Inspection on 28/01/06 for Greenhaven Resource Centre

This inspection was carried out on 28th January 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

Greenhaven Resource Centre 17/07/07

Greenhaven Resource Centre 30/05/06

Greenhaven Resource Centre 01/09/05

Greenhaven Resource Centre 10/02/05

Greenhaven Resource Centre 18/08/04

Greenhaven Resource Centre 09/03/04

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

CARE HOMES FOR OLDER PEOPLE Greenhaven Resource Centre Grout Street West Bromwich West Midlands B70 OHD Lead Inspector Linda Elsaleh Unannounced Inspection 28/01/06 09:00 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 Greenhaven Resource Centre DS0000035520.V279590.R01.S.doc Version 5.1 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. Greenhaven Resource Centre DS0000035520.V279590.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Greenhaven Resource Centre Address Grout Street West Bromwich West Midlands B70 OHD 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) 0121 557 8088 0121 522 2354 Sandwell Metropolitan Borough Council Care Home 46 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (31) of places Greenhaven Resource Centre DS0000035520.V279590.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. All requirements contained within the registration report of 6 & 7 December 2002 are met within the timescales contained within the action plan agreed between Sandwell Metropolitan Borough Council and the National Care Standards Commission. A maximum of 31 people in the category of OP to be accommodated on the ground floor, 5 of whom may be aged 57 years and over. A maximum of 15 people in the category DE(E) to be accommodated on the first floor, 2 of whom can be 57 years and over 01/09/05 2. 3. Date of last inspection Brief Description of the Service: Greenhaven is a local authority home providing services for 46 older people. The home has 46 bedrooms with facilities to provide services to 46 people. This includes the provision of dementia care and rehabilitation services. The home is situated within easy travelling distance of Great Bridge town. It is accessible by public transport from Birmingham, Dudley and West Bromwich. The building is two-storey, with a lift providing access to all communal areas and there is good access for wheelchair users. There is a large dining room on the ground floor and smaller dining areas throughout as well as a number of lounges of varying size. Two flat-lets are available to cater for more independent living and represent part of the rehabilitation provision. There is a contained garden area with raised flowerbeds. Greenhaven Resource Centre DS0000035520.V279590.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 28th January 2006. The focus was to assess the home’s performance on meeting certain key standards of the National Minimum Standards for Older People and report on its progress in meeting some of the requirements made during previous inspections. The process involved the examination of relevant records, interviews with the manager and staff and observations of care practices. Ten of the seventeen requirements made at previous inspections were assessed. Six have been fully met, two partly met and one is yet to be fully addressed. Three new requirements have been in respect of the standards assessed during this visit. On arrival the atmosphere within the home was friendly and inviting. Breakfast was being served in the main dining room and additional dining areas. A brief tour of the premises found it to be clean and free of odour. Bowls of fresh fruit were available in all communal lounges. The information board contained photographs of staff and names of those on duty throughout the day. Brief discussions were held with some residents, who stated they were satisfied with the service being provided. A member of the senior staff team was administering medication. What the service does well: The staff team demonstrated a caring approach when meeting the needs of residents and provided a friendly welcome to visitors. Residents’ wishes with regards to receiving visitors are respected and good arrangements are in place to enable visits to take place in private, if the resident so wishes. Appropriate recruitment procedures are followed for the appointment of staff and arrangements are in place to cover duties whilst this process is being completed. The home has good procedures in order to protect and safeguard residents. Evidence is available to demonstrate the effectiveness of these procedures. Greenhaven Resource Centre DS0000035520.V279590.R01.S.doc Version 5.1 Page 6 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. Greenhaven Resource Centre DS0000035520.V279590.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Greenhaven Resource Centre DS0000035520.V279590.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed during this inspection. EVIDENCE: N/A Greenhaven Resource Centre DS0000035520.V279590.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 The home has systems in place for the management and safe handling of medication. Residents who are able to manage their own medication are supported to do so safely. Senior staff regular monitor and review these systems to ensure the safety of residents. The home is making progress in addressing the issues raised. Greenhaven Resource Centre DS0000035520.V279590.R01.S.doc Version 5.1 Page 10 EVIDENCE: A senior member of the care team was administering morning medication at the time of this visit. The inspector was informed senior staff are responsible for the management and safe handling of medication, for which training is undertaken. The manager must ensure this training is appropriately accredited. There are appropriate procedures in place for the safe handling of medication that includes receiving, recording, administration and disposal. A system is in place for the hand over of responsibility for medication at the change of each shift. This enables any queries/errors to be identified and addressed promptly. The effectiveness of this system was demonstrated during the inspection. The home needs to ensure the recorder’s initials and codes entered on the medication administration record sheets (MARS) are easily identifiable. It is advisable for a sample of staff initials are kept with the medication records for ease of reference by the reader. The majority of residents’ medication is managed on their behalf by the home. Residents who retain their right to manage their own medication, subject to satisfactory risk assessments, are provided with suitable storage facilities in their bedrooms. The manager reported that some self-administering residents continue to prefer to store creams and lotions in their bedrooms where they can be easily seen. Further discussions and risk assessment needs to be carried out with these residents to ensure their storage arrangements are satisfactory and does not pose a risk to other residents. The inspector was informed the safe storage of creams and lotions has also been discussed with care staff. They have been delegated with the responsibility for applying these, for residents who are unable to do this themselves, and for ensuring entries are made on the individual’s medication administration record sheets (MARS). Senior staff monitor these tasks and have reported some omissions in recordings. The manager is addressing this matter through training and supervision. A pharmacist visits on a regular basis to carry out an audit on the safe handling of medication within the home and provides them with advice and guidance. The last visit was made on 24th January 2006. The pharmacist provides the home with a written report of each visit. Greenhaven Resource Centre DS0000035520.V279590.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 The staff team provide welcome to visitors. Residents’ wishes with regard to receiving visitors are respected and suitable arrangements are in place to enable visits to take place in private. The majority of residents enjoy the regular visits made to the home by a local choir. EVIDENCE: Visitors are welcomed into the home by a friendly staff team. The inspector observed a steady stream of visitors arriving at various times throughout the morning. Residents are able to receive visitors in private by using their own bedrooms or the visitors’ room. Staff stated most residents receive their visitors in one of the several communal lounges because they enjoy sharing the company of their visitors with other residents. The wishes of residents with regards to receiving visitors is known and respected by the staff. Greenhaven Resource Centre DS0000035520.V279590.R01.S.doc Version 5.1 Page 12 The home has developed a good relationship with visitors. They are kept informed of events via the home’s notice board, which is situated near the reception. The dates of residents’ meetings and the outcome of these meetings are posted here. Visitors provide support for their relatives who are unable to express their wishes in this kind of setting by contributing to the agenda on their behalf. The home is sensitive to residents needs in maintaining contact with family and friends. Where appropriate, they endeavour to enable contact to be maintained with relatives who are less frequent visitors to the home. Residents enjoy monthly visits from a local choir and enjoy a sing-a-long at the end of the planned programme. Greenhaven Resource Centre DS0000035520.V279590.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The home has suitable policies and procedures in order to protect residents from abuse. Staff are provided with training and guidance. Senior staff monitor records and staff performance on a regular basis. EVIDENCE: The home has policies and procedures to ensure residents are protected from abuse and staff attend relevant training. Regular records are kept of each resident’s well being and any concerns are reported directly to a senior member of staff. The home has an assessment and admission procedure that assists them in identifying possible areas of concern. Where there are concerns about an individual’s safety these are managed in line with the local authority’s Vulnerable Adult Protection Procedures. The home forwards details of adult protection issues to the Commission for Social Care Inspection (CSCI). All visitors and contractors are required to sign the visitors’/contractors book on arrival and departure. Greenhaven Resource Centre DS0000035520.V279590.R01.S.doc Version 5.1 Page 14 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): These standards were not fully assessed. However, issues raised at the previous inspection in respect of providing residents with a safe, wellmaintained environment have been satisfactorily addressed by the home. EVIDENCE: Since the last inspection a new carpet has been fitted in the hallway and toilets and bathrooms have been re-decorated. Residents, where applicable, have been provided with new modern-style commodes. Greenhaven Resource Centre DS0000035520.V279590.R01.S.doc Version 5.1 Page 15 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 & 29 The staff numbers and skill mix has not been addressed to reflect the changes in the home’s range of services. Appropriate recruitment procedures are followed for the appointment of staff and arrangements are in place to cover these duties whilst the process is completed. EVIDENCE: The home accommodates residents with a wide range of needs including personal care, dementia, rehabilitation and respite care. However, this is not reflected in the home’s compliment and deployment of staff. The manager has skills as a dementia care mapper and has provided some in-house training to staff in this area. The home has recently been allocated additional hours to provide training for staff in rehabilitation. Overnight staffing levels is maintained to a maximum of three members of staff. One provides personal care to 31 residents and another provides care to 15 residents requiring dementia care. One senior member of staff is on duty to provide both staff members with support and supervision. The manager states that discussions have been held with senior managers about the need to revise overnight staffing levels. However, proposals to meet the outcome of the home’s review of night staffing levels against current dependencies of residents have yet to be addressed. Greenhaven Resource Centre DS0000035520.V279590.R01.S.doc Version 5.1 Page 16 There is currently four staff on long-term sick leave and one on secondment within the department. The rotas show staff work additional hours and agency staff are employed to provide cover for absences and vacancies. The home has recruited to three vacant care staff posts and is awaiting satisfactory clearance from the Criminal Records Bureau (CRB) before appointment dates can be confirmed. The home also has domestic and catering vacancies. Arrangements are in place to ensure satisfactory standards are maintained for residents while the recruitment process is being carried out. Greenhaven Resource Centre DS0000035520.V279590.R01.S.doc Version 5.1 Page 17 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): 35 Residents’ financial interests are safeguarded by the home’s procedures and recording systems. EVIDENCE: The finances of some residents are managed on their behalf by relatives and Sandwell Appointeeship Unit manages the finances for others. The home has appropriate procedures in place for monitoring and recording the monies it manages on residents’ behalf. A senior member of staff is nominated with the day-to-day responsibility for residents’ monies and for any purchases made on their behalf. Two signatures are obtained to verify any withdrawals or deposits and receipts are kept. Staff follow the home’s system for transferring responsibility from one senior to another at each change of shift. Greenhaven Resource Centre DS0000035520.V279590.R01.S.doc Version 5.1 Page 18 The inspector was informed that the refrigerators sited on the units were not currently in use. However, the manager is aware that a system must be implemented for checking and recording temperatures when these are brought back into use. Approved closures have been fitted to fire doors that are kept open throughout regular periods of the day. The requirement made with regard to this has now been met. Greenhaven Resource Centre DS0000035520.V279590.R01.S.doc Version 5.1 Page 19 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 4 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 4 X X X X X X X X STAFFING Standard No Score 27 2 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X X Greenhaven Resource Centre DS0000035520.V279590.R01.S.doc Version 5.1 Page 20 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 OP6 Regulation 18 Requirement The registered person must provide staff that are qualified and/or trained and appropriately supervised to use techniques for rehabilitation including treatment and recovery programmes. Not assessed at this inspection. The registered manager must ensure that care plans are completed thoroughly with the information required. Not assessed at this inspection. The registered manager must ensure the regular monthly reviews are being completed and updated to reflect the changing needs and current objectives. Not assessed at this inspection. The manager must ensure that the training provider for the management and safe handling of medication is appropriately accredited. Confirmation of accreditation to be forwarded to CSCI. Timescale for action 30/11/05 2 OP7 15 30/11/05 3 OP7 15 31/10/05 4 OP9 13, 18 24/02/06 Greenhaven Resource Centre DS0000035520.V279590.R01.S.doc Version 5.1 Page 21 5 OP9 13 6 7 OP9 OP22 13 23 8 OP23 23 9 OP27 18 10 OP33 26 Ensure creams and lotions kept in bedrooms are stored in a discreet and safe manner. Partly met. The application of creams and lotions must be recorded at the time it is applied. The registered person must ensure due consideration is given to the provision of a loop system following assessment of the premises and the service users’ needs. Not assessed at this inspection. Ensure existing single rooms which fall below the 10sq.m standard, but are no lower than 9.3sq.m, will be permitted if other quality standards are present as follows; additional communal space made available for private use or en-suite facilities in single rooms. Not assessed at this inspection. The registered manager must ensure that the home always maintains appropriate staffing levels over a 24-hour period to meet the dependency levels of service users. Review the night staff levels against the current dependencies and submit proposals to National Care Standards Commission (now CSCI). Original date for compliance 10th February 2005 not met. The registered person must ensure there are regular monthly, unannounced visits to the home to determine that it is fulfilling its Statement of Purpose to meet the requirements of regulation 26. The registered person must ensure a copy of the report of DS0000035520.V279590.R01.S.doc 24/02/06 24/02/06 31/07/05 01/04/07 24/02/06 31/10/05 Greenhaven Resource Centre Version 5.1 Page 22 11 OP36 12 12 OP38 13 this visit is sent to the manager of the home and to CSCI. Not assessed at this inspection. The registered manager must ensure all staff receive supervision at least six times a year and this matter must be addressed by both parties, supervisor and supervisee. Not assessed at this inspection. The registered manager must ensure readings are taken and recorded of the temperatures of the refrigerators on the units are completed and maintained on a regular basis when brought back into use. 31/10/05 24/02/06 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 OP9 Good Practice Recommendations The manager is advised to keep sample initials of staff readily available with the medication records. Greenhaven Resource Centre DS0000035520.V279590.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Greenhaven Resource Centre DS0000035520.V279590.R01.S.doc Version 5.1 Page 24 - 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!