Inspection on 30/05/06 for Greenhaven Resource Centre

This inspection was carried out on 30th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 28/01/06

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 Mrs Cathy Moore Key Unannounced Inspection 30th May 2006 07:00 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.V296065.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. Greenhaven Resource Centre DS0000035520.V296065.R01.S.doc Version 5.2 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.V296065.R01.S.doc Version 5.2 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 28th January 2006 2. 3. Date of last inspection Brief Description of the Service: Greenhaven care home is owned and managed by Sandwell Local Authority. It provides residential services to a maximum of 46 older people. Five of the places are allocated for rehabilitation purposes, thirteen to older people who have a diagnosis of dementia. The home is situated in a residential area of Great Bridge West Bromwich. It is in easy reach of Great Bridge Town where bus links are available to neighbouring Dudley one side and West Bromwich the other. The home is located in a favourable position adjacent to Farley Park. A number of rooms have views over the park. The building is set out on two floors, with a lift providing access to all communal areas of the home. Access for wheelchair users is good. There are dining and lounge facilities on the ground floor with a number of smaller quiet lounges situated throughout the home. Living space includes two conservatories which offer a warm, bright place to sit or use for leisure purposes. The home has generous sized, attractive, safe garden areas which accommodate raised flower beds. Two flats cater for more independent living and represent part of the rehabilitation provision, these are not fully in used at the present time. The homes fees range from £0-£467 per week. Greenhaven Resource Centre DS0000035520.V296065.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector on one day between 07.00 and 19.40 hours. Pre inspection, a number of resident questionnaires were sent to the home for completion however, only 7 were returned. Information from these questionnaires was used as part of the inspection process and is also included in this inspection report. During the inspection four residents’ were ‘ case tracked’ this process involved speaking to them in person, looking closely at their needs, care, records and where possible bedrooms. Eight other residents’, two relatives and three staff members were also spoken to. The manager and senior carers were involved in the inspection day. The premises were randomly viewed to include bathrooms, toilets, four bedrooms, living space, the garden and laundry. The kitchen on this occasion was not inspected as Environmental Health have carried out an inspection in January 2006 and follow up visit in April 2006. Medication systems were assessed as were health and safety and maintenance records. Three staff files were examined to determine the homes’ compliance with recruitment processes and training. What the service does well: The home is owned by Sandwell Council therefore, having access to a wide range of advice and support networks. The location of the home is favourable as it is situated in a pleasant residential area adjacent to a park. All bedrooms within the home are single occupancy, enhancing privacy and dignity. The home offers generous communal/living areas with both smoking and non-smoking lounges. The home in general is bright, airy and well maintained. It has a warm, friendly, welcoming atmosphere. The home has a range of aids and adaptations to enhance resident safety, mobility and independence. Staff/ resident interactions observed were positive. Staff caring, giving choices to residents’ where possible. The home very much encourages residents’ to maintain contact with family and friends. It has open, flexible visiting times ‘ within reasonable’ daytime/evening hours. For residents’ accessing the rehabilitation service health professionals from the community visit and assess their progress or other wise at least twice a week. Positive comments were received from residents and relatives including the following; “ The staff are o.k, they help you, I get on with them all”. “ The meals are not too bad, I get a choice”. “ I’m quite pleased with the home and my bedroom”. “ I know my mother-in-law is happy here”. “ I am very happy and would like to live here permanently”. “ The care workers are very good and helpful”. Greenhaven Resource Centre DS0000035520.V296065.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home needs to improve on the present assessment of need/admission processes and to put paper work in place to prove that these processes are thorough enough. Health and personal care needs big improvement this to include care planning processes, attention to the daily personal care needs of the residents’ and medication safety. More robust processes need to be implemented to determine personal preferences and resident last wishes. More work is needed to find out the preferred daily routines of residents’ such as rising and retiring times, bath or shower and bathing times. Activity provision must be explored and improved to ensure that there are adequate leisure facilities and stimulation for all residents’. Menus and meals need improvement one resident commented;” Could be a better variety for people to ask for and get”. Signage and policies throughout the home must be produced in formats that aid the understanding of residents such as pictorial/large print versions. Processes and reporting concerning adult protection need further attention. Infection control processes are lacking. This area needs attention and improvement. Staffing needs attention to ensure that adequate staff in terms of numbers and competence are available at all times. One resident commented;” Staff are too busy sometimes to listen and forget what you want”. Staff have received little training in rehabilitation techniques yet the home admits residents straight from hospital with fractures and other physical complaints. Similarly the home caters for 13 residents’ who have dementia, it is vital that all staff receive accredited dementia training. Staff development, supervision and team building measures must be continued with to ensure that staff listen and respond to residents’ and all know and promote the homes’ good practice standards. Quality assurance processes require fine-tuning and ongoing monitoring to ensure that all staff are working as they should. A number of health and safety issues need attention. Greenhaven Resource Centre DS0000035520.V296065.R01.S.doc Version 5.2 Page 7 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.V296065.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Greenhaven Resource Centre DS0000035520.V296065.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4,6. Shortfalls examples of which being; the lack of resident contracts/ terms and conditions and assessment of need records are apparent this section ’choice of home’ has therefore only been assessed as being ‘ adequate’. EVIDENCE: There were no contract/terms and condition documents on the resident’ files viewed in the home thus preventing important information being confirmed such as; rules and any limitations of the home, the weekly charge and allocated room number. Staff asked seemed unfamiliar with this documentation. However, of the seven completed resident questionnaires received five confirmed that they had received a contract. They may have mistaken this document with the financial assessment form. Three of the seven completed resident questionnaires received confirmed that they felt, ‘they did not receive enough information about the home before they moved in to decide if it was the right place for them’. Two said, they ‘did’, others made comments about relatives visiting the home on their behalf. There is a general lack of assessment of need processes and documentation making it difficult for the home to evidence that they could meet any Greenhaven Resource Centre DS0000035520.V296065.R01.S.doc Version 5.2 Page 10 prospective residents’ needs. Further, although letters are in place for use to confirm to residents’ that the home can/ cannot meet their needs they are not being used. The home provides short term rehabilitation services. There is dedicated bedrooms and living space for these residents’. Dedicated, trained staff in this area are lacking at the present time. Greenhaven Resource Centre DS0000035520.V296065.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. There was no care plan in place for one new resident, important areas such as risk are lacking in care plans, recording of health care visits and personal care delivery is inconsistent, medication systems require improvement to prevent risk to residents’ and there was little evidence that the last wishes of residents’ are being explored. Because of these shortfalls this section ‘ Health and Personal Care’ is assessed as being ‘poor’. EVIDENCE: It is positive that care plans are available for residents’ who have been in residence for some time. However, it was disappointing to discover that there was a lack of records for one new resident who had been admitted for rehabilitation, there was no care plan for this person who had been transferred to the home from an acute hospital bed and had a history of various, possibly concerning ailments. Care plans lack some detail particularly aggression and risks identified from risk assessment processes. There was limited evidence available to demonstrate resident involvement in care plan production. Review processes in some instances are very limited or inconsistent. Greenhaven Resource Centre DS0000035520.V296065.R01.S.doc Version 5.2 Page 12 There are no processes in operation to assess tissue viability as a preventative measure or to determine a ‘baseline’ measurement on admission. Records concerning health care visits are not being accurately recorded this applies particularly to optician, chiropody, annual medical reviews and dental screening. Although there was no evidence that one new resident had been weighed on admission generally, residents are being weighed monthly and weights are being monitored. It is very pleasing that none of the residents’ case tracked had lost any significant weight. The home has in operation a tick chart method for recording weekly personal care delivery, whilst it was noted that one of these was being consistently completed all others were not. A question ‘Do you receive the care and support you need?’ is asked in the residents’ questionnaire sent for completion pre-inspection. Three residents’ responded as ‘Always’, three as ‘usually’ and one as ’sometimes’. Another question asked is ‘Do you receive the medical support you need?’ Three residents’ responded as ‘Always’, four ‘Usually’ and an additional comment of; ” Could be better” was received. The manager has identified that a significant number of falls/near misses has occurred concerning residents this year. To address this she is analysing falls and incidents monthly to identify trends and patterns in order to implement preventative measures. It is being considered at the present time for a ‘Telecare’ system to be installed for closer monitoring of residents’ at risk of falling. It is positive that the incidents of falls had decreased the month before. A number of shortfalls were identified concerning medications which is a high risk area and needs improvement. Not all resident medication records had a photo attached for identification for administration purposes. A significant number of medication records are handwritten yet there was no evidence to demonstrate that two staff are verifying that the transfer of information from medication bottles and packets to the records is correct. Known allergies are not being recorded on the medication record. One relative had told the staff that her Dad reacted badly to paracetomol. Although this was written in the residents’ daily notes it was not recorded on his medication record. There was no evidence of short term care plans for short course medication such as antibiotics to alert staff to side effects or for ‘ as needed’ medication to give guidance to staff on when the medication should be given. There was no evidence of risk assessments for residents’ who self administer their medication. Good practice was observed concerning medication. Controlled medications are counted at the start and end of each shift. A medication key handover process is in place. A short observation of medication administration showed the staff member waiting to sign the medication records until he was sure that the resident had taken the tablets. Residents who are being prescribed pain relief were asked if they required these. Drinks were available on the trolley. The home receives regular medication audits from their providing pharmacist. Only one staff initial gap was noted on the medication records observed which is very positive. Greenhaven Resource Centre DS0000035520.V296065.R01.S.doc Version 5.2 Page 13 Staff observed during the inspection showed respect to the residents’. Giving them choices and giving them support. Residents’ observed were dressed appropriately females with leg coverings on. The home has a pay phone for residents’ to make personal phone calls. There are ample lounges to enable residents’ to spend time alone in private if they want to. Further, all bedrooms are single occupancy enhancing privacy and dignity. There was little evidence to suggest that the preferred form of address of each resident and their preferences in terms of personal care being provided by opposite gender staff are being determined. There was no documentary evidence available to demonstrate that the last wishes of residents’ in terms of death and dying are being explored. Greenhaven Resource Centre DS0000035520.V296065.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Activity and meal provision requires further development and improvement. Visiting arrangements are open and flexible. Overall, this section ‘Daily Life and Social Activities’ has been assessed as being’ adequate’. EVIDENCE: There was little evidence to suggest that the preferred daily routine of each resident is being explored and detailed in their care plans examples being; bath, shower times, meal times, rising and retiring times. One resident who was fairly independent said;” I get myself up and go to bed when I want to”. Activities were in progress during the inspection. A number of residents’ on the dementia unit were writing and colouring. A reminiscence session was being carried out on the ground floor. The home has a snooker table in one of the conservatories, games and books were seen in the home. One resident said;” I go out when I want to. I catch the bus and go to the shops”. Another described his Saturday outings on the Ring and Ride service to a local cricket ground. The home would greatly benefit, due to it’s size and the complex needs of the residents’, from a dedicated activities provider. One staff member said; “ There is no real programme of activities- they chose daily what they want to do”. Greenhaven Resource Centre DS0000035520.V296065.R01.S.doc Version 5.2 Page 15 Examination of activity participation records showed that the names of residents’ participating is not being entered. A question asked in the resident questionnaire; ‘ Are there activities arranged by the home that you can take part in?’ was responded to as follows; No residents’ answered as ‘Always’, one of the seven residents’ answered ‘Usually’, four residents answered’ Sometimes’ and one ‘never’. One comment was received;” I am limited to doing most activities’. Another said; “ Not much activity going on but I always try to get involved with anything going on”. Visiting arrangements are open and flexible. Residents’ spoken to confirmed that they receive visitors regularly. One relative confirmed that he could visit the home when he wanted to. He further said; “ One member of the family visit everyday”. There was no information or contact numbers available for external advocacy services thus residents are not being informed that these services exist. The home ensures that residents’ are enabled to vote if they wish during local or general elections. All residents’ can bring into the home with them personal belongings of their choice. One resident had brought in his own television, other photos, pictures and ornaments. The home is very fortunate as it has access to the services of a dietician who is employed by the council. The dietician is ready to give support and advice on nutrition, the management of concern- ‘building people up’ and the production of the homes’ menus. The home has been awarded a ‘ Five for Life’ award. A set menu was available within the home offering a range of varied meals. The menu details four meals per day and snacks in between. The menu is at the present time produced in print only which may decrease the understanding of residents with dementia. The home has a main dining room on the ground floor which is very pleasant with nicely laid tables and laminate flooring. There is also a smaller dining room come lounge on the first floor and other places throughout the home where residents’ can eat in private if they wish. The main meal time was observed on the first floor- the dementia unit. There was a choice of fish or liver and onions. Two of the three residents’ did not eat their meal when asked why one said; “I can not chew the liver as I do not have any bottom teeth”. The other said, “ I am not keen on liver”. There was no choice for pudding - just rice. Feedback from completed resident questionnaires concerning meal provision was not too positive as follows; one of the seven respondents confirmed that they ‘Always’ liked the meals at the home. Four confirmed that they ‘ Usually’ did, one responded as ‘Sometimes’. One comment received was the “meals are mostly o.k.” Another stated; “ Could be a better variety for people to ask for and get”. Greenhaven Resource Centre DS0000035520.V296065.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Improvements and developments are needed in the areas of both complaints and protection. This section is assessed as being ‘adequate’. EVIDENCE: The manager was not able to provide documentary evidence of complaints procedures within the home. These are vital to inform residents and other stakeholders of the complaints procedures. With this in mind complaints documentation must be produced in a format appropriate to all residents’. Completed questionnaires did confirm however, that four of the seven respondents said that they ‘ Usually’ know who to speak to if they were not happy. Further comments received suggested that residents’ would speak to the staff in the office if they were unhappy. Three of the seven respondents confirmed that they ‘ Usually’ know how to make a complaint and that one that they ‘ Always’ know how to make a complaint. Three residents’ stated that if they had a complaint they would speak to office staff. One resident wrote on the response form; “ Are complaints always taken care of?” The home has never had a high number of complaints. No complaints about the home have been received by the Commission. It is positive that the majority of staff have received abuse awareness training provided by Sandwell Council. Whilst policies and procedures aimed to protect vulnerable adults were seen in the home there was no evidence to demonstrate that these have been read by staff. Greenhaven Resource Centre DS0000035520.V296065.R01.S.doc Version 5.2 Page 17 It was identified during the inspection that two residents’ on the first floor have fairly regular aggressive moments. One resident had been involved in aggressive behaviour 4 times in the month of May 2006 yet this had not been reported to their social worker or other. Greenhaven Resource Centre DS0000035520.V296065.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,22,23,24,26. Generally, the homes’ environment is safe, well maintained, warm, comfortable and spacious. The major shortfalls identified in this section concern infection control. This section is assessed as being ‘ adequate’. EVIDENCE: Greenhaven is a large, detached home that was purpose built and opened in the late 1970’s. Externally the home is sound. Window frames have all been replaced with a UPVC material. The home needs attention in a few areas examples being; living room and dining room re-decoration and the re-painting of some woodwork in corridors. One major issue highlighted is the corridor carpets where joins have frayed, potentially placing residents’ at risk of tripping. This issue has been raised by the home with the maintenance department a number of times but as yet it has not been given the required remedial attention. The home has attractive, spacious gardens which at the present time need some attention as there is weed and moss growth. The garden furniture/benches are in need of re-varnishing. The manager said that this was in hand at the present time. Greenhaven Resource Centre DS0000035520.V296065.R01.S.doc Version 5.2 Page 19 One of the residents’ said; I like to do the garden, planting and looking after the plants”. He has been given responsibility for one or two raised flowerbeds in the garden. The homes’ communal areas are attractive. There are a number of lounges, two of which have spacious conservatories off. Communal areas are homely and domestic in style. There are birds in a cage in one conservatory one resident said; “ It is my job to see to the birds”. Corridors and layout of the first floor could be improved upon to allow more freedom and interest. At the present time only straight corridors are provided which do not ensure orientation or interesting wandering. The home has a range of aids and adaptations to aid independence and safety examples being; a passenger lift assisted bathrooms and toilets, ramped access and a call system point in each room. Signage and symbols throughout the home could be better to aid orientation. An outstanding requirement remains concerning the lack of a loop system within the home. A number of bedrooms are below the recommended 10 Sq Metres. New occupants being offered these rooms must be made aware of the deficit. A number of bedrooms were viewed these were seen to be well maintained and comfortable. It is pleasing that some work has been carried out to audit furniture/fittings provided in each bedroom. On observation however, it was noted that the list does not cover all items detailed within standard 24.2 there is no provision on the document for the individual resident to sign to state their satisfaction with their bedroom and contents or otherwise. It was noted that not all bedroom doors on the rehabilitation unit are fitted with a lock preventing residents’ from being able to lock their doors. A number of concerns were noted concerning infection control. The sluice room was full of commode pots- it is unclear if these are marked with room numbers, if they are cleaned individually and how effective the cleaning of these are. Laundry cleaning schedules are not being signed after the completion of tasks as they should be; the same applies to evening cleaning schedules. Dirty washing was seen direct on the laundry floor. There were no gloves or aprons available in the laundry. Infection control procedures displayed on the wall in the laundry did not contain sufficient detail and have not been reviewed since 2001. The bucket in the sluice area was marked ‘toilets’. The staff member indicated that there was a shortage of buckets. The mop was seen left soaking in dirty water. Throughout the home in toilets and bathrooms there was a distinct lack of ‘ hand wash’ signs. Waste bins are lacking in some toilets. Used paper towel had been left on the hand wash basin in one toilet room. These concerns could promote infection transmission instead of promoting infection prevention. It is positive that staff have received infection control training- this training must however be put into practice in the workplace. It was noted that carpets in corridors and lounges were stained, badly in places and would benefit from a regular more frequent deep clean. Greenhaven Resource Centre DS0000035520.V296065.R01.S.doc Version 5.2 Page 20 Four of the completed resident questionnaires received confirmed that the home is ‘Always’ fresh and clean, two answered ‘Usually’ to this question. One resident commented; “ It could not be any cleaner”. Another said; “ The staff try their best to keep it so”. Greenhaven Resource Centre DS0000035520.V296065.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. The home needs to be staffed with a competent, trained workforce in all areas. Staff recruitment in some areas needs tighter procedures to prevent residents’ being placed at risk. This section is assessed as being ‘poor’. EVIDENCE: Staffing levels are provided as follows; Am -Three carers upstairs and four down stairs plus a senior or team leader. PM – The same levels are maintained as AM. Night – three wakeful staff. Concerns are ongoing whether or not these levels at night are adequate and are being monitored. Day time the home provides domestic, laundry a cook and kitchen staff. Unfortunately the handyperson has been off for some time. The manager has been working hard to provide direction and leadership to the staff and has undertaken some team building. This must be continued. A suggestion was made that staff do not always follow instruction from external health professionals. ‘ Do the staff listen and act on what you say?’ was asked in the residents’ questionnaire. One of the seven respondents said ‘ Always’ to this question, two ‘Usually’ and one ‘Sometimes’. One commented; “ Staff too busy sometimes to listen and forget what you want”. Positive comments were received about the staff in general and included; “ Care workers are very good and helpful”. “ The staff are brilliant”. “ Everyone is helpful and no-one grumbles”. “The staff are great- could do with a few more though”. Greenhaven Resource Centre DS0000035520.V296065.R01.S.doc Version 5.2 Page 22 The manager provided evidence to suggest that over 60 of the care staff team have achieved N.V.Q level 2 or above in care. Unfortunately when an audit of staff names against N.V.Q certificates was carried out only one of the four certificates was available. Staff files were seen to be fairly well managed in individual folders, locked away to ensure confidentiality. Generally, required documents were available for inspection with the exception of the two newest. For one there was no evidence of an Enhanced Disclosure or Protection of Vulnerable Adult list check. There was no reference received from the direct last employer for one staff member and only one official source of identity. Training is ongoing however, it was difficult to ascertain the precise receipt of training as the training matrix is not up- to –date. It was pleasing to see that new staff had been given induction materials. Greenhaven Resource Centre DS0000035520.V296065.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38. Developments and improvements are needed concerning quality assurance and monitoring, staff supervision and health and safety. This section is assessed as being ‘adequate’. EVIDENCE: The manager was officially appointed during the winter months. She is in the process at the present time of applying to the Commission for registration. The manager has achieved N.V.Q level 4 in management and is working towards the same level in care. The manager has no responsibility for any other establishment. It is extremely positive that the home and/ or organisation have been accredited with ISO 9001, ISO 14001, Investors In People and Chartermark. It was identified however, that some monitoring of the home is not being carried out consistently an example being; the cleaning/ laundry cleaning schedules. The home does not at the present time have a current business Greenhaven Resource Centre DS0000035520.V296065.R01.S.doc Version 5.2 Page 24 plan. The manager and seniors are aware of some non-conformances and have arranged a meeting with the appointed senior in the organisation to ensure corrective actions are taken. Although it is positive that the home uses satisfaction questionnaires for residents’ and relatives these to date have not been extended to stakeholders in the community examples being; external health workers. A number of residents’ have their money held in safekeeping by the home. Four of these were randomly audited with balances checked against money. All were found to be correct. An issue was raised in that a withdrawal of £50 had been made from the money held for one resident yet, no receipts could be found to verify expenditure. Inventories are in place to record residents personal belongings brought into the home. It was noted however, that large items an example being televisions are not being recorded as they should. It is positive that staff one to one supervisions are being carried out they are not however, to date being carried out to the required frequency of six per year per staff member. A number of issues were raised in respect of health and safety. One in particular being staff footwear. A significant number of staff were seen wearing ‘ flip flop’ type shoes which could place them and residents at risk when moving and handling. The manager was unsure when the last portable electrical appliance test was carried out. Further electrical equipment brought into the home by residents’ is not always being checked before use potentially being a fire risk. Greenhaven Resource Centre DS0000035520.V296065.R01.S.doc Version 5.2 Page 25 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 1 2 2 x 2 HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 2 11 1 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 2 3 x 2 2 2 x 1 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 2 2 x 2 Greenhaven Resource Centre DS0000035520.V296065.R01.S.doc Version 5.2 Page 26 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 OP2 Regulation 5(1)(b) (c) Requirement The registered person and manager must ensure that all residents’ are issued with a contract/ terms and conditions document on admission as per standard 2.This must be done retrospectively for residents’ already accommodated. The registered person and manager must ensure that an assessment of need is carried out for each prospective resident. Documentary evidence must be available to demonstrate that this is being done. The registered person and manager must ensure that each prospective resident is issued with a written assurance that their needs can be met by the home and how they will be met. Timescale for action 15/06/06 2 OP3 14(1)(a) 10/06/06 3 OP4 14(1)(d) 10/06/06 4 OP4 14(1) 18(1)(a) The registered person must 15/07/06 provide staff that are qualified and/or trained and appropriately supervised to use techniques for rehabilitation including treatment DS0000035520.V296065.R01.S.doc Version 5.2 Page 27 Greenhaven Resource Centre and recovery programmes. Timescale of 30/11/05 not fully met. 5 OP7 15(1) The registered manager must ensure that care plans are completed thoroughly with the information required. Timescale of 30/11/06 not fully met. Care plans must include all needs, ( health, personal and medical) risks and goals, violence, aggression, abuse etc. 6 OP7 15(2)(b) The registered manager must ensure the regular monthly reviews are being completed and updated to reflect the changing needs and current objectives. Timescale of 31/10/06 not fully met. The registered person and manager must ensure that a care plan is produced and is in operation for each resident before admission or at least within 2 days of admission. The registered persons and manager must ensure that there is provision on the care plans for residents’/ or chosen others to sign and date to demonstrate that they are aware of their care plan and have been involved in its production. The registered person and manager must ensure that all health care visits are recorded examples being; dentist, chiropodist, optician annual healthcare reviews from doctors. The registered person and DS0000035520.V296065.R01.S.doc 10/06/06 01/07/06 7 OP7 15(1) 05/06/06 8 OP7 15(1) 15(2)(c) 01/07/06 9 OP8 12(1a) 12(1b) 17(2) 10/06/06 10 OP8 12(1)(a) 01/07/06 Page 28 Greenhaven Resource Centre Version 5.2 12(1)(b) 13(4) 11 OP8 13(4) manager must ensure that a tissue viability assessment tool is obtained and put into operation. The registered person must 10/06/06 ensure that all residents are weighed on admission and that this baseline weight is recorded. The registered person and manager must ensure that the personal care delivery chart SS/534.. is completed diligently for each resident. The registered person and manager must seek confirmation from the CSCI pharmacy inspector to determine whether or not the current medication training is adequate. The application of creams and lotions must be recorded at the time it is applied. Timescale of 24/02/06 not fully met. The registered person and manager must ensure that any allergies concerning medication are clearly detailed on the residents’ medication sheet, for example; paracetomol. The registered person and manager must ensure that where medication records are handwritten 2 staff sign to confirm that the information being transferred from bottles and packets is correct. The registered person and manager must ensure that a medication care plan is in place for ‘ As needed’ medications and short course medication an example being antibiotics. These must give guidance and instruction to staff and highlight DS0000035520.V296065.R01.S.doc 12 OP8 12(1)(a) 17(2) 10/06/06 13 OP9 13(2) 01/07/06 14 OP9 13(2) 10/06/06 15 OP9 13(2) 05/06/06 16 OP9 13(2) 05/06/06 17 OP9 13(2) 10/06/06 Greenhaven Resource Centre Version 5.2 Page 29 18 OP9 13(2) common side effects to be alerted to. The registered person and manager must ensure that Latin abbreviations are not used on medication records. ( PRN) 10/06/06 19 OP9 13(2) 20 OP9 13(2) The registered person and 01/08/06 manager must ensure that each permanent resident has a specific medication review at least on an annual basis from their doctor and that this is highlighted and recorded on their professional visit chart. The registered person and 05/06/06 manager must ensure that a documented risk assessment is carried out for any resident who self medicates. ( this applies to all routes of administration oral, topical, inhalant etc). The registered person and manager must ensure that a photo of each resident is attached to their medication record. Provision must be available at all times to ensure that this can be done for residents’ accessing respite and rehabilitation services. The registered person and manager must ensure that an up-to-date staff initial list ( Concerning those staff who administer medication) is available at all times. The registered person and manager must take and record daily temperatures of the treatment rooms where medication is stored to ensure the temperature does not go above 25oc. The registered person and manager must ensure that all medications coming into the DS0000035520.V296065.R01.S.doc 21 OP9 13(2) 10/06/06 22 OP9 13(2) 05/06/06 23 OP9 13(2) 10/06/06 24 OP9 13(2) 05/06/06 Greenhaven Resource Centre Version 5.2 Page 30 25 OP9 13(2) home are counted and recorded. The registered person and manager must ensure that where a choice of dosage is prescribed examples being; ‘ one tablet or two-One or two spoonfuls’ that the amount actually administered is recorded. The registered person and manager must ensure that where dosages or administration times have been changed that this has been ratified by the residents’ doctor and an account why is made on the residents’ medication care plan. The registered person and manager must determine from each resident; Their preferred form of address. Their choice or otherwise in care provided by opposite gender staff. The outcome of this consultation must be recorded and acted on. The registered person and manager must ensure that the last wishes of each resident ( where possible ) are explored and recorded ( on admission where possible and retrospectively for those already accommodated) in terms of funeral arrangements, burial, cremation etc. The registered person and manager must determine and record the daily routine preferences of each resident and ensure that these are honoured examples being; rising/ retiring times, bath or shower, bath times etc. The registered person and manager must ensure that; DS0000035520.V296065.R01.S.doc 05/06/06 26 OP9 13(2) 05/06/06 27 OP10 12(3) 12(4)(a) 10/06/06 28 OP11 12(3) 12(4a) 12(4b) 01/07/06 30 OP12 12(3) 01/07/06 31 OP12 16(2)(m) (n) 26/06/06 Greenhaven Resource Centre Version 5.2 Page 31 Activity programmes are in operation at all times. That activities are provided to meet individual residents’ preferences and capabilities. That one to one activity provision is offered to those residents’ who are frail or have complex needs. That the activity participation of each resident is recorded daily. 32 OP14 12(3) The registered person and 15/06/06 manager must ensure that contacts are displayed concerning external advocacy services to cater for all needs. The registered person and 15/06/06 manager must ensure that meals provided are to the liking and meet the needs of the residents. The registered person and manager must ensure that menus are produced in a format appropriate to the needs of the residents ( large print and pictorial) and are prominently displayed at all times. The registered person and manager must ensure that; Complaints procedures are available within the home. Complaints procedures are produced in formats appropriate to the needs of the residents’. The registered person and manager must consult with Sandwells’ Adult protection Coordinator about the two residents who display aggressive behaviour towards each other and to determine when issues of DS0000035520.V296065.R01.S.doc 33 OP15 16(2)(i) Sch 4(13) 34 OP15 12(2) 01/07/06 35 OP16 22(1) 22(2) 01/07/06 36 OP18 13(6) 07/06/06 Greenhaven Resource Centre Version 5.2 Page 32 37 OP18 13(6) 38 OP18 13(6) this nature need to be reported via the multi-agency procedures. The registered person and manager must ensure that the homes ‘Whistle Blowing’ policy is up-to-date and is available to staff at all times. The registered person and manager must be able to evidence at all times that staff have read the in-house abuse procedures and Sandwell Multiagency Adult Protection procedures. The registered person and manager must produce a programme of decoration and refurbishment complete with timescales this to include the following; The carpet joins where frayed in corridors. The redecoration of lounges and damaged wood work/doorways in corridors. The tidying/ weeding of the gardens. Re-varnishing of garden benches. The regular deep cleaning of corridor and lounge carpets. A copy of which must be forwarded to the CSCI. 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. Timescale of 31/07/05 not fully met. 01/07/06 01/07/06 39 OP19 23(2)(b) (d) 01/07/06 40 OP22 23(n) 01/08/06 Greenhaven Resource Centre DS0000035520.V296065.R01.S.doc Version 5.2 Page 33 41 OP22 23(n) The registered person and manager must ensure that colour schemes and signage throughout the home are improved to aid orientation. The registered person and manager must ensure that; The audit (as per full list standard 24.2 should be detailed) of each bedroom is undertaken with the occupant of the room. They must be asked to sign and date that they are satisfied or not with what is provided. Where they want the full range listed these must be provided unless risk factors have been highlighted. Existing single rooms which fall below the 10sq.m standard are clearly detailed on the documents mentioned above so as to inform new residents of this shortfall. This process must be repeated each time a room is re-occupied. The registered person and manager must ensure that suitable locks ( approved by West Midlands Fire Service) are available on each bedroom door -this to include the rehabilitation unit. The registered person and manager must ensure that ‘ hand wash’ signs are on display in all bathrooms, toilets and other high risk areas. 01/08/06 42 OP23 23 01/07/06 43 OP24 12(a) 23(4) 01/07/06 44 OP26 13(3) 01/07/06 45 OP26 13(3) The registered person and 05/06/06 manager must ensure that dirty washing is not put directly on the laundry floor. DS0000035520.V296065.R01.S.doc Version 5.2 Page 34 Greenhaven Resource Centre 46 OP26 13(3) The registered person and manager must ensure that a second sink strictly for ‘hand washing’ purposes is provided in the laundry. 01/08/06 47 OP26 13(3) 48 OP26 13(3) 49 OP26 13(3) The registered person and 07/06/06 manager must ensure that disposable gloves and aprons are available within the laundry at all times. The registered person and 07/06/06 manager must ensure that laundry cleaning schedules are consistently completed after tasks have been attended to. The registered person and 12/06/06 manager must ensure that; Sufficient mops and buckets are available within the home. Mops and buckets should be clearly marked for the area they are to be used in and then only used/stored in those areas. 50 OP26 13(3) 51 OP26 13(3) 52 OP26 13(30 The registered person and manager must ensure that waste paper bins are available in all toilets to dispose of used paper towels. The registered person and manager must ensure that evening cleaning schedules are consistently completed after each task has been completed. The registered person and manager must ensure that; Bar soap is not made available in communal toilets and bathrooms. Talc is not used communally. It must be returned to the individual residents’ room after 05/06/06 07/06/06 07/06/06 Greenhaven Resource Centre DS0000035520.V296065.R01.S.doc Version 5.2 Page 35 use. 53 OP26 13(3) The registered person and 01/10/06 manager must provide at least one mechanical sluice machine in the home. The registered manager must 01/07/06 ensure that the home always maintains appropriate staffing levels over a 24-hour period to meet the dependency levels of service users. A review the night staff levels against the current dependencies must be carried out monthly. The registered person and manager must ensure that recruitment processes continue to ensure dedicated, sufficient numbers of staff are provided at all times on the different units dementia, rehabilitation. The registered person and manager must ensure that incidents involving staff as discussed during the inspection are reported to the CSCI in accordance with Regulation 37. The registered person and manager must ensure that staff development/ training/guidance/ team building and monitoring continues to ensure that staff; Listen to residents’ and act on what they say/request. Ensure that instructions from health care professionals are followed through at all times. 58 OP28 17(2) The registered person and manager must ensure that a copy of each staff members N.V.Q certificate is available on their personal/ training file. The registered person and DS0000035520.V296065.R01.S.doc 54 OP27 18(1)(a) 55 OP27 18(1)(a) 05/06/06 56 OP27 37(1)(g) 05/06/06 57 OP27 12(5)(b) 14(1) 01/08/06 20/07/06 59 OP29 19(2) 05/06/06 Page 36 Greenhaven Resource Centre Version 5.2 manager must ensure that recruitment processes are fully adhered to and that the following staff documents are available; Two written references- one from the last previous employer. Application form. Authentic evidence of CRB/POVA list checks. A clear photo of each staff member. Two official sources of identity. 60 OP30 18(1)(a) 13(4) The registered person and 01/10/06 manager must ensure that all staff ( who require this) receive mandatory training examples being; moving and handling, first aid, health and safety, infection control and food hygiene. Also accredited dementia training. 61 OP30 17(2) The registered person and 01/08/06 manager must produce an up-todate training matrix a copy of which must be forwarded to the CSCI. The registered person and 01/08/06 manager must ensure that quality assurance/procedures and policies are available to all staff in paper form. The registered person and manager must ensure that adequate monitoring of all areas of service delivery is undertaken and can be evidenced. 01/07/06 62 OP33 24 63 OP33 24 Greenhaven Resource Centre DS0000035520.V296065.R01.S.doc Version 5.2 Page 37 64 OP33 24 65 OP33 24 The registered person and manager must ensure that processes are in place to gain the views of the home from community stakeholders / health care professionals etc. The registered person and manager must ensure that a current business plan is produced for Greenhaven. A copy of which must be forwarded to the CSCI. The registered person and manager must undertake an investigation to find out what happened to the £50 deducted from (WW) personal allowance on 24.1.06 and ascertain if receipts were given for any expenditure. The outcome of this must be forwarded to the CSCI. The registered person and manager must ensure that all furniture, televisions etc brought into the home by residents’ are written on their inventory. 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. Timescale of 31/10/05 not fully met. 01/08/06 01/08/06 66 OP35 13(6) 17(2) 15/07/06 67 OP35 17(2) Sch 4(10) 05/06/06 68 OP36 18(2) 01/08/06 69 OP38 23(4) The registered person must; Determine when the last PAT testing was carried out and take appropriate action if over 12 months ago. Put in place actions to have electrical equipment brought into the home by residents’ 01/07/06 Greenhaven Resource Centre DS0000035520.V296065.R01.S.doc Version 5.2 Page 38 (examples being televisions brought in by rehabilitation residents’) between the annual checks to be PAT tested. To inform the CSCI of the outcomes of the above. 70 OP38 23(4) The registered person must ask an appropriate, suitably qualified person to confirm in writing that items listed in ‘prefix A’ of the five year fixed electrical wiring test dated 2003 have been addressed. A copy of this written confirmation must be forwarded to the CSCI. The registered person and manager must ensure that doors are not ‘wedged open’. Doors that need to be kept open must be fitted with an approved devise. For advice contact West Midlands Fire Service. The registered person and manager must ensure that ALL staff receive fire training and two fire drill sessions in any 12 month period. The registered person and manager must ensure that; A risk assessment is carried out concerning the rotary iron in the laundry. Written confirmation must be available to demonstrate that all staff using the rotary iron have been fully trained. Access to the sluice and laundry is limited to approved persons to prevent accidents. The registered person and manager must ensure that fire risk assessments are in place concerning the two smoke rooms DS0000035520.V296065.R01.S.doc 01/07/06 71 OP38 23(4) 15/06/06 72 OP38 23(4) 01/08/06 73 OP38 13(4) 23(c) 20/06/06 74 OP38 23(4) 10/06/06 Greenhaven Resource Centre Version 5.2 Page 39 75 OP38 13(4) 76 OP38 13(4) particularly the one on the first floor. The registered person and manager must ensure that all hot water temperatures are tested and recorded from each outlet monthly. The registered person and manager must ensure that the monthly accident analysis continues to look at ways to decrease falls/injuries. The registered person and manager must ensure that all staff wear suitable, safe footwear. The registered person and manager must ensure that food hygiene certificates relating to the cooks are forwarded to the CSCI office. 10/06/06 01/07/06 77 OP38 13(4) 13(5) 13(3 16(2j 18(1a)c) 07/06/06 78 OP38 15/06/06 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 2 3 Refer to Standard OP7 OP12 OP20 Good Practice Recommendations The registered person and manager should ensure that care plans are produced in formats appropriate to the individual residents i.e. large print / pictorial. The registered person and manager should ensure that a dedicated activities co-ordinator is appointed. The registered person and manager should consider extending communal space on the first floor and enhancing its layout. Greenhaven Resource Centre DS0000035520.V296065.R01.S.doc Version 5.2 Page 40 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.V296065.R01.S.doc Version 5.2 Page 41 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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