CARE HOMES FOR OLDER PEOPLE
Greengates Greengates Redland Lane Westbury Wilshire BA13 3QA Lead Inspector
Roy Gregory Unannounced Inspection 09:15 5 March 2008
th 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 Greengates DS0000048635.V358617.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. Greengates DS0000048635.V358617.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Greengates Address Greengates Redland Lane Westbury Wilshire BA13 3QA 01373 822727 01373 826320 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) Greengates Care Home Limited Mr Chong Siam Yeoh Care Home 54 Category(ies) of Dementia (51), Mental disorder, excluding registration, with number learning disability or dementia (3), Old age, not of places falling within any other category (51) Greengates DS0000048635.V358617.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 10th May 2006 Brief Description of the Service: Greengates is situated in a residential area of Westbury. The original property has been extended on several occasions. The home is built round a central patio area, which may be accessed directly from the lounges. The majority of service users rooms are on the ground floor, many looking onto the central courtyard. Seven bedrooms are on three separate first floors. The home is registered to provide care for up to 54 people. Around half of these places are in shared rooms. Weekly fees ranged between £344 and £402. A pictorial service user guide is made available to all residents and their families. Westbury has a main line station, which is about 15 minutes walk from the home, as are the town centre shops. Some parking is available on site and street parking is also available. There is a bus stop at the end of the road. Greengates DS0000048635.V358617.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes.
The unannounced visit for this inspection was made on Wednesday 5th March 2008 from 9:15 a.m. to 5:15 p.m., with a return visit the following day between 9:00 a.m. and 4:00 p.m. The owner/manager, Mr Yeoh, was available during the inspection visits. The inspector also spoke with senior carers, the activities co-ordinator, and members of the care and support staff teams. During the inspection there was direct contact with a number of residents, in the communal rooms and individual rooms, and by joining one resident for lunch in the dining room. This allowed for observation of the service of meals. Medications practice and storage were examined. The entire home was toured. Prior to the inspection, Mr Yeoh had supplied detailed information by way of the Annual Quality Assurance Assessment, as is required by the Commission for Social Care Inspection. Twelve survey questionnaires were sent to relatives of people that live in the home, of which six were returned. It was also possible to look at the initial results of the home’s annual survey of residents’ and relatives’ opinions. Other documentation looked at included records in respect of care planning and delivery, risk assessment, training and recruitment, and monitoring of systems for hygiene and health and safety. A number of instances of care giving were observed. There was an interview with a visiting community nurse. The judgements contained in this report have been made from evidence gathered during the inspection, which included the visits to the home. They take into account the views and experiences of people who live there. They also take into account random inspection visits that were made to Greengates on 30th January 2007 and 2nd August 2007. What the service does well:
When considering any referral to the home, Mr Yeoh was encouraging family members to visit the home at an early stage, so they could decide whether Greengates appeared to meet the criteria they would hope for, for their relative. Using the home’s assessment form, Mr Yeoh obtained good quality information from families, hospital staff and others who knew the prospective resident, alongside meeting the person concerned. Where possible, arrangements were made for prospective residents to visit the home, as part of the assessment process. For a person recently admitted, the daily care record showed that on their first day and night at the home they received a lot of attention and reassurance from staff. A close relative was also involved in
Greengates DS0000048635.V358617.R01.S.doc Version 5.2 Page 6 the settling-in period, giving assistance and guidance to staff on the person’s preferred ways of receiving care. Detailed care plans were in place for all residents, with evidence of monthly review. Care records demonstrated that care was given in line with care plans. For a person who needed to spend a lot of time in bed, appropriate charts were in use to show that care was closely monitored. There was an arrangement for a community nurse to visit every week. Pressure relieving equipment had been supplied and was in use. Staff noticed changes in people’s health and wellbeing, and were prompt at reporting concerns so professional attention could be accessed quickly. A visiting community nurse said home staff had a clear understanding of the threshold for referring concerns to the nurses, and were responsive to advice given about ongoing care needs. Respect for people’s dignity was indicated by attention to clothing choices and support to nail and hair care. All visitors that were interviewed were pleased with how the home recognised and met personal needs. A respondent to the relatives’ survey wrote, “The staff are always calm around the residents. They carry out their care to the residents with dignity”. Another saw the daily routines of the home as a strength that residents could relate to. Each care plan contained a sheet entitled ‘former lifestyle’. Relatives were invited to provide information about occupations, preferred daily routines, interests and significant dates. It was part of the key worker’s role to see that these needs were fulfilled. Each morning and afternoon shift had to organise at least one activity. There was a record of daily activities undertaken. One-toone passive activities such as looking at magazines, and occupational tasks like room or drawer tidying, were recognised as being equally as important as group activities. People’s participation and responses were recorded, so there was good information to assist reviews of care plans. During the inspection visits, the activities undertaken were singing, table skittles, a balloon game and a naming game. A resident with a visual disability confirmed they were regularly supported to listen to audio books and music of their choice. It was noted that spontaneous singing between staff and residents was a common feature of the home, and there was a lot of natural conversation. There was evidence that visitors were welcomed to the home. Some regular visitors considered themselves very much part of the home. Hot drinks were routinely offered to visitors and they could stay for meals. A ‘traditional’ menu was served. Additional fish dishes had been incorporated into the menu following a request made through a residents’ meeting. There was a choice of main course and sweet at lunch. Meat and vegetables were obtained from local suppliers. At the meal observed there were four fresh vegetables. In the dining room, there was good attention for people that needed prompting or more direct assistance to eating. People could take as long as they wished to eat.
Greengates DS0000048635.V358617.R01.S.doc Version 5.2 Page 7 On a tour of the entire building, very high standards of cleaning were in evidence, with no unpleasant odours. Rotas showed there were consistently six care staff on duty through the day and evening. One was a senior carer in charge of the early or late shift. In addition, a senior member of staff was not part of the rota, so was able to devote time to liaison with other agencies, ordering and checking of medications and reviews of care plans. Staff spoke in person-centred terms about people living in the home, and all care interactions observed were patient and sensitive. Staff remained calm and cheerful. There was gentle verbal engagement with people as they were assisted to the dining table, and when hot drinks were served. What has improved since the last inspection? What they could do better:
For two people a care plan had not been written to guide staff on the terms of use of ‘as needed’ prescriptions. This was a subject of requirement at the previous key inspection in 2006. Some good practice was identified in this regard, but it is important to ensure staff have the necessary guidance for each person prescribed medicines ‘as needed’.
Greengates DS0000048635.V358617.R01.S.doc Version 5.2 Page 8 Records showed staff received regular supervision from Mr Yeoh, but the emphasis was on one-to-one refresher training in the home’s systems and procedures. There was little indication of reflection on individual issues about team working, key work or development needs, and thus few links with people’s annual appraisals. It is recommended to ensure supervision is a twoway process. Additionally, it was suggested that care workers could benefit from some of their supervision being with the activities co-ordinator in order to consider specifically how their work can promote people’s quality of life. The activities co-ordinator’s wide view of activity and occupational promotion is a valuable resource to the home. People were offered a choice at meal times, but some of the choices were of similar meals. On the day of inspection, the choice was between pork casserole and bacon. On another day there were two fish dishes. It was agreed that alternatives offered should represent a real choice. Another item of discussion about meals was concern that the atmosphere of the dining room was spoilt in one area by the positioning of a trolley used for cleaning plates. Mr Yeoh agreed that different arrangements should be made. Training records were poorly organised, with much historical content. It would be of benefit to have one file that showed the current position only, together with a clear forward plan. All respondents to the relatives’ survey indicated that they considered staff to have the skills and experience to look after their relatives, but one added that staff “would benefit from specialised training in dementia care”. This was a valid observation, given the specialist nature of the home. In the home’s questionnaire to relatives, people were asked, “Do you wish to be more involved in decision-making in the home?” All responses received by the time of the inspection were “no”. However, an occasional newsletter or invitation to a meeting would enable people to be better informed, and give them an opportunity to express opinions and be heard, if they wished. 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. Greengates DS0000048635.V358617.R01.S.doc Version 5.2 Page 9 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 Greengates DS0000048635.V358617.R01.S.doc Version 5.2 Page 10 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): 1, 3 & 5. (Key standard 6 is not applicable to this home). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each person’s needs are assessed in detail to ensure that their needs can be met. People and their close relatives are given good information, and are invited to visit the home to help decide whether it suits their needs and wishes. EVIDENCE: Mr Yeoh carried out assessments of all people referred to the home. With many referrals coming from the Wiltshire County Council brokerage team, Mr Yeoh said he was increasingly making contact with social workers for information about people’s care and social needs, as brokerage referrals tended to concentrate on funding issues. Using the home’s assessment form, Mr Yeoh obtained good quality information from families, hospital staff and others who knew the prospective resident, alongside meeting the person concerned. He said he had been arranging visits to the home where possible, to enable an onsite assessment.
Greengates DS0000048635.V358617.R01.S.doc Version 5.2 Page 11 He was particularly encouraging family members to visit the home at an early stage, so they could decide whether Greengates appeared to meet the criteria they would hope for, for their relative. The assessment process could then follow, by agreement. All relatives were given a copy of the home’s service user guide. For the person most recently admitted, records showed relatives visited and contributed to assessment information. Mr Yeoh visited the person the next day in hospital, where further information was obtained from the staff nurse on the ward. Later, a discharge summary was provided by the hospital. The daily care record for the person showed that on their first day and night at the home they received a lot of attention and reassurance from staff. A close relative was also involved in the settling-in period, giving assistance and guidance to staff on the person’s preferred ways of receiving care. That relative confirmed family members had made an initial visit to the home, and made a decision that they considered it suitable for meeting their relative’s needs. He saw all the key family members as fully involved in the choice of home, aided by good written and verbal information. The visiting relatives of another person, admitted six months previously, said the initial admission was to have been temporary whilst a placement nearer their home was sought. However, they had seen their relative become increasingly settled, and considered the initial assessment to have been accurate, since the home was meeting identified needs to a good standard. Five of the six responses to the survey of relatives were that the home “always” met their relatives’ needs. Two of them commented on their relatives having become more settled as a result of admission to the home. Assessment information gathered included information about people’s life history and interests as well as physical care and health needs. Mr Yeoh said this was where family contributions were particularly helpful. It was confirmed in writing to each resident, that the home could meet their needs on the basis of initial assessment. There was experience in the home of declining to offer a place if it was considered the home could not meet identified needs. For a person admitted from a short stay in another care home, there was a full preadmission assessment, showing that their risk of falling and related factors were shared openly between the two establishments and the resident’s close relative. Greengates DS0000048635.V358617.R01.S.doc Version 5.2 Page 12 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): 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s personal and health care needs were met through care planning. People were treated with respect and their right to privacy was upheld. Residents were protected by the home’s procedures for the safe handling of medicines, except in the case of some “as needed” medicines where protocols for use were needed. EVIDENCE: Detailed care plans were in place for all residents, from the time of admission. There was evidence of monthly review, with amendments showing they were working documents. Care records demonstrated that care was given in line with care plans. Examples were seen of care plans related to specific conditions or needs, such as diabetes care. In all cases there was a plan for nighttime care. Greengates DS0000048635.V358617.R01.S.doc Version 5.2 Page 13 For a person who needed to spend a lot of time in bed, a chart was in use for staff to record that the person was being turned every two hours. Another chart recorded the person’s fluid and food intake, and staff were seen to use a syringe to assist drinking. There was an arrangement for a community nurse to visit every week. Pressure relieving equipment had been supplied and was in use. Every person’s care plan included an assessment of risk of pressure damage. Any assessment of more than a low risk led to a plan of care to reduce the risk of tissue breakdown. Mr Yeoh said the home’s general encouragement of people to walk to meals and regularly to the toilet, combined with provision of nutritious meals and individually assessed pressure-relieving aids, was in part aimed at reducing overall risk of pressure area problems developing. Staff generally were very aware of this facet of care. This represented an improvement since the random inspection visit on 1st August 2007. Then, there was a requirement for a consistent method for assessing risks of pressure area damage and nutritional compromise, and a recommendation to seek advice and guidance from the tissue viability nurse specialist on how best to assess and manage pressure area risks. Mr Yeoh and the staff received training input from the tissue viability nurse on 31st August 2007. The nurse had agreed that the pressure area assessment tool in use was appropriate to the home. A recommendation that writing risk assessments be limited to a few staff, appeared to have helped ensure consistent quality. Care notes, and notifications to the Commission, showed that staff were attentive to indicators of change in people’s health and wellbeing, and prompt at reporting concerns so professional attention could be accessed quickly. For example, one evening a carer had recorded noting someone had swollen ankles and a changed pattern of continence. A GP visit took place the following morning. A visiting community nurse, who was very familiar with the home, said all referrals to the nursing service were appropriate. There was a weekly attendance for people that were under the nurse’s care for particular reasons, but nurses were called upon and able to attend any day in response to injuries from falls. The nurse said home staff had a clear understanding of the threshold for referring concerns to the nurses, and were responsive to advice given about ongoing care needs. On the day of the visit, the nurse was critical of a choice of dressing that had been applied to a fragile skin. The senior carer undertook to obtain alternatives at once to place in the first aid supplies. All staff were booked to receive refresher training in first aid in June 2008. A requirement from the random inspection visit of 1st August 2007 was that weight records must be used actively to promote provision for the health of service users. The charts for recording weights now stated clearly to staff the home’s policy on changes to frequency of weighing, and the need to report any significant gains or losses to a team leader for action. A person’s care record showed that a weight loss had been identified. Their physical health care plan
Greengates DS0000048635.V358617.R01.S.doc Version 5.2 Page 14 had been amended, with a view as to why the loss may have occurred and a strategy for addressing this. The frequency of weight monitoring was increased. A weight gain had subsequently been achieved. For some people there were arrangements in place for ongoing liaison with a consultant psychiatrist or other mental health professionals. Care plans recognised individual behaviour patterns and personality traits, and identified ways of working with these. For example, some people liked to walk repeatedly around the building, or were more active in the late evening. A person had shown a risk of repeated falls. The care plan guided staff on one-to-one work, such as helping the person to read the newspaper, to encourage a less restive lifestyle. Observations and records showed this approach to be successfully meeting the person’s needs. One respondent to the survey of relatives considered a strength of the home to be how staff worked with people that presented challenging behaviours. Respect for people’s dignity was indicated by attention to clothing choices and support to nail and hair care. All visitors that were interviewed were pleased with how the home recognised and met personal needs. Care records showed that for some people, continence issues had been successfully addressed by careful routines, thus promoting dignity. Attention to privacy needs was also observed. A respondent to the relatives’ survey wrote, “The staff are always calm around the residents. They carry out their care to the residents with dignity”. Another saw the daily routines of the home as a strength that residents could relate to. The storage of medications and records of their administration were good. (In common with all homes that occasionally hold controlled drugs, the home is required to obtain controlled drug storage that meets new security standards). When staff conducted a medication round, security of the trolley was maintained, people were observed taking their medicines, and the record was signed to confirm what the carer had seen. ‘As needed’ medicines were clearly marked in the Medicines Administration Record (MAR) charts. However, protocols for their use were not always subject of care plans. There was a policy of ending the prescription of any ‘as needed’ medicine after a period of two months of non-use. This was good practice, but for two people who had been admitted with ‘as needed’ prescriptions, a care plan had not been written, out of expectation that the prescription would cease. With the medicines appearing on the MAR chart, care plans were necessary to guide staff on the terms of their use. Where such care plans were in place, they were good quality. For example, one showed how to decide if administration of the medicine appeared appropriate; if so, the carer was directed to discuss the matter further with the manager or senior carer on duty. There was guidance on how the administration must be recorded in the care record as well as on the MAR chart. Greengates DS0000048635.V358617.R01.S.doc Version 5.2 Page 15 The senior carer ordered repeat prescriptions and checked in medications as they were delivered. Refresher training for staff in the administration of medicines was due to be delivered by an external trainer in April 2008. Greengates DS0000048635.V358617.R01.S.doc Version 5.2 Page 16 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): 12 – 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was active in identifying and meeting people’s social, religious and recreational needs. People were encouraged to make choices and were able to keep in contact with family and friends. People had a choice of meals, served in a pleasant environment. EVIDENCE: Each care plan contained a sheet entitled ‘former lifestyle’. Relatives were invited at assessment, and subsequently by key workers, to provide information about occupations, preferred daily routines, interests and significant dates. For one person, for example, this information showed preferred rising and retiring times, preferences for hot drinks, and food likes and dislikes. There was an activity care plan that gave ideas for one-to-one engagement and showed the person liked singing, religious programmes on television and doing puzzles. It was part of the key worker’s role to see that these needs were fulfilled. The care plan included communication guidance, and recognised the needs of a close relative who visited most days. Records showed the relative sometimes joined meals in the home, and shared with staff in providing stimulation to the resident.
Greengates DS0000048635.V358617.R01.S.doc Version 5.2 Page 17 It was a designated task for each morning and afternoon shift that at least one purposeful activity had to be organised. At handover, the shift leader decided which member of staff would take responsibility for this. One-to-one engagement was recognised as equally important as group activities. There was a record of daily activities undertaken. Group activities were centred on the sitting and dining rooms, to give people a choice whether to join in. These included dominoes, word games, balloon and ball games, doing puzzles and singing. There were also records of time spent with individuals, on passive activities such as looking at magazines, and encouraging occupational tasks such as room or drawer tidying. People’s participation and responses were recorded, so there was good information to assist reviews of care plans. During the inspection visits, the activities undertaken were singing, table skittles, a balloon game and a naming game. A resident with a visual disability confirmed they were regularly supported to listen to audio books and music of their choice. Both sitting rooms had televisions, which were used discriminately. Smoking was provided for by a covered outside area. The very few residents that smoked seemed to have a good understanding of the arrangements made for them. They were always accompanied by staff, who ensured they were aware of the outside temperature and that they were dressed appropriately. All residents had access to the inner patio courtyard in good weather and there were wheelchairs to enable staff to take people for short local walks. It was noted that spontaneous singing between staff and residents was a common feature of the home, and there was a lot of natural conversation. There were records of visits by ministers of various denominations to individual residents. One resident stated they were of a particular denomination. They were able to name their minister, who visited them, and they had occasional trips to church. There was a monthly non-denominational service in the home, led by a member of staff with a visiting pianist. This was said to be very popular. A local minister provided communion six times a year, near major festivals. One of the senior carers was designated as activities co-ordinator. She had an overseas qualification in occupational therapy. Her role was to oversee the provision of activities. As part of this, like Mr Yeoh, she encouraged care staff to recognise the opportunities that arise in everyday care activities to promote self-help and choice. For example, she spoke of support to people in tasks like morning hair care, and using walks to meals or to the toilet to converse and to help individuals to recognise daily routines. People living in the home were also encouraged to assist in familiar tasks, such as dusting, setting and wiping tables and folding linen. A lady living in the home said she liked helping with cleaning. Greengates DS0000048635.V358617.R01.S.doc Version 5.2 Page 18 The activities co-ordinator’s wide view of activity and occupational promotion is a valuable resource to the home. It was suggested that care workers could benefit from some of their supervision being with the activities co-ordinator in order to consider specifically the activity and social needs of people to whom they are key workers, and how their work can affect people’s quality of life. Some residents spent a lot of time walking around the building. The layout of the building meant staff could maintain awareness of these people, and they in turn could not get lost. Clear walkways were maintained. As a consequence of this behaviour trait, it was policy in the home to keep bedrooms locked when not in use, so people could not wander into them and disturb contents, or get lost. All staff spoken to said rooms were unlocked for people on demand, which was supported by observation. Where people were less likely to make a positive choice to use different parts of the building, including their own room, staff were pro-active in asking and prompting them. A visiting relative said she was very much in favour of the door locking policy and how it worked in practice. Residents’ rooms showed they were encouraged to bring personal possessions to help them feel at home. There was evidence that visitors were welcomed to the home. Some regular visitors considered themselves very much part of the home. Hot drinks were routinely offered to visitors and they could stay for meals. A ‘traditional’ menu was served. Additional fish dishes had been incorporated into the menu following a request made through a residents’ meeting. There was a choice of main course and sweet at lunch (the main meal of the day). However, some of the choices were of very similar meals. On the day of inspection, the choice was between pork casserole and bacon. On another day there were two fish dishes. It was agreed to make sure contrasting choices were always made available. Meat and vegetables were obtained from local suppliers. At the meal observed there were four fresh vegetables. The kitchen had obtained a top score in audit by the environmental health officer. The cook confirmed working to guidance in “Safer food, better business”. In the dining room, there was good attention for people that needed prompting or more direct assistance to eating. People could take as long as they wished to eat. However, the atmosphere of the dining room was spoilt in one area by the positioning of a trolley. This meant that the noise and sight of cleaning used plates was uncomfortably close to some people eating. It was readily agreed by manager and staff that different arrangements should be made. Greengates DS0000048635.V358617.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is provision for receipt of and response to complaints. Staff and management understand and exercise responsibilities in respect of keeping residents safe. EVIDENCE: The home has a written complaints procedure that complies with regulations. It is provided to people with the service user guide. However, two out of six respondents to the relative’s survey indicated they did not know how to make a complaint. Mr Yeoh had provision for recording receipt and handling of complaints, but none had been received since the previous inspection. A visitor said they had made a complaint about three years previously. It had been addressed appropriately and they had confidence the same would be true again. Staff received training in abuse awareness and safeguarding procedures, by inhouse DVD resource and external trainers, including the Police vulnerable adults unit. They were given copies of the “No Secrets” brief guidance to local inter-agency safeguarding procedures. The home had been subject of two safeguarding alerts since the previous key inspection. The Commission conducted random inspection visits in response, in January 2007 and August 2007.
Greengates DS0000048635.V358617.R01.S.doc Version 5.2 Page 20 Issues raised externally proved on each occasion to have been recognised and addressed by the home, by environmental measures and care planning for individuals. With regard to pressure area and nutritional risks, three requirements and three recommendations were made as a result of the random inspection of 2nd August 2007, to improve resident safety. This inspection has confirmed systems have been put in place, and are working, to comply with the requirements and recommendations. Greengates DS0000048635.V358617.R01.S.doc Version 5.2 Page 21 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): 19 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was homely, safe and well maintained. There were good standards of hygiene around the home. EVIDENCE: On a tour of the entire building, very high standards of cleaning were in evidence, with no unpleasant odours. A completed programme of carpet replacement had resolved a previous odour problem in some areas. There was housekeeper attention to all areas every day, including weekends. There was a schedule of designated times each week for shampooing carpets in bedrooms, sitting rooms and corridors. The dining room received appropriate attention after each meal. Mr Yeoh recorded periodic cleaning audits, which he discussed with the housekeeper to check on priorities. There was evidence that any faults or breakdowns occurring in the home received prompt attention. Greengates DS0000048635.V358617.R01.S.doc Version 5.2 Page 22 New armchairs had been provided in the sitting rooms and some beds had been replaced. The patio courtyard had a re-laid surface, which made it safer than previously for independent access. There was a designated laundry shift each day. The laundry room was cramped but well ordered and laundry systems appeared to meet residents’ needs well. Clothing was sorted and washed according to temperature guides. There were proper arrangements for dealing with soiled or infected laundry. There was hand hygiene provision for staff in each bedroom. There was evidence of routine use of these resources and of protective clothing. Greengates DS0000048635.V358617.R01.S.doc Version 5.2 Page 23 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): 27 – 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have support from competent, trained staff who are provided in sufficient numbers. People are protected by sound recruitment practices that ensure nobody works at the home until checks on their background are complete. EVIDENCE: Rotas showed there were consistently six care staff on duty through the day and evening. One was a senior carer in charge of the early or late shift. Each shift began with a handover of information from the previous shift, and delegation of care and activities duties. Each person on shift was given the names of residents who were to be their particular responsibility. Among the staff group were two male members of staff. They gave personal care only to male residents. Any shortages on shift were covered by existing staff, or one ‘bank’ member of staff, as the home preferred not to take on agency staff for the sake of consistency of care to residents. Mr Yeoh said local recruitment proved very difficult. Therefore many members of staff were recruited from abroad. This had the advantage that these members of staff had between them a variety of qualifications and experience in health and social care. A relative wrote on a survey form, “The residents would benefit from English speaking carers.”
Greengates DS0000048635.V358617.R01.S.doc Version 5.2 Page 24 However, from observation, and the quality of written notifications completed by staff, this did not appear to be a major concern in the home. There was little turnover of staff. Records of the two staff recruited since the previous key inspection showed they had completed application forms, accompanied by records of their previous employment. Checks had been carried out by the Criminal Records Bureau, including confirmation their names did not appear on the Protection of Vulnerable Adults list. References had been obtained and they had undertaken an induction. In addition to daily staffing by care workers, a senior member of staff had essentially a ‘head of care’ role. She was not part of the rota, so was able to devote time to liaison with other agencies, ordering and checking of medications and reviews of care plans. Mandatory training was kept up by a mixture of in-house and external provision. Records showed what training individual members of staff had under taken and Mr Yeoh was able to identify where refresher training was becoming due. However, the training records were poorly organised, with much historical content. It would be of benefit to have one file that showed the current position only, together with a clear forward plan. Given the specialist nature of the home, attempts could be made to identify more regular external training provision to keep staff in touch with current dementia care practice. That said, staff spoke in person-centred terms about people living in the home, and all care interactions observed were patient and sensitive. Staff remained calm and cheerful. There was gentle verbal engagement with people as they were assisted to the dining table, and when hot drinks were served. All respondents to the relatives’ survey indicated that they considered staff to have the skills and experience to look after their relatives, but one added that staff “would benefit from specialised training in dementia care”. Nine out of fourteen permanent care staff had achieved National Vocational Qualification (NVQ) in care to level 2 or higher. Two others were currently working towards this. There were records of monthly staff meetings where mainly operational matters were discussed. Mr Yeoh frequently met with staff at handovers to give and receive information. Greengates DS0000048635.V358617.R01.S.doc Version 5.2 Page 25 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): 31, 33, 36 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is attentive to the daily needs of the home. The care workers are regularly supervised. Feedback is sought from people with an interest in the home, but in a limited way. There are systems in place to identify and promote the health and safety needs of residents and staff. EVIDENCE: Mr Yeoh as registered manager and provider was clearly familiar to all people that live at Greengates. He holds the Registered Managers Award. He spoke a lot about providing “a local service for local people”. He has been responsive to requirements and recommendations made at previous inspections. His wife provided some administrative and organisational back-up. Greengates DS0000048635.V358617.R01.S.doc Version 5.2 Page 26 In the entrance hall there were quality feedback forms that visitors could pick up and complete at any time. These forms had been sent to relatives and advocates of all residents in February 2008. Sixteen had been received back at this time, all making positive observations of how the home was run. Mr Yeoh had completed and signed off a bought-in Quality Assurance audit in February 2008. It was suggested that such audits should not be completed until after returns were received from the questionnaire survey, so that it was clear that stakeholder opinions influenced development planning. Some forms were submitted on behalf of residents, but for the most part these were identical and of no evident value. One question in the relatives’ survey was, “Do you wish to be more involved in decision-making in the home?” All responses so far received were “no”. However, an occasional newsletter or invitation to a meeting would enable people to be better informed, and give them an opportunity to express opinions and be heard, if they wished. The home did not provide a safe keeping service for residents’ cash or valuables. Families or advocates were asked to take care of people’s financial needs. They were billed directly for expenses such as hairdressing and chiropody. Records showed staff received regular supervision from Mr Yeoh, but the emphasis was on one-to-one refresher training in the home’s systems and procedures. There was little indication of reflection on individual issues about team working, key work or development needs, and thus few links with people’s annual appraisals. Provision for health and safety of staff and residents was good. All staff received health and safety training within the previous year and were due to renew first aid certificates. Mr Yeoh had completed health and safety audits in May and November, 2007. This acted in part as a check on routine servicing and replenishing, such as the annual check that the home was free of legionella, and servicing of hoists and electrical safety checks. It was clearly an active document. Greengates DS0000048635.V358617.R01.S.doc Version 5.2 Page 27 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X N/A 3 X 3 Greengates DS0000048635.V358617.R01.S.doc Version 5.2 Page 28 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 OP9 Regulation 15 (2)(b,c) Requirement Where a service user is prescribed as needed medicine, their care plan must include guidance on how such medicine is to be used and recorded. Timescale for action 31/05/08 This requirement was made at the previous key inspection, 10/05/06. It was found to be complied with at two random inspections in 2007 and was largely complied with at this inspection, but it has been necessary to re-state it. 2. OP9 15 (2)(b,c) Arrangements must be made to purchase and install a controlled drug cupboard that meets the current storage regulations (The Misuse of Drugs and Misuse of Drugs (Safe Custody) (Amendment) Regulations 2007. 31/07/08 RECOMMENDATIONS These recommendations (on the following page) relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Greengates DS0000048635.V358617.R01.S.doc Version 5.2 Page 29 No. 1. 2. 3. 4. 5. 6. 7. 8. Refer to Standard OP12 OP15 OP15 OP30 OP30 OP33 OP33 OP36 Good Practice Recommendations Arrange for care workers to receive some of their formal supervision from the activities co-ordinator, to promote consistency in how activity and social needs are met. Make sure choices at meal times are between real alternatives. Ensure the dining room offers all residents a conducive atmosphere for the enjoyment of meals. Training records and plans should be organised so that current needs and arrangements can be readily identified. Seek opportunities for staff to extend their knowledge and competency in working with people with dementia. The annual quality audit should not be completed without taking account of stakeholder feedback. Consider a range of ways of engaging with stakeholders. One-to-one supervision of staff should be more demonstrably a two-way process. Greengates DS0000048635.V358617.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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
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