Inspection on 23/05/07 for Greengarth

This inspection was carried out on 23rd May 2007.

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.

Other inspections for this house

Greengarth 09/06/08

Greengarth 11/10/06

Greengarth 18/01/06

Greengarth 29/06/05

Greengarth 03/11/04

Greengarth 23/06/04

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

CARE HOMES FOR OLDER PEOPLE Greengarth Bridge Lane Penrith Cumbria CA11 8HY Lead Inspector Diane Jinks Unannounced Inspection 23rd May 2007 09:30 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 Greengarth DS0000036484.V338970.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Greengarth DS0000036484.V338970.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greengarth Address Bridge Lane Penrith Cumbria CA11 8HY 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) 01768 242040 www.cumbriacare.org.uk Cumbria Care Mrs Susan Jane Tweddle Care Home 39 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (39) of places Greengarth DS0000036484.V338970.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 39 service users to include: up to 39 service users in the category of OP (Old age, not falling within any other category) up to 10 service users in category DE(E) (Dementia over 65 years of age) 11th October 2006 Date of last inspection Brief Description of the Service: Greengarth is registered to provide accommodation and care for up to 39 older people, of whom 10 have dementia. The home is operated by Cumbria Care, which is an internal business unit of Cumbria County Council. Greengarth is situated close to the centre of Penrith and is on a bus route. Accommodation is provided in four separate living units, each with a lounge/dining room and kitchen area, communal bathrooms and toilets. Bedrooms are close by. There is also a large communal lounge that is used for special events, and a pleasant conservatory/garden room. There is a small day centre in the home, which operates Monday to Friday for people who live locally. This is managed separately and therefore not included in this inspection. There is a passenger lift and a range of mobility equipment to assist people in their daily lives. Outside there are garden areas and two pleasant easily accessible internal courtyards. There is a small car park for staff and visitors. The home produces a guide to the services and facilities provided and this is available on request from the manager. The scale of charges range from £363.00 - £422.00 per week (October 2006), subject to the assessment. Greengarth DS0000036484.V338970.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The assessment of this service included an unannounced visit, which took place over one day. A random visit had also been made to this home in March 2007 and information obtained from this visit was also used in this assessment where appropriate. The visit to the home included talking to people who live at Greengarth and some of the staff that work there in order to obtain some of their views on the service. Questionnaires were also sent out to relatives and health and social care professionals. This helps to get as many different opinions as possible about the home. The registered manager had completed a self-assessment of the service, which assisted in verifying information throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better: Social and leisure activities for people living at the home still require some attention. People using this service and their relatives all commented on the lack of stimulation and activities. Greengarth DS0000036484.V338970.R01.S.doc Version 5.2 Page 6 Concerns were also raised about the numbers of staff on duty and the duties that they are expected to perform. Many visitors completing questionnaires felt that there was often insufficient staff on duty and this had an effect on the activities that were provided and the cleanliness of the home. Some of the people living at the home were concerned about the ‘pressure’ that staff were sometimes under. One person living at the home has an allocated day for bathing and added ‘if it’s convenient and staff are not too busy’. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Greengarth DS0000036484.V338970.R01.S.doc Version 5.2 Page 7 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 Greengarth DS0000036484.V338970.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 3. Standard 6 does not apply to this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager makes sure that people have their health and social care needs assessed prior to them moving into the home. This helps to ensure that the home can meet the needs and expectations of people who are considering moving to Greengarth. EVIDENCE: The manager has produced a guide to the services that can be provided by the home. This document gives people information about the manager and staff at the home. Details about the admission routines are included. This helps people who are considering moving into the home to understand the process. People living at the home indicate that they received sufficient information about the home prior to making the decision to live there. In some cases their families helped them with this. One person said that the manager visited them at her own home and her daughter was able to visit prior to making a decision. Individual care needs assessments are undertaken by the manager at the home and obtained from the Adult Social Care team where applicable, prior to a person being admitted to the home. Greengarth DS0000036484.V338970.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of information included in care plans has generally improved. This has not been consistently applied and means that some people living at the home may not always have their care needs met appropriately. EVIDENCE: Samples of care records were looked at during this visit. Most of them contained very detailed care plans, although one of them was out of date and was in the process of being updated. This person has extensive and complex care needs. The care plan should be completed quickly to ensure that staff are fully aware of the current care needs of this person. One person has been admitted to the home (in March), initially for respite care. The manager has obtained a care needs assessment and personal details are recorded along with records of medication needs and daily notes. There is no care plan for this person and risk assessments have not been undertaken. This was discussed with a member of staff, who indicated that care plans and risk assessments are not routinely undertaken for people admitted to the home for respite/short term care. However, the information that is recorded on the care needs assessment is taken into consideration. Greengarth DS0000036484.V338970.R01.S.doc Version 5.2 Page 10 Where care plans are in place, they contain an element of risk assessment both for moving and handling situations and in general terms. Care plans, risk assessments and functional assessments are kept under regular review. Records show that people living at the home have access to their doctor, community nurses, opticians, dentists, chiropodists and occupational therapists when necessary. Staff at the home assist people with accessing these services if required. Comments received from community nurses and the GP indicate that the home has a good relationship with these services and staff at the home were described as being ‘very good at coming forward and asking for advice’. Care plans indicate that some nutritional assessments are undertaken. Where concerns are identified, weights are monitored and a dietician has been consulted. Food/drink intake record sheets are said to be kept in respect of one person. However, after a search they could not be found. Some information is kept in the daily notes but this does not provide sufficient detail of the person’s nutritional intake. There is a medication policy and procedure in place at the home. Staff are informed of this process during their induction training and periodically as part of their on-going training. Supervisors are responsible for the administration of medication and a second person assists to ‘check’ the medication. This helps to reduce any risk of medication errors. The records looked at during this visit were in order and were completed accurately. Records include a photograph of the person. This again helps to reduce the chance of mistakes. People living at the home who wish to take responsibility for administering their own medication may do so. This is subject to an assessment to help ensure that the person can manage this task safely. A safe, lockable storage space is provided in the person’s own room in this situation. The medication storage facilities at the home were looked at during this visit. They were seen to be clean, tidy and well organised, with minimal stocks. There are facilities in place for medication requiring cold storage or more secure storage. People living at the home say that they are treated with respect and dignity. They are able to make some choices about matters that concern their daily life. Some comments made by people who live at the home indicate that they are assisted with some tasks at the ‘convenience’ of staff and that ‘sometimes, although they are very good, staff seem under pressure.’ Staff were observed assisting some of the people living at the home. Where help with personal care or assistance with other matters was required this was done with sensitivity and consideration for the persons privacy. Greengarth DS0000036484.V338970.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home tries to provide suitable activities both in the home and in the community, but resources are limited. This means that people living in the home may not always have their leisure and social expectations met. EVIDENCE: People living at this home are provided with some opportunities to take part in various activities. There are televisions, radios and music centres throughout the home. People living at the home are able to have newspapers and magazines delivered and some have access to talking books and the local, weekly newspaper. There are games, jigsaw puzzles, books, videos and music tapes available in the home. Both people living at the home and some of the staff working at the home indicate that social and leisure activities are limited. Comments were received to indicate that activities might be ‘restricted due to staffing levels’. Relatives and visitors to the home also commented on the lack of activities and stimulation for people using this service. Not all of the people living at the home want to join in such things either. On the day of this visit there were limited activities taking place – a ball game in one of the lounges (whilst waiting for lunch) and chatting after lunch about past life experiences. Greengarth DS0000036484.V338970.R01.S.doc Version 5.2 Page 12 Records kept at the home indicate that there is contact with the community. A church service is held each week and priests from other local churches visit parishioners at the home. Some of the people using this service were pleased with the church services and enjoyed attending them. Visits from local school choirs take place and the home is currently in contact with a local school trying to set up a programme of activities ‘reminiscence through drama’. It is hoped that people living at the home can work together with schoolchildren, teachers and families on this project. The project is based on school life at the beginning of the last century. One member of staff said that the home is starting to get a programme together and thought that ideally the home would benefit from an activities co-ordinator. People living at the home said that they have visitors and that they are able to see them in the privacy of their own room or in one of the communal areas as they wish. Visitors are said to be made welcome, ‘well looked after’ and are offered refreshments. Relatives confirmed that they are made welcome at the home when they visit. Residents meetings are held each month. Agendas are set and minutes kept. Some of the topics that have been discussed at recent meetings include; staff recruitment, inspection reports, menus and food choices, and suggestions for activities in the home. Each unit at the home has it’s own dining area. The tables had been laid ready for lunch with tablecloths, napkins, condiments and jugs of juice available. The service of the lunchtime meal was observed in one of the units. People had a choice (which had been made earlier) and the portion sizes were reasonable with extra available if wanted. People living at the home said the food was very good and that there was plenty of it. There was a nice atmosphere in the dining area with good interaction from most of the staff. The cook was spoken to during the visit. She is aware of any special diets, for example diabetic, vegetarian or soft diets that may be required. The menus at the home have been reviewed and changed where necessary. People living at the home were consulted about this. A hand blender has been purchased to help ensure that soft diets are presented in an appetising manner. Greengarth DS0000036484.V338970.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at this home are able to raise any concerns they may have and are confident that they will be taken seriously and acted upon. EVIDENCE: There is a brief complaints procedure in place at the home. People living at the home also have access to Cumbria County Council’s corporate complaints process. Details of the complaint process are included in the service user guide for the home. The process would benefit from a review to ensure that full details of what a complainant might expect, for example the process and timescale for receiving an outcome from any concerns raised, are included. Comments received from some relatives and friends of people living in the home indicate that they are not aware of the process for making a comment or complaint about the home. Others said that if they did raise any issues, they were always dealt with appropriately. Where concerns or complaints are raised, records are kept in order to check and monitor the progress or outcomes of complaints. The home holds residents meetings where more general concerns may be raised. People living at the home say that they know who to speak to if they have any issues and are confident that they would be listened to and their concerns taken seriously. Some staff at the home have undertaken training in the protection of vulnerable adults. Staff said that they would have no hesitation in bringing any concerns to the attention of the supervisors or manager. There is an up to date copy of the local authority’s guidance and procedures in relation to the Greengarth DS0000036484.V338970.R01.S.doc Version 5.2 Page 14 mis-treatment of adults. This helps to ensure that concerns are managed appropriately and people are protected from harm. Greengarth DS0000036484.V338970.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 21, 22 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 clean and comfortable. There are some areas of the home that require maintenance and upgrading, which will help ensure that people live in safe, comfortable surroundings. EVIDENCE: The décor and some of the furnishings at the home are looking particularly tired and in need of replacement in many areas. This is particularly noticeable in bathrooms, toilets, corridors and lounge areas. There are some areas in the home where the carpets are threadbare and need replacing. There are limited en-suite facilities at the home. There are shared bathrooms, shower rooms and toilets throughout the home. Some of these facilities are equipped with aids and adaptations to assist people to access them. There are a number of bathrooms that are not suitably adapted and therefore cannot be used by the majority of people living at the home. Many of the sinks and baths at the home do not have plugs or have plugs that are broken and this means Greengarth DS0000036484.V338970.R01.S.doc Version 5.2 Page 16 that sinks cannot be filled for washing and where plugs are broken, they cannot easily be removed from plugholes. There are aids and adaptations in most areas of the home including emergency call bells. There are grab rails, raised toilet seats, hand rails in corridors and bath seats in some but not all of the bath/shower rooms. There is a passenger lift to the first floor. The small sluice at the home was found unlocked on the day of the visit. It was cluttered and in need of tidying up. The cleaning trolley was stored in there and contained cleaning fluids and materials. Notice boards have been placed in each lounge area with the names of staff on duty for the day, date, weather information and the day’s menu. Not all of these had been updated to reflect current information at the time of this visit. There are several communal seating areas including lounges, dining areas and a conservatory. There are patio areas outside with seating and tables for use in good weather. The home has a designated room for people at the home who wish to smoke. A number of bedrooms were looked at during the visit. The décor was in good condition and the rooms were generally tidy. People had personalised them with their own small items of furniture, pictures and ornaments. Some of the bedrooms were dusty and needed to have the carpets vacuumed too. A visit to the laundry was made. This was found in a clean, tidy and wellorganised condition. Protective clothing is available as well as adequate hand washing facilities. This helps to reduce risks of cross infection at the home. At the time of this visit there was only one domestic employed at the home. There is a vacant post, which is currently filled by an agency member of staff. Discussions with staff indicate that toilets and bathrooms are cleaned daily but bedrooms may not be cleaned each day. The domestic arrangements are not adequate and care staff have the extra responsibility to undertake some of the cleaning tasks. This may mean that people living at the home do not always have their health and social care needs attended to in a timely and appropriate manner. One relative also commented on the lack of domestic assistants and was concerned that care staff are being taken away from their care duties. There have been some issues identified in relation to moving beds and furniture when cleaning. There is a protocol in place for this but not a risk assessment. The risk assessor was advised to carry out and record a risk assessment with the assistance of the health and safety officer if necessary. Greengarth DS0000036484.V338970.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home are generally satisfied with the standard of care that they receive, but staffing levels may not always be sufficient. This means that people living at the home may not always have their needs met in a timely manner. EVIDENCE: Staffing levels on the day of the visit appeared to be minimal. As well as providing care to people at the home, care staff are also responsible for some of the domestic duties such as bed making, dusting, vacuuming of bedrooms, cleaning commodes and making drinks for people who live at the home. The home has experienced problems with staff recruitment. Some of the staff were spoken to during the visit. They generally feel that there are enough staff on duty at most times and that there is a relaxed atmosphere at the home. However, there is sometimes a lot of pressure to get things done. People living at the home also notice the pressure that staff seem to be under at times. One person said that the staff are excellent but under pressure with the work. Another said that activities are restricted due to staffing levels. The design and layout of the home causes further problems for the effective and efficient deployment of staff. Staffing and staff recruitment issues have also been discussed at the residents meetings. A sample of staff training and development files were looked at. These contain up to date information regarding staff training and supervision. Evidence was seen to confirm that the manager is working on a staff training and Greengarth DS0000036484.V338970.R01.S.doc Version 5.2 Page 18 development plan to help ensure that staff will receive suitable and timely training. Staff said that they have recently updated some of their training and others have undertaken or are in the process of undertaking National Vocational Qualifications (NVQ’s). This training helps to ensure that staff have the knowledge, skills and competence to meet the needs of the people living at the home. Ancillary staff have also been provided with training, for example food hygiene, health and safety, manual handling and COSHH awareness. There is a robust recruitment and selection process in place at the home. This process is managed and overseen by the organisation’s human resource department. Staff recruitment files were only briefly looked at during this visit. They indicate that the service carries out all the necessary checks prior to employing people at the home. This helps to ensure that people living at the home are protected and cared for by suitable staff. The recruitment files for the newest members of staff are not yet available at the home. The two new members of staff confirmed that they had almost completed their induction training. Greengarth DS0000036484.V338970.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, and 38. 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 run in the best interest of the people who live there. There are occasions where this may be compromised by low staffing levels. EVIDENCE: An experienced manager manages the home and people living at the home are confident in her abilities. She has undertaken appropriate training and continues to keep her skills and knowledge up to date. A random inspection visit has been made to the home in between the two key inspections. A report of this visit is available on request from the Commission for Social Care Inspection. The reports identify several matters that the manager should act upon quickly and other good practice recommendations that the manager was asked to give consideration to. It is evident that the manager has taken the matters seriously and has either resolved the matters or is in the process of doing so. Greengarth DS0000036484.V338970.R01.S.doc Version 5.2 Page 20 Samples of various records were looked at during the visit including fire records, accident records, notifications and the arrangements in place for people’s money and safe keeping of their valuables. All the records looked at are generally up to date although there is evidence of some gaps in recording. At the last key inspection there were several issues relating to health and safety matters that were brought to the manager’s attention. These matters appear to have been remedied. Accident records are kept for both staff and people living at the home. The accident book at the home shows that the most common accident to people living at the home involves a fall. Information and guidance regarding falls and risk assessments has been obtained. It is proposed that this guidance will be implemented. This will help to minimise hazards and risks to people living at the home who may have poor mobility for whatever reason. Records indicate that the manager may not always notify the Commission for Social Care Inspection about matters that may adversely affect the home and the people that live at the home. This was discussed with the person in charge during the visit to the home. The home monitors its own practice. Residents, staff and visitors to the home are asked for their views on the service provided. The information gathered from this process is included in the corporate quality review and business plan. Greengarth DS0000036484.V338970.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X 2 2 X X X 2 STAFFING Standard No Score 27 2 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 2 Greengarth DS0000036484.V338970.R01.S.doc Version 5.2 Page 22 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. Standard OP16 Regulation 22 Requirement There must be a simple, clear and accessible complaints procedure, which includes the stages and timescales for the process available at the home. This will help ensure that people using this service and their relatives are clear about how to make a complaint and the process to expect. Time scales of 01/12/06 and 01/05/07 not met. A care plan must be developed for each individual living at the home. This includes people receiving a short term care service. Care plans must identify health, personal and social care needs. They must also set out in detail the action, which needs to be taken by care staff in order to meet the identified outcomes for people using this service. There must be a detailed plan, including timescales, in place at the home to ensure that the general environment, décor, furnishings, fixtures and fittings DS0000036484.V338970.R01.S.doc Timescale for action 30/06/07 2. OP7 12(1) 12(2) 12(3) 15 30/06/07 3. OP19 16(j) 23 01/09/07 Greengarth Version 5.2 Page 23 at the home are maintained in a safe and satisfactory condition. This will help ensure that people using this service live in a safe and comfortable home. 4. OP27 18(1) Sufficient numbers of suitably 01/09/07 qualified and competent staff must be employed at the home at all times. Consideration must be given to the needs and numbers of people living at the home as well as the physical layout of the home. This will help to ensure the health, safety and welfare of people living at the home. Any event that adversely affects the care home or the health, wellbeing and safety of people using this service must be notified to the Commission for Social Care Inspection without delay. This information assists in the continued protection of people living at the home. The risk assessment process in place at the home must include the provision for assessing people at particular risk from falling. Strategies must be recorded to assist staff to minimise the risks to people using this service. People using this service for short term care must also undergo a risk assessment and strategies for minimising risks must be recorded to help ensure their health, safety and wellbeing. 30/06/07 5. OP37 37 6. OP38 12(1) 13(4) 13(5) 13(6) 30/06/07 Greengarth DS0000036484.V338970.R01.S.doc Version 5.2 Page 24 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 OP12 Good Practice Recommendations It is recommended that the arrangements for leisure, social and recreational activities are reviewed and updated in consultation with people living at the home, to suit their needs, preferences and capacities. It is recommended that sufficient domestic staff are employed in order to keep the premises clean and hygienic. This will help to minimise the risk of infection and release care staff so that they may meet the health, social and care needs of people using this service appropriately. It is recommended that the manager review the smoking policies at the home to ensure that the arrangements in place are sufficient to meet the new smoking legislation that is to be introduced from 1st July 2007. 2. OP26 3. OP38 Greengarth DS0000036484.V338970.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Greengarth DS0000036484.V338970.R01.S.doc Version 5.2 Page 26 - 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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