Inspection on 29/06/05 for Greengate Lodge

This inspection was carried out on 29th June 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.

Other inspections for this house

Greengate Lodge 26/01/08

Greengate Lodge 02/06/06

Greengate Lodge 16/12/05

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 HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Greengate Lodge Cave Road Plaistow London E13 9DX Lead Inspector Lea Alexander Unannounced Inspection 29th June 2005 2.00 pm 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 Older People and Care Homes for Adults 18 – 65*. 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 G57 G06 S34843 Greengate Lodge V236254 290605 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Greengate Lodge Address Cave Road, Plaistow, London, E13 9DX 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) 0208 430 2000 0208 548 0193 London Borough of Newham Mr Farook Ruhomally Care Home - PC 33 Category(ies) of OP - Old Age, PD - Physical Disability, DE registration, with number Dementia (33) of places Greengate Lodge G57 G06 S34843 Greengate Lodge V236254 290605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 21st January 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. Twenty-four beds are available for permanent service users, five places for respite care and two for intermediate 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 building 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 G57 G06 S34843 Greengate Lodge V236254 290605 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection over the course on an afternoon and evening by one inspector. During the course of the Inspection the Inspector met with the officer in charge and spoke individually to two support workers. The Inspector also met individually with four service users from the different units within the home. Additionally the Inspector viewed personal files, care planning documentation, medication records and policy and procedure. The Inspector carried out a tour of the premises. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Greengate Lodge G57 G06 S34843 Greengate Lodge V236254 290605 Stage 4.doc Version 1.40 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Standards Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Greengate Lodge G57 G06 S34843 Greengate Lodge V236254 290605 Stage 4.doc Version 1.40 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 The home meets prospective service users needs by ensuring all relevant information is gathered and an assessment carried out prior to their taking up residence. EVIDENCE: The Inspector viewed the file for one service user recently admitted for a period of respite care. Information provided prior to admission by the community based care team included a list of contacts, background information, assessed needs, risk assessment and care plan. The service user plan described areas in which they were independent and areas where support was needed, and how this support should be provided. Greengate Lodge G57 G06 S34843 Greengate Lodge V236254 290605 Stage 4.doc Version 1.40 Page 8 It was not clearly evidenced how the service user or their representative had been involved in the assessment or subsequent plan and no steps had been taken by the home since the admission to clarify this. The officer in charge fedback to the Inspector that despite having an emergency admissions policy there were on occasions difficulties as other parties or professionals did not provide relevant information promptly. Greengate Lodge G57 G06 S34843 Greengate Lodge V236254 290605 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10. The home aims to meet service users needs by completing and reviewing documents that form the service user plan. Practise across the unit in completing and reviewing these plans is variable and requires improvement and consistency. EVIDENCE: The Inspector sampled several service users files and established that the home has well established Service User Plan documentation. This includes a Care Plan profile, care plan notes and service user plan. Whilst all three permanent service users had these documents completed there were Greengate Lodge G57 G06 S34843 Greengate Lodge V236254 290605 Stage 4.doc Version 1.40 Page 10 variations in practice. Whilst some evidenced service user involvement by obtaining their signatures, others did not. Some care plan note sheets clearly stated review dates and were initialled to indicate that this had occurred. For other service users there was no evidence that their plan had been reviewed since inception. The Inspector noted that some service users experience urinary incontinence. On their service user plans it was identified that regular toileting should be encouraged to minimise the risk of leaking incontinence pads. During this inspection one service user was noted to be leaking from his pad. This was pointed out to staff and he was immediately assisted and supported with this. One service users personal file included a recent recommendation from a psycho geriatrician to monitor and record any changes in mental state or aggressive outbursts. This was not reflected in the care plan. Another service users plan had identified some time ago that he would benefit from counselling. Subsequent reviews had made no mention of this and it was unclear whether the need had been met, was being followed up or had been reassessed as no longer being required. There was also variation across the home with regard to risk assessments. One service user had a risk assessment that had been reviewed in February 2005 with a next review date recorded for six months. Another service user had a risk assessment dated August 2004 with no evidence of any review since then. A third service user had no risk assessment. Each permanent service user file sampled included a completed “doctors visiting sheet” and appt cards for other services such as dentistry and opticians. The Inspector viewed the homes comprehensive policy regarding medication. This includes policy and practise for service users who are self medicating. The Inspector reviewed the storage arrangements for one self-medicating service user. Whilst a draw in their bedside table had been fitted with a lock, the service user stated that the unit was too low and they were not able to use it. They were instead keeping their medication in an unlocked chest of draws. The Inspector noted that little or no information regarding self medication was included in these service users care plans. The Inspector viewed the homes medication file that indicated that the home maintains an up to date list of medications for all service users. The Inspector viewed the homes Medication Administration Records and found these to be in order. The home had received a visit from the community pharmacist earlier in the day. During the Inspection service users fedback that they felt treated with dignity and respect by care staff. The Inspector noted that for permanent service Greengate Lodge G57 G06 S34843 Greengate Lodge V236254 290605 Stage 4.doc Version 1.40 Page 11 users their individual plans did not detail the kind or manner of support agreed with that service user. Staff sometime work across units and development of this would promote best practice. Greengate Lodge G57 G06 S34843 Greengate Lodge V236254 290605 Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with asssistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15. The home promotes service users wellbeing and community contact by encouraging family contact and offering a range of activities. The home could develop its practise by providing the activities co-ordinator with training and developing individual activity plans with service users. The home is situated in a culturally diverse catchment area and needs to keep under review its organisation and strategies for addressing service users cultural needs. EVIDENCE: The home offers a range of activities for service users according to their social and cultural interests and needs. Individual and group activities are offered on the units or as a wider group. Weekly activity programmes are available. Greengate Lodge G57 G06 S34843 Greengate Lodge V236254 290605 Stage 4.doc Version 1.40 Page 13 Service users have recently been on a day trip to Lakeside, and notice boards around the unit indicate that other day trips are planned. The previous inspection had identified and recommended the development of individual activity assessments and action plans for individual service users. This has not occurred. A longstanding recommendation for additional training for the activity co-ordinator also remains outstanding. The Inspector noted that Roshni unit is currently having a trial period with a service user from a Turkish background. Whilst this service user specifically chose to come to this unit because of a previous respite experience that was extremely positive, thought must be given as to how to appropriately reflect aspects of her own cultural heritage within the unit. From discussions with service users, discussion with one family member and through perusal of personal files the Inspector was satisfied that the home promotes contact with family and friends in accordance with service users wishes. Previous inspections had highlighted the need to review the visitor’s policy and include a section on supervision and control of children during visits. The visitor’s policy was not available for inspection, and this therefore remains a restated recommendation. The officer in charge expressed the view that informal discussion about the running of the home between staff and service users occurred on a daily basis. This was not clearly evidenced during the inspection. One area of uncertainty was with regard to meals. Whilst service users expressed the view that they did not contribute to the dishes appearing on the menu, and only chose on the day between the dishes available, staff stated that there was an ongoing dialogue between service users and kitchen staff. The home employs catering staff and runs a centralised kitchen that produces a different daily menu for each unit. In addition each unit has its own kitchen where service users can store their own food, and where snacks and drinks can be prepared. Service users told the inspector that they were generally happy with the meals that are served. Greengate Lodge G57 G06 S34843 Greengate Lodge V236254 290605 Stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18. The home has a comprehensive complaints procedure that service users know how to access. To ensure that service users are protected, the home must develop its adult protection initial and refresher training. This should include information on the homes policy and procedure for protecting adults. EVIDENCE: The home operates a complaints policy and procedure developed from London Borough of Newham corporate policies. The Inspector viewed the complaints log and noted that the last entry was September 2004. The log detailed the complaint, actions taken and outcome. Service users spoken to during the Inspection stated that they felt comfortable to make a complaint should it be needed, and most stated that they would approach the manager with their concerns in the first instance. The Inspector viewed a photocopy of a document that outlined the procedures for adult protection. The officer in charge advised the Inspector that a more detailed document was not available, as it had been sent for photocopying. The two members of staff interviewed as part of the inspection were both able to identify types of abuse that vulnerable adults may experience. Neither staff member was aware that the home had a policy regarding adult protection and both stated that they had not had any training regarding adult protection. Greengate Lodge G57 G06 S34843 Greengate Lodge V236254 290605 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 23, 24 & 26. The home promotes service users wellbeing by providing care in units that provide a homely and comfortable environment. The home is free from offensive odours and maintained to a reasonable standard. EVIDENCE: The home is purpose built, and a homely atmosphere is promoted by using the home as four units. Each unit is individually decorated and the hallways between them display pictures representative of the service user group. The Greengate Lodge G57 G06 S34843 Greengate Lodge V236254 290605 Stage 4.doc Version 1.40 Page 16 home is generally well maintained, however several repairs were identified during the inspection and are stated in the requirements section of this report. Externally there is a large rock garden with covered pond. The Inspector noted that this area contains an unlocked cupboard that contains hazardous garden products. Each service user has a private bedroom and access to a communal lounge dining area. These communal areas are individually decorated and have a homely atmosphere. Several service users showed the Inspector their bedrooms and it was noted that each contained a bed, wardrobe, chest of draws, bedside table, armchair and en-suite shower facilities that were wheelchair accessible. The Inspector noted that the premises were clean, hygienic and free from offensive odours. Staff carry out laundry in a self contained area that contains commercial type equipment. The home has separate sluicing facilities. Greengate Lodge G57 G06 S34843 Greengate Lodge V236254 290605 Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 29 and 30 (Older People) and Standards 34 and 35 (Adults 18-65) the key standards to be inspected at leat once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 30. The home has promoted service user support and protection by reviewing its staffing rota. A training programme has been in operation throughout this year. EVIDENCE: At a previous inspection in January 2005 the home had been required to ensure that sufficient numbers of staff are on duty. The Inspector viewed staffing rotas for the four units and spoke to the officer in charge and staff on duty. Since the last inspection the rota has been reviewed and increased numbers of staff have been included in the rota. A general improvement in staffing levels was noted by staff. As the homes manager was on leave, the Inspector was unable to access staff personnel files or the staff training record on this occasion. A previous requirement regarding staff training is therefore restated. The Inspector did however view the unit’s day log that suggests that a programme of training Greengate Lodge G57 G06 S34843 Greengate Lodge V236254 290605 Stage 4.doc Version 1.40 Page 18 including manual handling and risk assessment had undertaken since January 2005. Greengate Lodge G57 G06 S34843 Greengate Lodge V236254 290605 Stage 4.doc Version 1.40 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s polies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 33, 35 and 38 (Older People) and Standards 23, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 35, 37 & 38. Service users feel the home is generally well run. The home need to develop their systems for consulting with service users. The home has procedures to promote service users independence with their finances. The home needs to develop a quality assurance system that includes all stakeholders. Greengate Lodge G57 G06 S34843 Greengate Lodge V236254 290605 Stage 4.doc Version 1.40 Page 20 EVIDENCE: The Inspector noted that service users meetings are held on a variable basis, the most recent being in February of this year on the Roshni Unit. For other units meetings had taken place in July of last year and in October 2003. Service users spoken to by the Inspector expressed the view that they were generally happy with the way the home was run. The officer in charge advised the Inspector that the home has no system in place at present to systematically obtain feedback from service users, their relatives, other professionals and other stakeholders. The home encourages service users to maintain control of their finances if they are able to. Part of the initial assessment prior to moving in considers establishes service users financial situation and their ability to manage it. Many service users receive only their residential allowance and this is paid to them weekly in cash by the home. Records of these transactions are recorded on a finance sheet that is kept in the personal file. Some service users have elected to have their personal allowance paid directly into a post office account, and in this case they retain their passbooks. The Inspector noted that information required by regulation is contained within service user personal files. However the Inspector noted that some personal files were poorly maintained with large numbers of loose pages that had not been filed. The officer in charge was unable to locate the electrical testing certificate for the building, and this is therefore a restated requirement. From the inspection of the premises the Inspector noted that in the commercial kitchen that serves the home there were unlabelled and undated opened and prepared foodstuffs in the fridge and freezer. On the Roshni unit there were undated and unlabelled foodstuffs stored in the freezer. The Inspector noted that on the Emotan unit there were gaps in the log to record fridge and freezer temperatures. The Inspector viewed staff meeting minutes and noted that these had last occurred on the 7th March 05 and 1st December 04. Greengate Lodge G57 G06 S34843 Greengate Lodge V236254 290605 Stage 4.doc Version 1.40 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 x 2 x 3 3 4 x 5 x 6 x HEALTH AND PERSONAL CARE ENVIRONMENT Standard No 19 20 21 22 23 24 25 26 STAFFING Score 2 3 x x 3 3 x 3 Score Standard No 7 8 9 10 11 Score 2 3 2 3 x Standard No 27 28 29 30 3 x x 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No 16 17 18 Score 3 x 2 MANAGEMENT AND ADMINISTRATION Standard No Score 31 x 32 3 33 2 34 x 35 3 36 x 37 2 38 2 Greengate Lodge G57 G06 S34843 Greengate Lodge V236254 290605 Stage 4.doc Version 1.40 Page 22 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 7 Regulation 15(1) & 15(2) a & b Requirement Timescale for action 28/12/05 2. 9 13(2) 3. 4. 12 33 12(4)b 12(2) The home must develop the information it records on it service user plans. (1) These must be drawn up with the involvement of the service user and signed by them or their representative. (2) The home must evidence that service user plans are reviewed at least once per month and updated to reflect changing needs. (3) The service user plan needs to set out in detail the action that needs to be taken by care staff. (4) It should also include appropriate information regarding service users who self medicate. (5) Service user plans must include a risk assessment. Self medicating service users 28/09/05 must be provided with an appropriate lockable space in which to keep their medication. Social contact and activities must 28/12/05 satisfy service users social and cultural needs. Regular service user meetings 28/12/05 and consultation must be held to promote their autonomy and choice in the running of the Version 1.40 Greengate Lodge G57 G06 S34843 Greengate Lodge V236254 290605 Stage 4.doc Page 23 home. 5. 18 18(c )i The home must ensure that all staff receive initial and refresher training regarding adult protection and are aware of the homes policy and procedure. The following maintenance must be carried out:(1) On the Emotan unit the hand dryer in the hallway toilet must be repaired. (2) The badly stained patio table on the Emotan unit must be cleaned or replaced. (3) The Emotan dishwasher tray is rusted and must be replaced. (4) The room occupied by the recently admitted service user on the Roshni unit must have wallpaper cleaned and repaired or be redecorated. (5) On the Dundee unit towel rails must be fixed, or repaired in each service users room. (6) Doors on the Dundee unit require maintenance to ensure that they open and close quietly. (7) The garden storage cupboard containing hazardous materials must be secured. The home must ensure staff are appropriately trained in current manual handling techniques. This is a restated requirement. The home must develop a quality assurance system 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 CSCI. Service users personal files must be regularly maintained and all necessary papers properly filed. All opened or prepared foods 28/12/05 6. 19 23(2)b & c 28/09/05 7. 30 18(1)a & 13(4)c 24(1) a & b 28/09/05 8. 33 28/12/05 9. 10. 37 38 17(3)a 13(4)c 28/09/05 28/09/05 Page 24 Greengate Lodge G57 G06 S34843 Greengate Lodge V236254 290605 Stage 4.doc Version 1.40 11. 37 13(4)c 12. 13. 32 38 21(2) 13(4)a stored in the homes fridges and freezers must be labelled and dated. The home must monitor and record fridge and freezer temperatures. This is a restated requirement. The home must hold regular staff meetings. A copy of the electrical installation certificate must be forwarded to the Commission for Social Care Inspection. This is a restated requirement. 28/09/05 28/12/05 28/09/05 14. 15. 16. 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. 4. Refer to Standard 7 12 12 13 Good Practice Recommendations The service user plan could be developed to include information on how service users prefer to receive their personal care. Individual activity assessments and action plans should be developed for service users. This is a restated recommendation. The Activity Co-ordinator should be provided with appropriate activity training. This is a restated recommendation. The Visitors policy should be developed to include the supervision and control of children visiting the unit. This is a restated recommendation. Greengate Lodge G57 G06 S34843 Greengate Lodge V236254 290605 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection 4th Floor, 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 G57 G06 S34843 Greengate Lodge V236254 290605 Stage 4.doc Version 1.40 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. 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!