Inspection on 08/06/06 for Greenaways Rest Home

This inspection was carried out on 8th June 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Greenaways Rest Home 15/05/07

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 56 Collington Avenue Bexhill-on-sea East Sussex TN39 3RA Lead Inspector Jenny Blackwell Key Unannounced Inspection 8th June 2006 10:00 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.V292064.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 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.V292064.R01.S.doc Version 5.1 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.V292064.R01.S.doc Version 5.1 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 4th October 2005 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 provider is Mrs J Brittain. A large, rear garden provides a safe and pleasant area for residents to spend time in. The fee information for Greenaways is yet to be passed to the Commission. This information will be required from provider for the next published report. More detailed information about the services provided at Greenaways can be found in the home’s Statement of Purpose and Service User Guide – copies of these documents can be obtained directly from the Provider. Latest CSCI inspection reports are kept in the home’s office. Greenaways DS0000021119.V292064.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulations 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Greenaways are referred to as “residents.” People working at the home will be referred to as “staff” or by their job title. This report reflects a key inspection based on the collation of information received since the last inspection, feedback from representatives and visiting professionals and an unannounced and follow up announced site visits which lasted a total of ten hours on Thursday 8th June and Thursday 15th June. The site visits included a tour of the premises and an examination of medication, care and staffing records. The Inspector joined residents for their supper. Throughout the inspection process, the Inspector spent time with the majority of the residents, two residents individually and observed the way the people were supported in communal areas. Time was spent with the staff at the home and telephone conversations were held with a volunteer and a relative. Written feedback was received from five relatives. The manager was met with during the site visit. In addition one staff was interviewed individually and two others together. Two night staff were also seen during the visit. What the service does well: The inspection process has identified that the home is performing good in most areas and adequately in others. Residents were supported by a team of staff who are committed to meeting their needs. During the site visit, staff were observed to be assisting residents in a sensitive and respectful manner. The atmosphere was friendly and relaxed. The manager and staff have continued to make progress in working from clear individual plans. Each contained information about their interest and support needs. Information had been recorded about the individuals needs their physical and mental well being. The care staff were observed when they were supporting the residents. They acted in a friendly and professional manner and operated in a relaxed atmosphere. One relative commented that “staff were always pleasant friendly Greenaways DS0000021119.V292064.R01.S.doc Version 5.1 Page 6 and helpful.” Another relative said “ all of the staff are caring, considerate and efficient and extremely helpful at all times.” The manager of the home was found to be responsive to the inspection process and had been open about improvements that could be made at the home. She was self motivated to research issues experienced by people with dementia and had developed some useful activities that promoted the residents mental well being. What has improved since the last inspection? What they could do better: Requirements from this inspection primarily focus on assessment and admission of residents to the home, epilepsy and fire safety training, food menus, refurbishment, storage of records and ensuring the home has a quality assurance system in place. The assessment process needed to be improved as one resident needs had not been fully assessed as being able to be met by the home. Some gaps were noted in training for staff although generally staff had good access to training and development. The manager was required to look at the development of the menus at the home that were based on the preferences of the residents and also to review the meals at supper where of a reasonable standard. Further work is needed around the house although the house was generally well presented some areas needed some repair work and decoration. The staff records needed to be held more securely at the home. The home had begun work on developing a quality monitoring tool, however this need to be expanded and include all the elements described in the National Minimum Standards. Greenaways DS0000021119.V292064.R01.S.doc Version 5.1 Page 7 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.V292064.R01.S.doc Version 5.1 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 DS0000021119.V292064.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides perspective residents with information about services at the home. One person had moved to the home without a full and comprehensive assessment. Intermediate care is not provided by the home. EVIDENCE: Since the previous inspection the manager had ensured that the Statement of Purpose for the home had been written to reflect the services provided at the home. A copy of the statement of purpose was seen in a residents individual plan. The assessment process of the newest person to move to the home was checked. The manager and owner had undertaken a pre admissions assessment for the person, they visited him and met with the staff at the home he was living in and talked to the persons family. Greenaways DS0000021119.V292064.R01.S.doc Version 5.1 Page 10 The assessment produced by the home was clear and contained most information they needed to support the person. However the individual was subject to a full assessment by East Sussex Social Services as his support needs had changed. This assessment had not been given to the manager of the home prior to the person admission. As this assessment would contain specific information needed for the home to write the persons individual plan it needed to be in place before the person moved in. The manager had acknowledge this and said she had tried to get the assessment from the social worker. She would be writing to her to ensure she had the assessment at the home. It is required that the home only admits people once they have a full and thorough assessment. The home does not provide intermediate care. Greenaways DS0000021119.V292064.R01.S.doc Version 5.1 Page 11 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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and well being needs of the residents were set out in their individual plans and their health care needs were met. Medication procedures protected people from errors in medication. Through observation, discussion and viewing documents residents were seen to be treated with respect and their privacy was upheld. EVIDENCE: Three residents individual plans were looked at. Each contained information about their interest and support needs. Information had been recorded about the individuals needs their physical and mental well-being. Information had been transferred from admission assessments to make up the individuals plan. This included information about the resident’s religious beliefs, family background and contact details and their wishes in the event of their death. Some good information was contained in one resident’s plan that described the way in which staff should communicate with the person. It gave Greenaways DS0000021119.V292064.R01.S.doc Version 5.1 Page 12 guidance to staff to give time for the person to talk giving them information of why this was important for the resident. During the visits to the home time was spent with staff discussing the support needs of the residents. On several occasions those staff spoken to made reference to the individuals plan. For example one staff talked about a new personal care routine that had been revised in a plan because of the changing needs of the individual. A new system had been introduced to start recording daily information about the residents, a new coding system identified areas that must be recorded each day, such as health care. The manager reviews the care plans monthly and she makes changes if necessary. It was noted in on plan that a meeting was held with one resident about his plan but not evident in others if the residents are involved in reviewing the plans. The manager demonstrated good knowledge of the health care needs of the residents. She was able to talk about when the health care needs change to such an extent that the home would no longer be able to support someone. The home had good links with community health care professionals and the residents have their own G.P’s. One relative commented in the survey that her mother medication had been changed since going to the home which she benefited from. Four survey’s returned to the commission said that the resident always needed the medical support they need whilst two others said usually. It was noted that two residents were epileptic. Although the staff had supported the individuals well they had not received training in epilepsy. It was required that they received appropriate training in epilepsy. A check of the resident’s medication was conducted with the manager. All the residents rely on the staff to help them with their medication. The medication was stored administered and recorded correctly. The staff were seen to administer medication to the residents in accordance with the homes policy. Some residents of the home were not able to directly respond to questions about how the staff treated them, due to their health issues. Time was spent observing the interaction between the staff and this group of residents. The two care staff working were respectful to the individuals and ensured that they tried to give choices to the residents. Both staff were seen to redirect a confused resident back to his bedroom when he needed personal support. This was done sensitively and respectfully. Two residents were spoken to directly about their experience of living at the home. Both were happy at the home and felt they were supported by staff to make choice through the day. One resident said the staff were polite and treated him well. Greenaways DS0000021119.V292064.R01.S.doc Version 5.1 Page 13 5 out of the 6 surveys returned said that the staff always listened and acted on what the residents said, 1 survey replied sometimes. Greenaways DS0000021119.V292064.R01.S.doc Version 5.1 Page 14 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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are supported to experience their preferred lifestyle as much as possible, including maintaining contact with family and friends. Mealtimes will need to be monitored to ensure suitability of the diet and appropriate staffing levels. EVIDENCE: The atmosphere on the day of visits was noted to be calm and relaxed. Staff were observed engaging with residents in a friendly and appropriate manner. One staff member said that an activity was planned for each afternoon. On the first visit a member of staff was doing the resident nails. She was seen to spend time with individuals chatting with them and responding well when a resident didn’t want they nails done. Later the staff member asked if the residents wanted to turn the television of and put some music on. She sated that one resident in particular liked to dance to music. She encouraged the resident to have a dance and they were both laughing and smiling whilst having a dance. Other residents joined in clapping hands and singing. Greenaways DS0000021119.V292064.R01.S.doc Version 5.1 Page 15 The manager produced an “activities file” that she had put together from guidance from the Alzheimer’s Society that promoted recall and memory skills. She gave an example of a session she was involved with recently were she had a group of residents have a look at maps of England and the world. From that the residents were encouraged to talk about places they used to live and places they had travelled. These sessions were checked and seen recorded in resident’s files of when they participated in activities and what the outcome was. Some relative’s comments from the surveys were “Enjoys the entertainment organised, staff take time to talk to her which she likes best” and “ each month we have been invited to entertainment at Greenaways.” Once a month a person comes to the home to lead a motivation session we she encourages the residents to join in exercises. Two resident’s commented about how important the garden was. They both spent time in the well-kept, large garden and enjoyed watching the birds and wildlife. The garden was secure and enabled residents to spend time there unaccompanied. They felt they had control over their lives and made choices about their daily lives. For some people living at the home exercising their choice was more difficult. The staff were seen to use their acquired knowledge of a person to help them make choices. For example one person was reminded about a food preference at supper time. Staff were asked about the cultural or religious needs of the residents. One member of staff said that the current individuals did not request or require any support form them to exercise their beliefs or cultural requirements. A volunteer was spoken with over the phone. She had visited the home for over ten years befriending residents and providing religious services when the residents requested. She said she was always welcome at the home Some residents at the home had identified themselves as friends and spent time in each other’s company. Relatives were encouraged to visit the home when they wished. On the day of the first visit a relative was leaving just as the inspector arrived. The staff said that the relative came regularly to the home along as do other residents relatives. Staff were able to name the family members and their patterns of visiting. One relative commented that when they visit they are always offered tea, coffee cakes and biscuits. Those residents spoken to and feedback form relatives indicated the food was generally of a good standard. The meals are prepared by the care staff that have undertaken their food hygiene certificates. On the day of the first visit the inspector joined the residents for supper of chicken soup, a slice of bread with Greenaways DS0000021119.V292064.R01.S.doc Version 5.1 Page 16 margarine and fruit segments and yogurt. The residents at the table were asked about the meal two said the meals at the home was nice and enjoyed that evening’s supper. The other person did not enjoy the supper much, and was able to make some brief comments about not enjoying the soup. The inspector found the supper to be of an adequate standard. The dinning room tables were set up nicely although no condiments were available to the residents. The menu for the day was not displayed in the dinning room. It is recommended that the manager review the supper menu to ensure its nutritional content is appropriate. It was noted that a four weekly menu was written by the head office and supplied to the home. This indicates the menus were not written around the likes and preferences of the residents. When asked about this the manager said that the adapt the menu for the residents to their preferred choices. However, it is required that the home designs its menus around the specific preferences of the residents at the home. The supper time was quite busy for the two staff that were on shift. They prepared supper, served it and helped some people to eat. One resident needed 1:1 support for the meal. As residents conditions may deteriorate it is important the manager regularly reviews staffing levels at meal times in the future. Greenaways DS0000021119.V292064.R01.S.doc Version 5.1 Page 17 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives are enabled by the homes policies and procedures to have the complaints dealt with. Systems and training are in place to reasonable protect people from abuse EVIDENCE: The Commission for Social Care Inspection had not received any formal complaints about the services provided at Greenaways. The home had received a complaint from a relative in November ’05. This was recorded and dealt with appropriately and in accordance to the homes policy. The manager had a new complaints form that was being introduced to the home. A duplicate copy of the form went to the head office for monitoring. Feedback from relatives and visitors indicated that they would tell the manager or owner if they have any concerns or issues that require addressing. Staff spoken with were clear about what to do if a relative or visitor complained. The home had detailed adult protection procedures in place. One day staff and two night staff were booked on an adult protection course in July. The manager stated that she reviews the incidents and accidents books to check for patterns of falls, bruising or conflict between residents to guard against abuse. The manager had completed her N.V.Q 4 training in May’06 and described the training she had received in identifying and reporting suspected abuse. Greenaways DS0000021119.V292064.R01.S.doc Version 5.1 Page 18 Conversations with staff and observation of the interactions between the staff and residents indicated that the home operates in a manner that reduces the risk of abuse in the home. A flow chart of the correct procedures for reporting adult protection alerts was displayed in the kitchen. Greenaways DS0000021119.V292064.R01.S.doc Version 5.1 Page 19 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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally safe and homely, and reasonably maintained. Further improvements in the decoration and refurbishments are needed. EVIDENCE: The inspector toured the building at several points during the two visits. In general the home was presented in a clean and homely way. Some areas of the home were in need of improvement. The metal windows frame were in a poor condition in parts especially the front room bay window. A area in the downstairs hallway had a heavy artex surface on the walls. This was an area that the residents used a lot to wonder around in the evenings. It is recommended that the wall coating is checked to ensure it does not pose a risk to the residents if they were to knock themselves against it. It was noted that some gaps in the door frames of two bedrooms in this area had been filled in with foam gap filler. This was pointed out to the manager as Greenaways DS0000021119.V292064.R01.S.doc Version 5.1 Page 20 potentially compromising the effective ness of the fire doors to the rooms. It was required that the manager ensures the fire doors to these two bedrooms are compliant with Fire Regulations. The lounge was bright and clean and had been decorated with St Georges cross flags for the start of the world cup football. Some residents were spoken about this and said they enjoyed seeing the flags. The dining room chairs were showing signs of wear and tear and will need attention. The individual’s bedrooms were decorated with personal items and in some cases residents had brought their own furniture form home. One resident showed the inspector her bedroom and was very happy with it. She particularly enjoyed the views to the garden she had. The room was light airy and clean. Three of the single bedrooms and one of the double bedrooms have ensuite facilities. The bathrooms were adequate for the residents needs but were dated in decoration. They had assisted seating facilities that enabled the resident easy access in and out of the baths. The laundry facilities were viewed the washing machine had the programmes needed to washing foul laundry to the correct temperatures. Staff had received training in infection control. It was noted that staff were using correct procedures when handling foul laundry to reduce the risk of infection. Although a ceiling extractor fan had been installed in the laundry room the room was noted to been very hot the room did not have any natural ventilation. It was recommended that the manager reviews the temperatures in the laundry to ensure that are safe to work in and also to store cleaning products. Comments from relatives said they found the home to been clean and hygienic. The home has a welcoming atmosphere in the communal areas and a very well kept large garden. It is required the manager provide the Commission with a refurbishment and decoration programme for the home. Greenaways DS0000021119.V292064.R01.S.doc Version 5.1 Page 21 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by a team of staff who are committed to meeting their needs. Staff were generally well trained and recruitment procedures were robust. EVIDENCE: Throughout the two visits to the home the staff were seen to interact well with the residents. The staffing levels appeared reasonable through the day although a little stretched during the suppertime. Usually two staff are on shift through out the day. A cleaning member of staff works each day and helps out at the lunchtime meal. The staff present were asked about the staffing levels. They felt they were adequate usually however recently managing the workload had been a little more difficult due to the health care needs of a resident. This was noted through the visits that staff were often needing to leave what they were doing to support the particular resident. This was raised with the manager who produced some evidence to show she had highlighted the difficulties with the residents funding authority to try to resolve the situation. The Commission in conjunction with the home will monitor the progress. Relative’s comments were positive about the staff and managers of the home. One person said “ we are able to chat with them (staff) at every visit if we Greenaways DS0000021119.V292064.R01.S.doc Version 5.1 Page 22 want to and are encouraged to phone if we need to.” Another said “ all of the staff are caring, considerate and efficient and extremely helpful at all times.” Time was spent with the residents during the visit and those who were able to were asked about the staff. One resident said staff were very helpful and Greenaways was “home from home”. The home has made great improvements in the recruitment procedures of the staff. The staff files were seen for three staff. All contained written references one form previous employers, a copy of the application form supervision and induction information and training records and certificates. Criminal Records checks had been undertaken for all staff. The records were not stored securely and it was required that these were kept locked. The manager demonstrated good knowledge about the recruitment process and her duty to receive the identification documents and employment history of new staff. It was noted through discussions with day and night staff that the staff are shared amongst the other homes in the Britannia group. It is recommended the manager monitors the movement of staff between homes to ensure continuity is upheld for the residents. Three staff out of the nine employed currently hold an N.V.Q level 2 or above. Five staff hold a current first aid certificate. Staff spoken to confirmed that they had undertaken food hygiene training moving and handling courses. One staff talked about a Dementia workshop she had been on which she found useful. Records were seen of 1:1 supervisions the manager holds with the staff on a monthly basis. Each member of staff has an annual appraisal to assess their work skills and training needs. Greenaways DS0000021119.V292064.R01.S.doc Version 5.1 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 37. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The responses from the residents, relatives and staff indicate that the manager is held in high regard. A voluntary member of staff said that she found the manager welcoming and approachable. She has recently completed an N.V.Q level 4 and has undertaken training provided by the organisation in care planning and recruitment. The manager was co operative through out the visit to the home and demonstrated a good knowledge about providing a quality service for the residents. She showed concern about some residents who’s needs have changed recently and had taken appropriate steps to ensure their needs were met. Greenaways DS0000021119.V292064.R01.S.doc Version 5.1 Page 24 The home is set up to accommodate the needs of the individuals. The current group of residents appear to have their needs met by the management of the home and the care staff. It was noted that if a residents health needs deteriorate the staffing levels can become stretched. The manager demonstrated that she was responsive to the support needs of the residents and would make changes if needed. The home has a policy that it does not get involved with residents’ finances or hold valuable items for residents. The manager confirmed this at the time of the inspection. Residents are supported with their finances by either relatives or appointed solicitors. A discussion was had with the manager about how the home ensures residents can access money when they wish to. The manager said that relatives usually made arrangements that there relative had some money available to them. The manager was unable to provide information about the fee charges of the homes as the head office deals with this. The manager said that she would get the information about fees and pass to the Commission. At the previous inspection a requirement was made for the home to develop a quality assurance monitoring tool. The home has developed a new checklist that is yet to be implemented. The requirement will be continued to this report. A representative of the organisation have begun to visit the home on a monthly basis and produce a report after each visit. Health and safety records were checked on the visit and found to be in order generally. The staff undertook check on the fire detecting system weekly and monthly; call bells weekly and water temperatures monthly. A fire risk assessment had been complete by the home. The manager produced a new format that was being introduced by the organisation. It was recommended the new fire risk assessment be forwarded to the Commission once completed. Fire training for staff had still not been completed. This requirement due for completion at the end of the year will continue to be monitored. Greenaways DS0000021119.V292064.R01.S.doc Version 5.1 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Greenaways DS0000021119.V292064.R01.S.doc Version 5.1 Page 26 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. Standard OP3 OP8 OP15 Regulation 14(1) (a-d) 18(1)(c) (i) 16(2)(i) Requirement Timescale for action 08/06/06 4. OP19 23(4)(c) (i) It is required that the home only admits people once they have a full and thorough assessment. It was required that the staff 31/12/06 received appropriate training in epilepsy. It is required that the home 08/06/06 designs its menus around the specific preferences of the residents at the home. It was required that the manager 31/07/06 ensures the fire doors to these two bedrooms are compliant with Fire Regulations. It was required that staff records are held securely and kept locked away. That the quality assurance system is expanded to include regular consultations with relatives by means of questionnaires. (From previous inspection October ’05) That all staff are trained in fire protection matters. 08/06/06 31/07/06 5 6. OP29 OP33 17(2) 24(1-3) 7. OP38 18(1)(c) (i) 04/11/06 Greenaways DS0000021119.V292064.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 2 Refer to Standard OP15 OP19 Good Practice Recommendations It is recommended that the manager review the supper menu to ensure its nutritional content is appropriate. It is recommended that the wall coating is checked to ensure it does not pose a risk to the residents if they were to knock themselves against it. It was recommended that the manager review the temperatures in the laundry to ensure that are safe to work in and also to store cleaning products. It is recommended the manager monitor the movement of staff between homes to ensure continuity is upheld for the residents. It was recommended the new fire risk assessment be forwarded to the Commission once completed. 3 OP19 4 OP27 5 OP38 Greenaways DS0000021119.V292064.R01.S.doc Version 5.1 Page 28 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. Extracts may not be used or reproduced without the express permission of CSCI Greenaways DS0000021119.V292064.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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