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Inspection on 25/04/05 for Greenfield Road 9

Also see our care home review for Greenfield Road 9 for more information

This inspection was carried out on 25th April 2005.

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

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

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 inspector initially asked the registered manager/provider `what does the service do well.` The response given was that so far the organisation has had no complaints from the service users or the placing authorities. As a registered care home the organisation is working hard and positively towards improving the service, ensuring that all the Regulations are met. It was evident during the inspection that the a new

What has improved since the last inspection?

It was evident at this inspection that a number of improvements have been achieved by the registered manager/provider, with regards to the environment and that the record keeping with regards to service users care and health needs are up dated. At the previous inspection the report identified twenty-four areas for improvement and two recommendations. Seventeen areas have been addressed at the time of this inspection. These improvements related to healthcare needs, key working roles, the environment, medication procedures, staff supervision, care plans and adequate furnishing in service users rooms. However, at this inspection there is stillroom for further improvements. Service users spoken to state that the registered provider has installed new vanity sink unit in their rooms. One service user who had returned from the opticians was happy with the outcome of the visit.

What the care home could do better:

As identified above there are eighteen areas for improvements and two recommendations. Seven areas are restated from the previous report. The registered person is required to submit an action plan to the Commission for Social Care Inspection, which describe how they will address these matters. The action plan must describe how the registered person addresses andensures that the Statement of Purpose is amended to include room sizes and the section on `other services` to be changed, to review the smoking policy, register with the Data Protection body, obtain a medication review for one specific service user, some maintenance issues to be completed and obtain a current CRB checks for a number of care staff who are employed by the home and to ensure that the recruitment procedures is followed through correctly as stated in the Regulation 19 Schedule 2 of the CHR 2001. The service users that were spoken to stated that some improvements have been made. Although they did make a number of comments regarding the shower that has been broken for a number of months and that the service users would like to smoke in their rooms. This was discussed with the manager and has been addressed in the main body of this report.

CARE HOME ADULTS 18-65 9 GREENFIELD ROAD South Tottenham N15 5EP Lead Inspector Karen M Malcolm Unannouced 25 April 2005 @ 10:25 am 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. 9 GREENFIELD ROAD G59 S10810 Greenfield Road V213703 25.04.05 (4).doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Greenfield Road Address 9 Greenfield Road South Tottenham London N15 5EP 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) 020 8809 7044 020 8809 7044 campanionincare@hotmail.com Campanion in Care Limited Mr John Ajumobi Care Home 3 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding learning disability or dementia (3) of places 9 GREENFIELD ROAD G59 S10810 Greenfield Road V213703 25.04.05 (4).doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25 October 2004 Brief Description of the Service: Greenfield Road is registered as a care home for a maximum of three adults between the ages of 18 and 65 who may have mental health problems or learning difficulties. The home’s registered provider has been changed in October 2003 to “Companion in Care Ltd. The company owns two other homes in Brent and Newham. The home consists of a large three-storey town house situated in South Tottenham in the borough of Haringey. There are good public transport links to the area and a good variety of shops and other amenities are close by. On the ground floor, there is a kitchen/ lounge/diner, a toilet and bathroom, with access through the lounge to the garden and a laundry area. Two bedrooms and an office are situated on the first floor. A toilet and bathroom and two more bedrooms are located on the second floor. None of the bedrooms are en-suite. There is a small garden at the front of the property and a large paved garden at the rear. The home is not suitable for people with mobility problems. The stated aims of the home are to provide care, support and attention to service users to enable them to lead as normal a life as possible. 9 GREENFIELD ROAD G59 S10810 Greenfield Road V213703 25.04.05 (4).doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 10.25am – 1.45pm. On duty on the day was one care staff that assisted the inspector through a part of the inspection process. The registered provider and the registered manager/provider assisted the rest of the inspection. Both parts of the inspection were very positive and open. Presently the home is fully occupied. The service users who presently live at Greenfield are three men with mental health problems and have live at there for a number of years. The inspector spoke to two of the three service users individually and the feedback was positive and informative. What the service does well: What has improved since the last inspection? What they could do better: As identified above there are eighteen areas for improvements and two recommendations. Seven areas are restated from the previous report. The registered person is required to submit an action plan to the Commission for Social Care Inspection, which describe how they will address these matters. The action plan must describe how the registered person addresses and 9 GREENFIELD ROAD G59 S10810 Greenfield Road V213703 25.04.05 (4).doc Version 1.30 Page 6 ensures that the Statement of Purpose is amended to include room sizes and the section on ‘other services’ to be changed, to review the smoking policy, register with the Data Protection body, obtain a medication review for one specific service user, some maintenance issues to be completed and obtain a current CRB checks for a number of care staff who are employed by the home and to ensure that the recruitment procedures is followed through correctly as stated in the Regulation 19 Schedule 2 of the CHR 2001. The service users that were spoken to stated that some improvements have been made. Although they did make a number of comments regarding the shower that has been broken for a number of months and that the service users would like to smoke in their rooms. This was discussed with the manager and has been addressed in the main body of this report. 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. 9 GREENFIELD ROAD G59 S10810 Greenfield Road V213703 25.04.05 (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 9 GREENFIELD ROAD G59 S10810 Greenfield Road V213703 25.04.05 (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 & 2 Prospective service users are not able to access the correct information needed to make a clear judgement on the types of services being provided by the home. As not all the information with regards to the home is recorded correctly in the Statement of Purpose. Service users are confident that the written contracts are a biding agreement of the services provided. EVIDENCE: 9 GREENFIELD ROAD G59 S10810 Greenfield Road V213703 25.04.05 (4).doc Version 1.30 Page 9 At the previous inspection it was required that the registered person amends the home’s Statement of Purpose to include the numbers and sizes of rooms within the care home and to amend the statement that states ‘The home is unable to provide personal toiletries and cloths and beddings for service users as this is not part of the placement fees.’ The amended statement should state…. ‘all service users who reside at Greenfield are provided with their own individual bedding and linen and this is laundered and changed regularly’. However, it was evident in the home’s Statement of Purpose that these changes have not been amended at the time of this inspection. Therefore these requirements are restated. Since the previous inspection, there has been no admission or discharge to a from the home. The service users who reside in the home have lived there for a number of years. At present there are no vacancies. The home’s admission policy and procedure is clear and comprehensive and forms part of the Statement of Purpose. At the previous inspection the manager stated he was negotiating with the placing authority for one of the service users to obtain a clothing allowance due to the user not having enough money for personal clothing. At this inspection this has now been agreed with the placing authority and the service user now receives a regular clothing allowance. A letter from the placing authority with regards to this was on file. Each service user has a written costed contract in their case files. These outline the home’s terms and conditions of residence and are signed by the service users. 9 GREENFIELD ROAD G59 S10810 Greenfield Road V213703 25.04.05 (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, 9 & 10 The manager has ensured that service users confidential information is protected properly. Service users can not be confident that their assessed, changing needs, reviews and any decisions are handled appropriately by the home. EVIDENCE: 9 GREENFIELD ROAD G59 S10810 Greenfield Road V213703 25.04.05 (4).doc Version 1.30 Page 11 Two care plans were examined. Each service user had an appropriate care plan, based on a thorough needs assessment. The care plans were dated as having been reviewed within six months. There is evidence that service users have taken part in the development of these plans. It was also evident that service users are consulted on every matter of their health and changing needs. The service users spoken to on the day confirmed this. At the previous inspection it was required that the registered person ensures all service users who smoke have in place a comprehensive risk assessment with regards to smoking in the home. This is to include the areas of risks and what measures are put in place to minimize these risks. The risk assessment is to be reviewed six monthly by care staff and amended accordingly if any changes occur. It was evident that risk assessments with regards to smoking are in place but not detailed. However, both of the service users interviewed stated that they would like to be allowed to smoke in their bedrooms. During the tour of the building there was evidence that all the service users smoke in their bedrooms, although the home’s policy clearly states ‘no smoking in bedrooms’. This was discussed with the manager and the provider and it was advised that this should be reviewed with the individual’s social worker and the user. The requirement made at the previous inspection is restated. The inspector interviewed two of three service users who reside in the home, with regards to the home, food provided and activities they participate on a daily basis. Both service users expressed that they were happy in the home, the food is good and the staff were supportive. It was evident that the service users were independent and able to come and go as they please. At the previous inspection it was required that the registered person ensures that any information relating to individual service users finances is recorded on file, including a brief account of what benefits they receive, building society accounts held and whether or not the home supports the individual with their finances or not. The manager informed the inspector that he has now opened a bank account for one service user. However, the manager is still trying to set up with the local authority to transfer the service users weekly allowance into the service user’s own bank account. It was evident that this service user has his bank account in place. It was also evident that all the service users care plans, medication charts and other personal information are kept securely in the office. At the previous inspection it was also required that the registered person registers with Data Protection body and obtain a data protection number with regards to holding personal data on service users and care staff employed by the organisation. It was evident that the manager has not submitted an application to the Data Protection body. This requirement is restated. 9 GREENFIELD ROAD G59 S10810 Greenfield Road V213703 25.04.05 (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) 12, 13, 15 & 17 Service users are able to access the local community independently, engaging in social, recreational and educational activities. Service users maintain contact with family and friends and they are offered a healthy balanced diet daily. EVIDENCE: The manager stated that one service user has a voluntary job with Outreach Tower View, packing gifts into boxes. Another service user either attends the day centre or goes out to the local café or shops and one user spends most of his time in the local betting shop. The manager stated he has spoken to the user who gambles, as it is costly. To help this individual the home has put in place a plan of action, each day the user is given a small portion of his weekly allowance, this enables the user to have money each day of the week instead of spending it in one. There is a visitors’ policy, which states that visitors are welcome at the home at any reasonable time and with the consent of the service users. It was evident on individuals’ files that family contact is maintained. Most of the service users’ families live close by. One user’s family lives aboard and he keeps in contact by phone or letter. 9 GREENFIELD ROAD G59 S10810 Greenfield Road V213703 25.04.05 (4).doc Version 1.30 Page 13 It was also evident at this inspection that a menu plan is in place and they clearly showed what individual dietary needs were on a daily basis. Service users interviewed express that the food provided by the home was good. 9 GREENFIELD ROAD G59 S10810 Greenfield Road V213703 25.04.05 (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 & 20 Service users health care needs are being addressed, however, services users are not adequately protected as a result of failures in the following the home’s medication policies and procedures. EVIDENCE: The home has in place a medication policy and procedure. At the previous inspection it was required that the registered person ensures that all medication prescribed is then copied on to the individual’s MAR chart stating the name of the service user, name of the medication that is clearly stated on the label, the strength, the dosage, the route and the times of day the medication is to be administered. Any changes are to be referred back to the GP. It was evident at this inspection that this is now in place. However, on the MAR charts examined one service user medication prescribed for morning had a number of gaps. This was discussed with the support worker who stated that particular morning the user had taken his medication, but this is not consistent. This was discussed with the manager and provider later, who stated that staff finds it difficult to ensure the service user takes his morning medication as he often refuses it. There were no reason/s to why the medication was refused on MAR charts examined. A requirement relating to this has been made. 9 GREENFIELD ROAD G59 S10810 Greenfield Road V213703 25.04.05 (4).doc Version 1.30 Page 15 Health care needs of individuals have been addressed. The manager informed the inspector that one of the service users was at the optician. During the inspection the opticians rang the home and gave the manager a brief feedback regarding the appointment for the service users. Records of other health care needs were recorded on individual care plans. 9 GREENFIELD ROAD G59 S10810 Greenfield Road V213703 25.04.05 (4).doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 &23 Service users know that their views are listened to and that they are protected from abuse, neglect and self-harm. EVIDENCE: The home has in place a complaints and abuse policies and procedures. It was evident at this inspection that no complaints were recorded. All care staff have undertaken adult protection training. The new care staff stated she was undertaking her training on adult abuse the following day after the inspection, the rota shown indicated this. 9 GREENFIELD ROAD G59 S10810 Greenfield Road V213703 25.04.05 (4).doc Version 1.30 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26, 27 & 30 The service users are provided with a homely, clean, comfortable and safe environment, which meets their needs. Service users do not always feel that at all times they are supported appropriately to make positive and informed choices regarding their independence in their personal space. The home has failed to protect service users at all times with regards to health and safety and ensuring staff that are employed in the home have proper checks completed. EVIDENCE: The service user spoken to stated that they were now happy with the vanity basins units that were installed in their bedrooms. However, one service user stated that the shower in the bathroom has not been working for months and would like this repaired. The user also stated that he has complained before. There was no record of a complaint made in the complaints logbook. This was addressed with the manager on the day, who stated that this was part of the works order for the handyman to complete. The support worker on duty showed the inspector around the building. Since the previous inspection it was evident that a number of environmental improvements have been made to the home. Improvements made were a 9 GREENFIELD ROAD G59 S10810 Greenfield Road V213703 25.04.05 (4).doc Version 1.30 Page 18 vanity sink unit in each of the users bedrooms, the kitchen area now has brand new units fitted, and the dryer’s extractor air vent was now installed safely in the laundry room. Bedrooms examined were found to be at the time of the inspection clean and odour free. The rug in one of the service users bedroom, which at the time of the previous inspection had a number of cigarette burns, was now replaced. However, it was observed in the same user’s bedroom that the bed linen on the bed was not age appropriate for the service user. This was discussed with the manager and it was advised that a part of the home’s ‘service philosophy’ is around choice and this should be followed through in the care practice of the home. A requirement has been made relating to this matter. In the office area a damp patch on the wall was found in the corner of the room this was addressed with the manager and the provider, who stated to the inspector that this was hand. The inspector clarified if the handyperson/s is employed by the organisation to undertake maintenance in the home, they must be subject to a satisfactory CRB disclosure. A requirement has been made relating to this. At the previous inspection an Immediate Requirement was issued with regards to the gas boiler in the kitchen, which at the time was deemed unsafe. Prior to this inspection an action plan was submitted to the CSCI stating that the gas boiler was now encased and made safe. This was evident at the inspection. 9 GREENFIELD ROAD G59 S10810 Greenfield Road V213703 25.04.05 (4).doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33 & 34 The home has failed to ensure that service users are protected and supported by competent and qualified staff who have been subjected of the full range of requirement and appropriate checks. Service users must therefore be deemed to be at risk. EVIDENCE: It is clear from the rota shown to the inspector that the home runs on a minimum staff team. This consists of the manager, one full time member of staff, one part time member of staff and three relief workers. The rota did not reflect correctly which relief staff was covering the vacant shifts. One of the relief worker’s who was recorded on the rota was the registered manager’s wife, who is also the registered manager for another care home in Stratford, East London. At the previous inspection it was required that the registered person reviews the present staffing situation in the home and copies of all care staff personnel files are kept in the home at all times. However, it was evident that this remains the same as at the previous inspection. These requirements are restated in this report. The care staff on duty personnel records examined did not have in place a current CRB certificate or references. The inspector was informed that this specific care support staff has completed their CRB check, however, this was at the organisation’s head office. It was reminded that all personnel records for all care staff working in the home must be kept in the home. A number of 9 GREENFIELD ROAD G59 S10810 Greenfield Road V213703 25.04.05 (4).doc Version 1.30 Page 20 requirements have been made relating to recruitment procedures. Prior this report being written the registered provider submitted copies of current care staff CRB checks. However, a number of the CRB checks examined were completed by another organisation. It was advised at the time of the inspection that the present employer cannot accept transferred CRB checks. These are to be completed by the current employer, prior to the care staff starting a shift. 9 GREENFIELD ROAD G59 S10810 Greenfield Road V213703 25.04.05 (4).doc Version 1.30 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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, 39 & 42 Service users benefit from a manager who understands the home and the service users group. Service users are aware that their views are sought by the home. However, these views should be expanded to a wide range of stakeholders who also have a personal interest in the home and the service users who live there. Adequate monitoring of the hot water temperatures will help to ensure a safe and healthy environment. EVIDENCE: The manager has a Diploma in Social Work and has extensive experience of working with people who have mental health problems. The manager stated that he has not completed his NVQ level 4 in management and care, and is reminded this must be completed by the end of the year. Since the previous inspection the registered manager has introduced quality assurance monitoring, which the service users have completed. However, it is reminded that the manager must review quality assurance feedback yearly. The outcome should reflect how the home is going to monitor or implement the outcomes from the feedback forms from service users. It was also advised that the questionnaires should be extended not just to service users but also to 9 GREENFIELD ROAD G59 S10810 Greenfield Road V213703 25.04.05 (4).doc Version 1.30 Page 22 families, friends, advocates, stakeholders and other professional who are linked to the home. Health and safety certificates were in place. However, what the water temperature checks are completed weekly, by the records made do not indicate which areas were tested. A requirement relating to this has been made. 9 GREENFIELD ROAD G59 S10810 Greenfield Road V213703 25.04.05 (4).doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 2 x x 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 3 2 x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 x 3 Standard No 31 32 33 34 35 36 Score x 2 1 2 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 9 GREENFIELD ROAD Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 x 2 x x 2 x G59 S10810 Greenfield Road V213703 25.04.05 (4).doc Version 1.30 Page 24 Yes 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 1 Regulation 4(1)(c ) Schedule 1.16 Requirement The registered person must amend the homes Statement of Purpose to include the number and size of rooms in the care home as set out in Regulation 4(1)(c ) Schedule 1.16 of the Care Homes Regulation 2001. (Previous timescale of 30 December 2004 not met.) The registered person must amend the homes Statement of Purpose to include a statement that all service users who reside at Greenfield residential care home are provided with their own individual bedding and linen and this is laundered and changed regularly. (Previous timescales of 30 December 2005 not met.) The registered person must ensure that all service users who smoke have in place a comprehensive risk assessment with regards to smoking in the home. This is to include the areas of risks and what measures are put in place to minimise these risks. The risk assessment is to be reviewed monthly by care staff and Timescale for action 30 May 2004 2. 2 16(2)(c) 4(1) (c) 30 May 2005 3. 9 14(2)(a) 30 June 2005 And from then on 9 GREENFIELD ROAD G59 S10810 Greenfield Road V213703 25.04.05 (4).doc Version 1.30 Page 25 4. 9 14(2)(a) 5. 10 Data Protection Act 1998 6. 20 13(2), 12(1)(a) 15(2)(b) 7. 20 13(2) amended accordingly if any changes occur. Copies of the completed risk assessement is to be submitted to the CSCI. (Previous timescale of 30 December 2004 not met.) The registered person must arrange separate meetings with the individual service users and their social worker regards the current situation around the No smoking policy in the home. The outcome of the meeting is to clearly state whether individuals are now allowed to smoke in their rooms, what risk assessments are to be put in place, these are to be monitoried monthly by the home and when the decision will be reviewed. A record of the meeting is to be placed on each of the service users care plan. The registered person must register with the Data Protection body and obtain a data protection number. Once obtained a copy of the certificate is to be submitted to CSCI area office. (Previous timescale of 30 December 2004 not met.) The registered person must ensure that the specific service user who does not take his morning medication consistently has an appointment made with the GP or the CPN to review the specific service users current medication. A copy of the action taken by the GP or CPN is to be recorded on file. The registered person must ensure that the medication adminstration records are complete. Non-adminstration must be coded as to the reason the medication is not adminstered. 30 July 2005 30 May 2005 30 May 2005 30 May 2005 And from then on 9 GREENFIELD ROAD G59 S10810 Greenfield Road V213703 25.04.05 (4).doc Version 1.30 Page 26 8. 26 9. 10. 24 24 23(2)(b) 19 Schedule 2 19 Schedule 2 11. 34 12. 34 19 Schedule 2 The registered person must ensure that care staff that support individuals service users on a day-to-day basis are aware of how to give informed positive choice, with regards to bedlinen for individual service users. The registered person must ensure that the damp patch in the office area is repaired. The registered person must ensure that the handyperson employed in the home has completed a standard CRB check prior starting work The registered persons may not employ any further person to work in the care home in any capacity without first obtaining an appropriate CRB Disclosure including a POVA check along with other information required by regulation. All staff employed since July 27th 2004 without an enhanced CRB Disclosure that includes a POVA check, must only work under the individual and direct supervision of a named staff member who has been appropriately checked. So as to safeguard service users, the registered persons must in respect of these specific staff undertake a POVA First check for each person through their Umbrella Body. The strict supervision arrangements must then, remain in place until the full CRB Enhanced Disclosure is received and is seen to be satisfactory. The registered person must operate a thorough recuitment procedure based on equal opportunities and ensuring the protection for service users. (Previous Timescales 30 January 2005 not met) 30 June 2005 And from then on 30 July 2005 30 June 2005 30 June 2005 And from then on 30 June 2005 And from then on 9 GREENFIELD ROAD G59 S10810 Greenfield Road V213703 25.04.05 (4).doc Version 1.30 Page 27 13. 39 21 14. 42 13(4) 15. 27 22 16. 33 18(1) 17. 33 17(2) Schedule 4.7 18. 33 19 Schedule 217(2) Schedule 4.6 The registered person must actively seek views from family friends, advocates and of stakeholders in the community. The registered person must ensure that the water temperatures checks records include all the baths and sinks in the home. The registered person must ensure that all complaint/s whether verbal or written are fully investigated by the manager under the homes complaints procedure. a record of the complaint must be made with the action taken. The registered person must review the present staffing situation in the home and a copy report of the outcomel must be submitted to the CSCI on completion. (Previous Timescale of 30 January 2005 no met.) The registered person must indicate clearly on the rota all staff shift patterns, sickness, annual leave and time on shift as required under 17(2) Schedule 4.7 in the Care Home Regulation 2001(CHR 2001). (Previous timescale of 20 December 2004 not met.) The registered person must ensure all care staff personnel records who work in the home are kept in the home and on file, ensuring all the requirements as set out in Regulation 19 Schedule 2 and 17(2) Schedule 4.6 are in place. (Previous timescale 30 December 2004 not met.) 30 August 2005 And from then on 30 May 2005 And from then on 30 June 2005 And from then on 30 June 2005 30 June 2005 And from then on 30 June 2005 And from then on 9 GREENFIELD ROAD G59 S10810 Greenfield Road V213703 25.04.05 (4).doc Version 1.30 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 37 33 Good Practice Recommendations The registered manager is reminded that he must undertake and complete by 2005 the NVQ level 4 in Management and Care. The registered person is reminded that he must ensure that by 2005 50 of the care staff team is to be trained to NVQ level 2 or above. 9 GREENFIELD ROAD G59 S10810 Greenfield Road V213703 25.04.05 (4).doc Version 1.30 Page 29 Commission for Social Care Inspection North London Area Office Solar House, 1st Floor 282 Chase Road London N14 6HA 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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