021119.V252183.R01.S.doc Version 5.0 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37 & 38 Management and administrative systems in the home are generally good and work well in supporting staff in their day-to-day work. EVIDENCE: The manager is experienced in caring for older people with dementia and throughout the inspection demonstrated a clear understanding of the needs associated with their condition; she is registered as manager with the Commission for Social Care Inspection and is part way through the required management training course. The home does not hold any money on behalf of service users. The insurance certificate for the home indicated that insurance levels are set at the required levels. From discussions with staff and an examination of records it was evident that staff receive the one to one support from the manager that is required. Records confirmed that the manager has consulted with service users to ascertain their views of the service and any improvements that they would like; because of service users mental health Greenaways DS0000021119.V252183.R01.S.doc Version 5.0 Page 16 needs this is not always successful, it has therefore been required that the manager expands this process to include relatives. A selection of records and policies and procedures required by regulation were examined, these were in order and stored securely. The manager showed an understanding of health and safety matters including the risk assessment process. A selection of health and safety records were examined, these were in order. Greenaways DS0000021119.V252183.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 3 3 3 3 2 Greenaways DS0000021119.V252183.R01.S.doc Version 5.0 Page 18 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 2 Standard OP1 OP19 Regulation 4 23 Requirement That the statement of purpose is individualised to the home. That the following maintenance issues are addressed; the holes in the two doors discussed are filled; the unfinished radiator guards and the stair gate are treated and room 16 is refurbished. That 50 of staff are trained to NVQ level 2. That the manager is trained to NVQ level 4 in management. That the quality assurance system is expanded to include regular consultations with relatives by means of questionnaires. That all staff are trained in fire protection matters. Timescale for action 04/01/06 04/11/05 3 4 5 OP28 OP31 OP33 18 9 24 31/12/05 31/12/05 04/01/06 6 OP38 18 04/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Greenaways DS0000021119.V252183.R01.S.doc Version 5.0 Page 19 No. Refer to Standard Good Practice Recommendations Greenaways DS0000021119.V252183.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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