Inspection on 02/06/06 for Greengate Lodge

This inspection was carried out on 2nd June 2006.

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

Greengate Lodge 26/01/08

Greengate Lodge 16/12/05

Greengate Lodge 29/06/05

Greengate Lodge 21/01/05

Greengate Lodge 02/08/04

Greengate Lodge 24/02/04

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

CARE HOMES FOR OLDER PEOPLE Greengate Lodge Greengate Lodge Cave Road Plaistow London E13 9DX Lead Inspector Lea Alexander Key Unannounced Inspection 2:30 2nd June 2006 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 Greengate Lodge DS0000034843.V295284.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. Greengate Lodge DS0000034843.V295284.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greengate Lodge Address Greengate Lodge Cave Road Plaistow London E13 9DX 020 8430 2000 020 8548 0193 farouk.ruhomally@newham.co.uk 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) London Borough of Newham Mr Farook Ruhomally Care Home 33 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0), Physical disability (0) of places Greengate Lodge DS0000034843.V295284.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th December 2005 Brief Description of the Service: Greengate Lodge is a thirty-three bedded residential home providing care for older people in Newham. The home is owned and run by the London Borough of Newham (LBN). Twenty-four beds are available for permanent service users and seven for respite care. The home is currently arranged to deliver care to service users in four different units. The Abbey unit provides care for more independent older people. The Dundee unit provides care for older people with mental health support needs. The Emotan and Roshni units provide culturally specific residential care for older people from the African Caribbean and Asian communities respectively. The home is a purpose built dwelling on one level. There are thirty-one single rooms and one double. All rooms have their own en-suite facilities. The home has a central courtyard with protected pond and there are additional patio areas with outdoor seating. The home is located in a residential area in Plaistow, close to shops and amenities. A range of nearby bus routes can be easily accessed. The nearest underground stations are Plaistow and Upton Park on the District Line. The home has a small car park and unrestricted street parking is available. Greengate Lodge DS0000034843.V295284.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this inspection over the course of a two half-day visits. The main focus of the inspection was to look at the homes compliance with key National Minimum Standards. The Inspector met privately with Registered Manager, a residential support worker and three service users. In addition service users personal files and other relevant paperwork was sampled and the premises toured. The Inspector would like to thank service users and staff for their assistance whilst conducting this inspection. What the service does well: The home has been assessed as exceeding National Minimum Standards in the support and opportunities it offers service users to engage with occupational, leisure and community activities and to maintain relationships with family and friends. The home obtains assessment information and care planning documents from the local authority and other professionals as part of the referral process. The home also carries out its own assessment and develops an individual service user plan. The Abbey, Emotan and Roshni units assess service users risk of falls and mobility needs as part of the planning process. Records of GP appointments and their outcome were evidenced as being maintained on the Roshni, Dundee and Abbey units. The home recognises the specific culture and religious needs within the service user group and aims to meet these in line with service users preferences. The home has flexible routines, including meal times and varied, nutritious and culturally appropriate meals are provided. Service users are supported to manage their own finances and details of any transactions undertaken on their behalf are recorded in the personal file. Service users told the Inspector that personal care is provided with dignity and respect and that staff are “flexible” and “helpful”. There is a homely atmosphere, and the environment aims to reflect the personalities and cultures of the service users living there. The home provides a range of communal facilities and a private bedroom for each service user that they are able to personalise. The home is generally well maintained, hygienic and free from offensive odours. The home implements corporate London Borough of Newham medication, complaints and recruitment policies and procedures and maintains a Greengate Lodge DS0000034843.V295284.R01.S.doc Version 5.2 Page 6 complaints log and records of all accidents and incidents occurring within the home. The home has evidenced good medication administration and recording practises and take appropriate action when service users have apparent adverse reactions to new medications. The home has an experienced manager who has attained NVQ level 4, and over 50 of care staff has obtained NVQ level 2. A staffing rota is prepared in advance and indicates that sufficient numbers of staff are on duty. New staffs receive an induction to the home and records are generally well maintained. What has improved since the last inspection? What they could do better: All units should review service user plans on a monthly basis and assess service users risk of falls. The home should consider its arrangements for key workers who review individual plans also signing as the service users representative. The home must evidence that all service users are supported to access healthcare services according to need and risk assess service users who selfmedicate. The home must ensure that it implements its adult protection policy and that policies and procedures are readily accessible. The home should consider developing a policy for the assistance with, and management of service users finances. Any loose papers in service users personal files should be filed. Regular service users meetings should be held in all units. The home must evidence that satisfactory pre employment checks are carried out on all staff members and each staff member must receive six supervision sessions each year. The home should develop its quality assurance process to include feedback from service users, their representatives and other professionals. Weekly fire alarm drills should be conducted and recorded. All fridge and freezer temperatures should be recorded on a daily basis and food stored in the freezer should be appropriately labelled. Greengate Lodge DS0000034843.V295284.R01.S.doc Version 5.2 Page 7 A programme of redecoration for communal areas and some service users bedrooms should be implemented. 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. Greengate Lodge DS0000034843.V295284.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Greengate Lodge DS0000034843.V295284.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Prospective service users have their needs assessed by the home. EVIDENCE: The Inspector sampled the available documentation for a service user who had been admitted to the Dundee unit in February 2006. As part of the referral process a copy of the local authority comprehensive needs assessment and mental health service care planning documents had been obtained. The home had completed its own “Needs Assessment and Record” and from this a “Service User Plan” had been developed. The home does not provide intermediate care, and standard 6 is therefore not applicable. Greengate Lodge DS0000034843.V295284.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users benefit from individual plans, and the home has good medication administration and recording practises. However, a record of healthcare appointments is not maintained for all permanent residents and selfmedication is not subject to a risk assessment. EVIDENCE: The Inspector sampled the personal file and individual planning documentation for a service user from each of the homes four units. Each of the service users sampled was evidenced as having a service user plan that provides the basis for the care being provided. Each of the plans addressed the health, personal and social care needs of the service user and included information relating to personal care, dietary needs, communication needs, mobility and social interests. One of the service users sampled by the Inspector is currently selfmedicating, and this was detailed in their plan. However, a risk assessment for this activity was not available. Self-medicating service users are provided with a lockable cupboard in which to store their medication. Greengate Lodge DS0000034843.V295284.R01.S.doc Version 5.2 Page 11 The plans for service users in the Abbey and Emotan units included a monthly care plan review sheet which had been completed to evidence a review of the service users plan and any changes in need. On the Roshni unit the service user plan sampled had been annotated to indicate reviews in February and March 2006. On the Dundee unit the service user plan developed in February 2006 had been reviewed in April 2006. The plans sampled by the Inspector had been signed by the service user or by their key worker acting as the service users representative. The planning documentation sampled by the Inspector for service users on the Roshni and Dundee units include risk assessments that address the risk of falls. The plan sampled for the service user from the Emotan unit clearly identifies them as a wheelchair user and a risk assessment to address use of this had been completed. The service user from the Dundee unit was found to have a risk assessment that addressed risk associated with smoking but did not include the risk of falls. The personal files for three of the service users sampled included a record of GP appointments and their outcome. A fourth service user who has recently become a permanent resident after an extended period of respite care did not have records of any healthcare appointments attended. The home operates a corporate LBN medication policy developed for implementation in residential care homes. This is a comprehensive document that includes guidance on the acquisition of medication and its administration and the storage of controlled medicines. The policy also includes guidance on service users who are able to self medicate. The Inspector viewed the medication available and the Medication Administration Record (MAR) for a service user from each unit. All available medications were listed on the MAR sheet. The MAR sheets seen by the Inspector had been appropriately completed and appeared in good order. However, one-service users asthma inhalers were listed on the MAR sheet and then annotated to indicate that these are self-administered. The Inspector was unable to locate a risk assessment for this activity. During the Inspection the officer in charge advised the Inspector that a service user who had been taken a new medication had become unwell. As a result the home had appropriately contacted the GP and arranged a home visit and suspended the new medication in the interim period. Service users spoken to by the Inspector stated that staff attended to their personal care needs with dignity and respect. Greengate Lodge DS0000034843.V295284.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home supports service users to engage in a range of culturally appropriate community, leisure and occupational activities. EVIDENCE: The home is arranged into four separate units that aim to address the cultural needs and individual abilities of service users. The Emotan and Roshni units aim to meet the culturally specific needs of Afro Caribbean and Asian service users by providing culturally specific food and entertainment. A service user of Turkish heritage has also chosen to live in the Roshni unit and the home have aimed to meet their needs by offering culturally specific meals and a Turkish speaking visitor and Turkish books and films. The Inspector was advised that the service user had declined these preferring the Asian meals and entertainment that are already offered within the unit. The Registered Manager advised that the home aims to have flexible daily routines, including meal times, that can be varied to suit individual service users. The home offers a range of activities both inside and outside of the home that service users can choose to participate in. At the time of the inspection the home is providing a visiting aroma therapist once per week, a Greengate Lodge DS0000034843.V295284.R01.S.doc Version 5.2 Page 13 keep fit session, a reminiscence group, music sessions, a visiting hairdresser and arts and crafts sessions. An exhibition of service users work is due to be shown at a nearby day service. An external facilitator runs the homes reminiscence group and has also provided training on developing the homes activities programme and the skills of the staff involved in delivering these. The Inspector was advised that the home is currently developing a tool to record the activities individual service users are involved in. A catholic priest visits the home, and service users are also supported to attend church, temple or mosque, according to their wishes. Several service users attend day services and some have family and friends who visit them in the home and whom service users also visit. The home also arranges regular daytrips to local theatres and other places of interest. Service users are supported and encouraged to manage their finances independently. Some service users manage their personal allowance without assistance, whilst others receive support from their families. Service users are encouraged to open a building society account and have their personal allowance paid into this. Any financial transactions undertaken on behalf of service users are recorded on a financial transaction sheet that is kept in the personal file. The Inspector asked to view the homes policy on managing service users finances. A policy was subsequently provided to the Inspector on the protection of service users property, but this did not include information on managing service users finances. The home has a professional catering kitchen and employs catering staff to prepare a varied and nutritious diet. In addition each individual unit has its own small kitchen where snacks and hot meals can also be prepared. Each unit provides culturally appropriate meals that appear on the menu after consultation with service users. Each unit has its own dining area in which to serve meals, and dining times are flexible to suit service users routines and preferences. Greengate Lodge DS0000034843.V295284.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users are listened to and acted upon. However, the home must follow its policy and procedure when investigating adult protection allegations. EVIDENCE: The home implements the London Borough of Newham corporate complaints policy and procedure. The policy available within the home has been adapted to include contact details for the Commission for Social Care Inspection and timescales for responding to complaints. The home also maintains a complaints log that records details of the complaint, the investigation and outcome. Whilst sampling the homes complaints log the Inspector noted that a service user made an allegation of physical abuse against a staff member in February 2006. A summary of the investigation and actions taken by the homes Registered Manager were also recorded in the complaints log. The Inspector asked to view the homes adult protection policy. A copy of the local multi agency adult protection guidelines was readily available, but a copy of the homes policy was not. When the homes policy was produced and viewed by the Inspector it was not evidenced that the home had followed the guidance contained in the procedure in relation to the documentation that should have been completed as part of the investigation process. The Inspector also noted that the Commission for Social Care Inspection had not been notified in writing at the time of the allegation. Greengate Lodge DS0000034843.V295284.R01.S.doc Version 5.2 Page 15 The Inspector acknowledges that the allegation was made at a time when the Registered Manager was on secondment and that the allegation was handed over to them by the acting Manager on their return. Following on from discussions at the time of the inspection a formal written notification along with details of the investigation, actions taken and the outcome has been forwarded to the Commission for Social Care Inspection. The Inspector interviewed a member of support staff who demonstrated a good understanding of adult protection issues and the kinds of abuse vulnerable adults may experience. The support worker was also able to appropriately identify the steps they should take should they be concerned for a service users protection. Greengate Lodge DS0000034843.V295284.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service benefit from a safe, comfortable and homely environment. EVIDENCE: The home is single storey and purpose built. The space is divided into four units and each provides a homely atmosphere. Each unit is individually decorated and the hallways between them display pictures representative of the service user group. The home also provides offices for administration and management, a staff room, hairdressing salon, industrial style laundry facilities within a dedicated laundry room and sluice rooms. There is also a central industrial style kitchen. Each unit is individually decorated and comprises of a lounge dining room and a domestic style kitchen. Each unit has access to a specialist bathroom where service users can utilise specialist equipment such as parker baths with staff support. Greengate Lodge DS0000034843.V295284.R01.S.doc Version 5.2 Page 17 Each service user has a private bedroom. Several service users showed the Inspector their bedrooms and it was noted that each contained a bed, a wardrobe, a chest of draws, a bedside table, an armchair, en-suite toilet facilities, and in some cases an ensuite shower. Service users are able to personalise their rooms with mementos and pictures. Externally there is a large rock garden with covered pond. The Inspector noted that the premises were clean, hygienic and free from offensive odours. The home is generally well maintained, however a previous inspection had noted that the décor in the communal areas is tired and deteriorating and a programme of planned redecoration should be developed and implemented. Previous inspections have also identified that the most recently admitted service user on the Roshni Unit should have their bedroom wallpaper, cleaned, repaired or replaced, and this remains outstanding. The Registered Manager advised the Inspector that they were negotiating with a local community service group to provide labour for a programme of redecoration throughout the home. Greengate Lodge DS0000034843.V295284.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users benefit from being supported by trained, competent staff. However, the home must evidence that pre employment checks are carried out on all staff members. EVIDENCE: The Registered Manager advised the Inspector that twenty two service users were in residence at the time of the Inspection and that four unit supervisors and twenty two care staff are employed within the home. At any one time two supervisors are on duty. The Dundee unit has two care staff rostered on duty at all times. The Roshni unit has two care staff on duty each morning and one staff on duty at other times. The Emotan and Abbey units have one care staff on duty at all times with a third support staff rostered on duty and floating between the two units as required. The Inspector viewed the homes staffing rota and this reflected the situation described. Feedback from staff and service users indicated that sufficient staffs are on duty to meet the needs of service users. The Registered Manager also stated that support staffs are matched to units by their skills and experience. One service user spoken to by the Inspector commented that they found staff “very helpful” and another described staff as “flexible”. Greengate Lodge DS0000034843.V295284.R01.S.doc Version 5.2 Page 19 The Inspector was informed that fourteen of the homes care staff have currently achieved NVQ level 2, and that it is hoped that more care staff will commence this training later this year. The home operates within the London Borough of Newham corporate recruitment policy and procedure. A centralised personnel department conducts recruitment and pre employment checks and maintains a personnel file for each staff member. The Inspector sampled two of the personnel files maintained within the home. These contained copies of training certificates and qualifications but did not evidence that pre employment checks required by Schedule 2 of the Care Homes Regulations had been obtained. A summary sheet to be completed by the personnel office for each staff member addressing this shortfall was left with the Registered Manager. Since the last inspection the home has developed a central register that records the qualifications and training undertaken by each staff member. The Registered Manager has developed an induction checklist that is used for all new staff members to the home. Greengate Lodge DS0000034843.V295284.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users benefit from an experienced, qualified Registered Manager. However, the home should develop its quality assurance practises and ensure that all records required by health and safety is maintained. EVIDENCE: The Registered Manager has many years experience in managing residential care homes and has recently obtained their NVQ level 4 award. The home has recently been quality assessed by the LBN. The Registered Manager advised that the results were published and that the home was congratulated on its successes. The Registered Manager stated that the home is also considering implementing a carer’s forum that would be facilitated by an outside agency. Greengate Lodge DS0000034843.V295284.R01.S.doc Version 5.2 Page 21 The home should consider developing its quality assurance processes to include service user feedback and publishing and making available this information to interested parties. Each unit holds service users meetings, which aim to enable service users to contribute to the day-to-day running of the service. The Inspector viewed the available minutes for each unit. The Emotan unit had held meetings in April and May of this year; the Roshni unit held a meeting in March, and the Abbey unit in January 2006. It was not evidenced that the Dundee unit had held a meeting since April 2005. The Inspector examined the arrangements for assisting service users to manager their finances and details of these are contained in earlier sections of this report. The Inspector sampled the supervision records for two care staff, one of which works on the Dundee unit and the other on the Emotan unit. The Dundee staff member had available supervision records for February and March 2004 and December 2005. The Abbey unit staff member had supervision records available for December 2005 and January 2006. The Inspector was advised that a further supervision record for March 2006 was being typed. The records viewed by the Inspector were generally well maintained and in good order, however the Inspector noted that some service users personal files contained loose documents that had not been filed, and opened correspondence that remained in its envelope and had also not been filed. Some of the policies and procedures requested by the Inspector were not readily available. The Registered Manager advised that these are all kept electronically on the London Borough of Newham intranet site. The home should consider how to make these policies and procedures more accessible to care staff. The Inspector viewed a sample of the homes health and safety records. These evidenced that fire drills had been carried out in February and April of 2006. The London Fire Brigade carried out an inspection of the home in February 2006 and found all fire safety matters in order. The home maintains accident and incident logs. On the Abbey, Emotan and Dundee unit’s fridge temperatures are recorded daily and maintained within acceptable limits. The Inspector noted that the homes weekly fire alarm tests had not been conducted between the 24th February 2006 and the 10th March 2006. On the Roshni unit there was no record of freezer temperatures being recorded. There was also a gap in the daily fridge temperature on the 9th April 2006 and an occasion in February where the fridge temperature had been recorded as 9 degrees with no record of action taken to restore the temperature to an Greengate Lodge DS0000034843.V295284.R01.S.doc Version 5.2 Page 22 acceptable level. Prepared foods stored in the freezer were not labelled with their contents or the date of freezing. Greengate Lodge DS0000034843.V295284.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 X 3 1 2 2 Greengate Lodge DS0000034843.V295284.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15 Requirement The home must evidence that all service user plans are reviewed at least once per month and updated to reflect any change in needs. This is a restated requirement. Previous target dates of the 28/12/05 and 31/03/06 have not been met. All service users should be subject to a risk assessment that addresses prevention of falls. The home must evidence that all service users who permanently reside at the home are enabled to access healthcare appointments according to need. Service users who self medicate must do so within a risk management framework. The home must ensure that it fully implements its policy and procedure for the investigation, recording and reporting of adult protection allegations. The room occupied by the most recently admitted service user DS0000034843.V295284.R01.S.doc Timescale for action 30/09/06 2. OP8 12 & 13 30/09/06 3. 4. OP9 OP18 12, 13 & 17 12 & 13 31/08/06 31/08/06 5. OP19 23 30/09/06 Greengate Lodge Version 5.2 Page 25 on the Roshni unit must have its wallpaper cleaned and repaired or be redecorated. This is a restated requirement. Previous targets of the 28/09/05 and 31/03/06 were not met. The communal areas of the home including individual unit kitchens and corridors would benefit from redecoration. The home must have available 31/08/06 for inspection records that evidence pre employment checks have been carried out in accordance with Schedule 2 of the Care Homes Regulations. Regular service users meetings 30/09/06 and consultation must be held to promote their autonomy and choice in the running of the home. This is a restated requirement. Previous targets of the 28/12/05 and the 31/03/06 were not met. The home must develop its quality assurance process to obtain feedback from service users, their relatives, other professionals and stakeholders. The results of these surveys must be published and copies made available to service users and other interested parties, including the Commission for Social Care Inspection. This is a restated requirement. Previous targets of the 28/12/05 and 31/03/06 were not met. Care staff must receive formal supervision at least six times per year. Service users personal files must be regularly maintained and all necessary papers properly filed. DS0000034843.V295284.R01.S.doc 6. OP29 12, 19 & Sch 2 7. OP32 20, 21 & 22 8. OP33 12 & 24 30/09/06 9. 10. OP36 OP37 18 13, 17 & 18 30/09/06 31/08/06 Greengate Lodge Version 5.2 Page 26 11. OP38 16 This is a restated requirement. Previous targets of the 28/09/05 and 31/03/06 were not met. Carry out and record weekly fire alarm tests. Appropriately label prepared foods stored in the freezer. Record fridge and freezer temperatures on a daily basis, including any action taken when temperatures fall outside of acceptable parameters. 31/08/06 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 OP7 Good Practice Recommendations Where the key worker is the person reviewing individual service user plans, the home should consider asking a third party to act as the service users representative where they are unable to act for themselves. Individual activity assessments and action plans should be developed for service users. This is a restated recommendation. The home should develop a policy for safeguarding and assisting with service users finances. The Registered Manager should consider how to ensure that the homes policies and procedures are readily accessible at all times. 2. OP12 3. 4. OP14 OP33 Greengate Lodge DS0000034843.V295284.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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 Greengate Lodge DS0000034843.V295284.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!