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Inspection on 23/07/05 for Greenfield House

Also see our care home review for Greenfield House for more information

This inspection was carried out on 23rd July 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 found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The premises themselves were clean and in good decorative order and the bedrooms were personalised. All records seen were in keeping with the home`s statement of purpose and service user guide. Staff continue to have relevant training in order to meet service user needs. The home is adequately staffed with five members of staff at any given time and two during the night. During the inspection, the statement of purpose, the service user guide and other documentation were examined in order to assess the standards being looked at. It was very clear from these documents that the home only admits service users into the home based on a full pre admission assessment. The home has service user plans in place. There is no shortage of social and leisure activities for service users. The activities are both varied and interesting according the feedback received from relatives and staff. Records showed that activities range from eating out, visiting places of interest, walking, shopping and bowling.

What has improved since the last inspection?

Three out of the four requirements made in the last inspection have been met. The registered manager has now ensured that risk assessments are in place to justify service users not having their own keys. The home now also seeks the opinions and views of service users, relatives and stakeholders in the interests of quality assurance. The home`s business plan is now read and signed by all members of staff.

What the care home could do better:

It was noted that the service users` vulnerability had not been taken into account and risk assessed when it came to forming outside relationships. The contracts that were seen during the inspection were out of date, did not contain all aspects mentioned in standard 5.2 and were not signed. A requirement was made accordingly. Less than 50% of the staff team are NVQ2 qualified or above. It was recommended that the home endeavour to meet these Sector Skills workforce training targets.

CARE HOME ADULTS 18-65 Greenfield House Springfield Road Leek Staffordshire ST13 7LQ Lead Inspector Lorraine Mavengere Unannounced 23 July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Greenfield House E51 E09 S30345 Greenfield House V230980 230705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Greenfield House Address Springfield Road Leek Staffordshire ST13 7LQ 01538 385916 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Staffordshire County Council Mrs Annette Cox Care Home 9 2 9 2 2 Category(ies) of DE registration, with number LD of places MD PD Greenfield House E51 E09 S30345 Greenfield House V230980 230705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14 December 2004 Brief Description of the Service: Greenfield house is a purpose built Local Authority home that can accommodate nine adults with learning disabilities whose ages range from 32 years to 54 years of age. The home is located in a residential area close to Leek town centre, close to shops and amenities and is accessible by public transport. The home is pleasantly situated with extensive grounds and a patio area. Adequate car parking, external roadways and pathways are provided.Accommodation is provided on one floor and comprises nine single rooms. In March 2004 the home provided a self contained flat arrangement to accommodate two residents with en-suite toilet/shower, kitchen, conservatory dining area and lounge. The aim was to provide extra living space. There is one assisted bath, one domestic bath and two shower rooms. There are six toilets throughout the home and facilities are currently being upgraded to provide new furnishings and fittings in all service user rooms. Service users have three separate lounges, dining and activity spaces. Services and facilities including laundry, catering and hotel services are good with adequate staffing levels. Activities and entertainment take place and are facilitated by designated staff. Transport is provided when required with a purpose built minibus and families and friends are encouraged to take part in trips out. The home has strong links with day centres that are attended throughout the week. The home is owned by Staffordshire County Council and operated by Staffordshire Social Services. Revenue budgets are devolved to the home and capital expenditure is managed centrally Contingency monies are set aside for Greenfield House E51 E09 S30345 Greenfield House V230980 230705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this year’s inspections undertaken by the Commission for Social Care Inspection is on outcomes for service users, progress on meeting national minimum standards from previous inspections, and a focus on aspects of service provision that need further development, or pose the most significant potential risk to service users. Many of the standards that are relevant to this setting were inspected on this occasion. The home measured favourably and showed an improvement in overall performance since the 2004/ 2005 inspections. This inspection was unannounced and took place from midmorning into the early evening on the 23rd of July 2005. It was a Saturday inspection. The service has operated for a considerable number of years to meet the individual needs of eight service users who live within the premises. The inspector was able to conclude that the service provided at the home meets the needs of the service users and comprehensively provide for their health, safety and welfare. What the service does well: The premises themselves were clean and in good decorative order and the bedrooms were personalised. All records seen were in keeping with the home’s statement of purpose and service user guide. Staff continue to have relevant training in order to meet service user needs. The home is adequately staffed with five members of staff at any given time and two during the night. During the inspection, the statement of purpose, the service user guide and other documentation were examined in order to assess the standards being looked at. It was very clear from these documents that the home only admits service users into the home based on a full pre admission assessment. The home has service user plans in place. There is no shortage of social and leisure activities for service users. The activities are both varied and interesting according the feedback received from relatives and staff. Records showed that activities range from eating out, visiting places of interest, walking, shopping and bowling. Greenfield House E51 E09 S30345 Greenfield House V230980 230705 Stage 4.doc Version 1.30 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. Greenfield House E51 E09 S30345 Greenfield House V230980 230705 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Greenfield House E51 E09 S30345 Greenfield House V230980 230705 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, 4, 5 Service Users are provided with clear information about the home to enable them to make an informed choice about whether they wish to live there. The home can demonstrate its ability to meet service users’ needs enabling service users to be assured that they will be well catered for. The home offers introductory visits to all prospective service users so that they are aware of the services offered by the home, and get the chance to assess their own compatibility with the service. All service users are provided with a statement of terms and conditions. These however are not adequate and need reviewing, updating and confirmation through signatures of relevant parties. EVIDENCE: Both the service user guide and statement of purpose were examined during the inspection. The documents provided all relevant information as stated in the national minimum standards. The service user guide was made available in formats that are suitable to the service user group. These are picture and symbol format. The senior member of staff assisting the inspection confirmed that the service user guide could also be made available in large print, Braille, audio tape and different languages if required. Greenfield House E51 E09 S30345 Greenfield House V230980 230705 Stage 4.doc Version 1.30 Page 9 The statement of purpose and discussions with various members of staff demonstrated that the home is able to meet service users’ needs. The statement of purpose very clearly outlines who the service is for and the combined skills and experience of the staff team. Care files seen during the inspection showed that all service user needs had been assessed and care planned for in accordance with the home’s stated purpose. As per stated purpose of the home, records showed that staff are trained in various aspects of working with people with learning disabilities. At a basic level, these issues are also tackled during staff induction and supervision. As highlighted in the previous inspection report, the statement of purpose specifies that the home caters for specialist needs such as challenging behaviour, mental health diagnosis and sensory impairment. Recorded staff training and qualifications detailed in the statement of purpose, however, does not support all of this. The registered manager in the previous inspection report was required to demonstrate the home’s ability to meet the afore mentioned areas of specialism. This is currently still outstanding and must be addressed. Although none of the service users were able to confirm introductory visits due to communication difficulties, the statement of purpose verifies that all prospective service users are offered an introductory visit, during which time they and their representatives or relatives can assess the home’s suitability for their stated needs. This is further confirmed by the organisation’s admission policy. All the contracts seen on the day of inspection were not service user specific and they were not fully completed and signed by the relevant parties. None of the contracts seemed to have been reviewed nor updated since first being formulated. The registered manager must ensure that all contracts are updated, fully completed and signed by all concerned parties. It was also noted that the contracts did not contain all areas specified in standard 5.2. The registered manager must ensure that all areas specified in standard 5.2 are included in the contract. As an addition to the contracts, the home provides all service users with a Rules and Restrictions document that details restrictions that will affect service users choice and freedom and explains the reasons why the establishment has taken such measures. This document is signed on behalf of the establishment but where the service user is to sign is left blank. It is recommended that service users or their representatives sign this document. Greenfield House E51 E09 S30345 Greenfield House V230980 230705 Stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 10 The home has a formulated service user plan that describes the services and facilities offered to each individual service user in relation to there assessed needs. This ensures that all areas of care are met. Service users are assisted in making decisions about everyday matters with no restrictions except those assessed as a high risk. The home ensures that service users are offered opportunities to participate in the day to day running of the home and are consulted about various aspects of life in the home. All confidential information about service users is stored and maintained securely assuring service users that their confidences are kept. EVIDENCE: Four care files were sampled during the inspection. These files showed that all service users had a person centred care plan. It is understood from discussions with the senior member of staff that the care plans were formulated from the original care plans but have evolved as the service users’ needs have evolved. It was clear that this was possibly the case because the original assessments which were up to eleven years old did not indicate any of the service users Greenfield House E51 E09 S30345 Greenfield House V230980 230705 Stage 4.doc Version 1.30 Page 11 current needs. Records showed that alongside the care plan were documents such as the 24 hour support plan and the ‘Looking After Myself’ report which all assist in giving a clear understanding of the service users’ needs and how best to meet these. The plans seen were comprehensive and records showed that these were reviewed regularly. Records seen during the inspection showed that the person centred care plans had information on how each individual expresses choice and makes decisions. This is an extremely necessary part of the care documentation given the communication difficulties faced by the residents of Greenfield House. Some relatives were spoken to during the inspection. They were able to confirm that service users are facilitated in making choices about their lives and relatives are invited to help in this process. The senior member of staff spoken to stated that the home does not carry out service user meetings for the residents due to the limited nature of their communication. She also stated that this was tried and tested in the past and was found to be of no use to them. The plans seen demonstrated that service users were fully consulted about their daily lives. Staff spoken to showed knowledge on service users likes, dislikes and preferences. Observed practice showed that the home endeavours, as far as possible, to promote participation from the service users in the running of the home. Staff were seen using verbal and non verbal communication to facilitate participation. On the whole, discussions with various members of staff highlighted that due to the service users limited communication, it was extremely difficult for them to fully participate in the running of the home and in the making of major decisions. The home has a comprehensive policy on confidentiality that was seen during the inspection, the home’s current practices are in line with this. All confidential records are stored and maintained in accordance with the Data Protection Act 1998. Service users are given information within their service users guide about the home’s policy on confidentiality. This is also explained verbally to them. The home also has an Access to Records policy. It is stated within this policy that service users have the right to access any information held by the home about them. Greenfield House E51 E09 S30345 Greenfield House V230980 230705 Stage 4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15 Service users have the opportunity for personal development and participation in the community, leisure and are encouraged to form relationships outside of the home. EVIDENCE: Discussions with the senior member of staff confirmed that service users are given the opportunity to maintain and develop social, communication and independent living skills both with in the home and outside. Staff confirmed that these opportunities were given in accordance to each service users personal abilities and take into account areas of vulnerability. Records seen showed that service users attend the Moorlands Day Services. The Moorlands Day Services provides service users with educational and occupational opportunities. One of the service users attends Leek College. Records showed that the subjects covered at Moorlands Day Services include health and beauty, music and movement, communication through food, communication and community. The service user who attends Leek College attends pottery classes for which he indicated that he enjoys. Greenfield House E51 E09 S30345 Greenfield House V230980 230705 Stage 4.doc Version 1.30 Page 13 It was evident through records and discussions with staff and relatives that services users are very much present in the community. Service users go out regularly into the town centre, which is close to the home, they also eat out occasionally, pub visits, shopping and taking walks. All staff spoken to were aware of the service users’ right to access public facilities under the Disability Discrimination Act 1995. It was observed during the inspection that service users were taking part in different things. Some were indoors watching television or listening to music, while others were outside enjoying the good weather or walking in the garden area. Discussions with staff and relatives evidenced that various activities are organised by the home and service users are encouraged to take part. Currently the home is looking to hiring a wheelchair friendly cottage in one of the holiday areas so that service users can have a holiday this year. Plans for this have not yet been finalised. Although relationships are encouraged outside the home, none of the care records and risk assessments take into account service users vulnerabilities. These vulnerabilities must be risk assessed. Greenfield House E51 E09 S30345 Greenfield House V230980 230705 Stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, Service users have access to all primary healthcare facilities as well as any specialist services as required. All health needs are therefore adequately catered for. EVIDENCE: Records show that all service users are registered with a General Practitioner and have access to all primary health care facilities such as the optician, dentist, and chiropodist as needed. The senior member of staff confirmed that where needed, referrals would be made for specialist services to meet identified needs. All physical and emotional health care needs are identified in the care plan with instruction on how to met these needs detailed alongside. On the day of inspection, none of the service users had pressure sores and there had been no admissions into Accidents and Emergencies since the last inspection. It was noted from one of the care files that one of the residents was undergoing a change in medication for epilepsy. The change was causing some initial instability in the manner of epileptic seizures that she was experiencing. Observed practice showed that staff were aware of her whereabouts at all times and the level of care she received was intensified to ensure her safety. Staff were keeping a record of all incidents of seizures. This demonstrated staff competencies and ability to ensure that service users’ needs are met. Greenfield House E51 E09 S30345 Greenfield House V230980 230705 Stage 4.doc Version 1.30 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 Service users are provided with clear information on how to make a complaint with contact details of other relevant agencies should they wish to use these. As a result, service users are certain that their grievances will be dealt with in a timely fashion. EVIDENCE: Records show that the home has had no complaints since the last inspection. The Commission for Social Care Inspection have received no phone calls or letters of concern with regards to this home since the last inspection. The complaints procedure is comprehensive and is made fully available to service users and significant others. The procedure clearly states that all complaints will be responded to within a twenty-eight day time frame. Contact details for the Commission for Social Care Inspection and other relevant agencies are also made available in the procedure for complaining. On the day of inspection, the complaints procedure was on display, the senior member of staff confirmed that each service user is provided with their own copy of this document. The complaints procedure is made available in picture, symbol and audio tape format. Greenfield House E51 E09 S30345 Greenfield House V230980 230705 Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 28 On the day of inspection, the home was of good domestic cleanliness and carried no offensive odours. The premises are suitable for their stated purpose and provide adequate living accommodation for the service users. Service users bedrooms have useable floor space sufficient to meet individual needs and lifestyles. All communal areas are satisfactory in size allowing the service users un crowded living space. EVIDENCE: A detailed tour of the home showed it to be safe, comfortable, bright, cheerful, airy and clean. The home provides suitable heating and ventilation. All furnishings and fittings are of good quality and are as domestic, unobtrusive and ordinary as is compatible with fulfilling their purpose. The access to outdoor space is user friendly, no service users struggle to enter or exit the garden area. The premises also meet the requirements for their local fire service and environmental health department, health and safety and building Acts and Regulations. Observations showed that service users seemed comfortable in their living environment. Greenfield House E51 E09 S30345 Greenfield House V230980 230705 Stage 4.doc Version 1.30 Page 17 Room sizes were not taken during this particular inspection. Measurements of room sizes from previous inspections show that the service users’ bedrooms have useable floor space sufficient to meet individual needs and lifestyles. A tour of the building showed that the home has two dining areas and two living rooms. One of the living rooms also doubles up as a dining area. These areas are adequate in size. The home has an extension for which two service users reside. The idea behind this is that these two service users increase their independent living skills in accordance with their care plan. The extension has two bedrooms its own kitchen and a living room with a dining area. Greenfield House E51 E09 S30345 Greenfield House V230980 230705 Stage 4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33 Staffing levels are appropriate for current service user needs and the staff team collectively, and individually have the skills mix to meet needs. EVIDENCE: Observed practice on the day of inspection showed that staff know and support the aims and objectives of the home as outlined in the statement of purpose. Records showed that all new members of staff get a comprehensive six-day induction programme that covers all aspects of the home, policies and procedures and care provision. Records also show that some members of staff have completed the Staffordshire Social Services Department Foundation Programme or its equivalent. Discussions with the senior member of staff confirmed that all members of staff are provided with a job description and a statement of terms and conditions for the work they do in the home. Records seen indicated that eight members of staff are trained to NVQ level 2 or above. The statement of purpose, training schedule and discussions with the members of staff themselves, demonstrate that the team has the skills and experience necessary for the tasks they are expected to do. Observations showed staff to be approachable, good communicators, interested, motivated and committed. It is recommended that 50 of the staff team be trained to NVQ level two or above to meet the Sector Skills Council workforce strategy targets. Greenfield House E51 E09 S30345 Greenfield House V230980 230705 Stage 4.doc Version 1.30 Page 19 Rotas inspected show that there are 22 care staff and two staffing vacancies. The home operates on five members of staff during the morning shift, five members of staff during the afternoon shift and two waking night staff. Records showed that one member of staff had been off long term sick but was being slowly re introduced into the work place. As highlighted in the statement of purpose, the staff team have a mixture of skills and experience that enable them to meet service user needs. Staff spoken to were also able to confirm that they can attend various training courses to increase their competencies and as a rule are expected to attend mandatory training. Greenfield House E51 E09 S30345 Greenfield House V230980 230705 Stage 4.doc Version 1.30 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 41, 43 The registered manager is qualified, competent and experienced to run the home. The management of the home creates an open, positive and inclusive atmosphere. Record keeping policies within the home are in line with statutory requirements enabling service users’ best interests to be safe guarded. Service users benefit from competent and accountable management of service. Greenfield House E51 E09 S30345 Greenfield House V230980 230705 Stage 4.doc Version 1.30 Page 21 EVIDENCE: According to the statement of purpose, the home manager has two years management experience and holds an NEBSM and a D32/ 33. The registered manager confirmed that since the last inspection she has now qualified in NVQ level 4 in care management. All staff spoken to stated that they had faith in her management abilities and felt confident in her leadership skills. The atmosphere on the day of inspection was relaxed and cheerful. Staff spoken to all expressed their confidence in the registered manager and their leaders. Staff spoken to also confirmed that they understood and were comfortable with their lines of accountability. The processes of running the home appeared to be open and transparent. The home’s policy statements were seen to be appropriate to the setting. Staff have access to all policies and procedures and are informed as new ones are developed or updated. The complaints procedure and the fire policy are available to service users. The manager confirmed that all relevant policies and procedures will be made available, or explained to service users as required. Discussions with the senior member of staff confirmed that service users would not benefit from policies and procedures being formatted due to their levels of ability. The Employee’s Liability Insurance certificate was viewed during the inspection. This is as required by the regulations and meets with the National Minimum Standard. On the day of inspection, the business and financial plan for the establishment was not seen. The registered manager must ensure that a business and financial plan for the establishment is available and open for inspection. Greenfield House E51 E09 S30345 Greenfield House V230980 230705 Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x 3 3 2 Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 x 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x x 3 x x Standard No 11 12 13 14 15 16 17 3 3 3 3 2 x x Standard No 31 32 33 34 35 36 Score 3 3 3 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Greenfield House Score x 3 x x Standard No 37 38 39 40 41 42 43 Score 3 3 x x 3 x 3 E51 E09 S30345 Greenfield House V230980 230705 Stage 4.doc Version 1.30 Page 23 1 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA5 Regulation 5(1) Requirement Timescale for action 31/01/06 2. 3. YA15 All contracts must be reviewed, updated and signed, and contain all areas specified in standard 5.2 13(4)(b)(c All service user vulnerabilities ) must be risk assessed in relation to outside relationships. 31/01/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA32 Good Practice Recommendations It is recommended that 50 of the staff team are qualified to NVQ2 or above. Greenfield House E51 E09 S30345 Greenfield House V230980 230705 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Greenfield House E51 E09 S30345 Greenfield House V230980 230705 Stage 4.doc Version 1.30 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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