Inspection on 22/06/07 for Greenheys Lodge

This inspection was carried out on 22nd June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Greenheys Lodge 26/01/06

Greenheys Lodge 11/11/05

Greenheys Lodge 05/01/05

Greenheys Lodge 20/07/04

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

CARE HOMES FOR OLDER PEOPLE Greenheys Lodge Sefton Park Road Toxteth Liverpool Merseyside L8 3SL Lead Inspector Adele Berriman Unannounced Inspection 22nd June 2007 10:00 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 DS0000059312.V342694.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. DS0000059312.V342694.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greenheys Lodge Address Sefton Park Road Toxteth Liverpool Merseyside L8 3SL 0151 291 7822 0151 291 7821 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) European Wellcare Homes Ltd Ms Evonne Robinson Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places DS0000059312.V342694.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The Service may accommodate 2 named service users under pensionable age, within the overall number of 33 beds. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 26th January 2006 Date of last inspection Brief Description of the Service: Greenheys Lodge is a purpose built home in the Toxteth area of Liverpool. The home is near the city centre and close to local shops, bus, rail and road links. The home can accommodate up to 33 residents and does not provide nursing care. It is located within a ‘care village’ owned by a large private organisation, European Wellcare homes LTD. The care village consists of other similar homes that are all connected via a corridor. All homes share the same kitchen and laundry facilities, which are located within Greenheys Lodge. The home is on two floors and has a selection of dining and lounge areas. Two lounges are designated smoking areas. Gardens are located around the care village and can be used by residents and visitors. A large car park is also available. The cost of the service is between £328.75 and £447.56 per week. DS0000059312.V342694.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A site visit was made to the service on Friday 22 June 2007. The visit took place over an eight hour period. During the visit several residents, a visitor, the deputy manager, the home manager and the handy person spoke to the inspector. A selection of resident’s files were assessed along with a selection of staff files, records, policies and procedures in the home. A tour of some areas of the home also took place. The home was comfortable and clean and provided a pleasant atmosphere for people to live. Some information contained is this report was supplied by the manager of the home on a completed an Annual Quality Assurance Assessment for the service. The home had received one complaint about the service since the previous inspection which was being managed by a representative of European Wellcare Ltd. The complaint was a result of a resident dropping a teapot in their lap. No complaints had been received by the Commission for Social Care inspection about the home. Sixteen service user surveys forms were completed and returned to the Commission. Several of these forms had been completed by residents and other had been completed with the support of family, friends and the manager of the home. The majority of the residents stated that they were happy living at the home. All sixteen people who responded to the survey stated that they knew how to make a complaint. Positive comments received from relatives of residents living at the home included “settled in and very happy with the home” and “has been really happy and settled since she’s been here. The staff are always friendly and helpful. Said she wouldn’t be anywhere else.” One GP who completed and returned a health professionals survey stated that the service “responds well to service users need.” What the service does well: The home provides a fully accessible clean environment in which to live. Assessments, care planning and risk assessments are of a good standard. DS0000059312.V342694.R01.S.doc Version 5.2 Page 6 People are given a choice of menu at every meal. Residents feel supported by the staff team. Residents are comfortable in using the homes complaints procedure. 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. DS0000059312.V342694.R01.S.doc Version 5.2 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 DS0000059312.V342694.R01.S.doc Version 5.2 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): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs are assessed before they move into the home to ensure that facilities and services are available to meet the individual needs. EVIDENCE: A needs assessment is completed for each person prior to them moving into the home. Copies of these assessments were present on resident’s personal files and demonstrated that people’s care and support needs had been assessed prior to moving into Greenheys Lodge. This information then forms the basis for the resident’s care plan. The manager stated in the homes Annual Quality Assurance Assessment that training had been implemented for staff based on pre-admission documents. DS0000059312.V342694.R01.S.doc Version 5.2 Page 9 Thirteen people stated that they had received enough information about the home before they moved in. Two people said they didn’t receive enough information. Greenheys Lodge does not provide intermediate care facilities. DS0000059312.V342694.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning in the home is person centred and details how care and support is to be delivered. Resident’s healthcare needs are well managed and promote quality of life. EVIDENCE: At the time of this inspection a new person centred care planning approach was being implemented. Six newly devised individual care plans were assessed and the majority of these contained detailed, up to date information about the individual. Personal pen pictures were in use and gave important information about the person’s past history and family. The care plans considered all aspects of the individuals needs and wishes relating to communication, elimination, eating and drinking, washing and dressing, work and play, expressing sexuality, sleeping and religion. A section on the care plan titled ‘what you need to know to support me’, written in the first person, gave information about what assistance was required by the individual, for DS0000059312.V342694.R01.S.doc Version 5.2 Page 11 example, how I like my hair and how often I liked to be checked throughout the night. A further section titled ‘how you can help me stay healthy and safe’ gave information about the safety needs of individuals, for example, how people mobilise around the building and how they have a bath etc. The majority of the information contained in this section of the care plans was detailed. However, one care plan assessed stated that X preferred a shower and another stated that staff must assist X to have a bath or shower at least twice a week. These entries was discussed with the manager who agreed that further detail was required to be written regarding what actual support the individual’s needed to carry out these tasks. Individual risk assessments were available in residents care plans for continence, nutrition, moving and handling, falls and pressure area’s. Daily records were maintained by staff to record what care and support hade been offered/delivered to individual residents. The majority of these records were informative. However, records written by one staff member were not legible. Several other records contained inappropriate recordings, for example, the abbreviation PC was used on several occasions and one record read “X spent a lot of the night screaming for nothing.” It is essential that all records written in the home are legible and are written in a manner that respects each person. Records demonstrated that regular visits were made to the home by healthcare professionals. A district nurses and a GP were seen to visit the home during the visit. The newly revised care plan format gave opportunity for staff to record visits from healthcare professionals including visits relating to audiology, eye care, dental care, foot care and visits from the resident’s GP, social worker and district nurse. Fifteen people stated that they always receive the medical support they need. Medicines were stored in a locked secure room. The temperature in the room was very warm and it is strongly advised that a thermometer is placed in the room and checked on a regular basis to ensure that medicines are being stored at the right temperature. An audit of controlled drugs was carried out and all were correct. Medication Administration Records were assessed and all were recorded appropriately. Following the last inspection improvements had been made to how staff at the home record variable doses of medication. Entries into the controlled drugs register were double signed. All residents spoken to during the visit said that staff were polite. Staff were observed addressing residents in a dignified and respectful manner. DS0000059312.V342694.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Activities in the home met the needs of some people. Dietary needs of residents care catered for, however, residents should have the opportunity to have their meal at a temperature of their choice. EVIDENCE: An activities co-ordinator had recently been employed at the home. A programme of activities was planned for four evening a week between 6pm and 9pm. A record of what activities residents had taken part was contained in the residents care plan. Eight people stated that there are always activities arranged by the home that they could take part in, five people stated that there usually were and two people stated that there sometimes were activities arranged that they could take part in. Residents stated that they had the choice if they wanted to get involved in arranged activities, one resident wrote “I don’t usually take part, my own choice.” Other comments included “can take part in most activities”, “not interested in them”, registered blind so activities are limited” and “joins in DS0000059312.V342694.R01.S.doc Version 5.2 Page 13 with most activities, enjoys them.” The activity planned for the evening of the visit was card games. The previous evenings activity had been darts. During the visit two residents commented about the lack of stimulating activities available at the home. One resident said that “there should be more entertainment” and another person said “the days are long.” A party is held at the end of each month to celebrate the birthdays of residents that month. Residents have access to a ‘snoozelam room’ (a sensory room) and a hydrotherapy pool that are located within the home. However, staff stated that the pool was little used and had been out of order for some time. An open visiting policy was in operation at the home and residents confirmed that their visitors were welcome at any times. Several family members and friends were observed entering and leaving the building throughout the day. People’s wishes relating to their legal and administrative issues were recorded in their care plan. Residents confirmed that they were supported in opening their own mail and that they had a choice in whether they engaged in activities around the home or not. The food served within the home is cooked and prepared in kitchen that also facilities the other homes in the complex. The menu rotates on a monthly basis and demonstrate that residents have a choice of a cooked breakfast, lunch and evening meal each day. Alternative menus were offered for each meal and residents were asked on a daily basis what their choice was. The manager stated that when the menus were reviewed, several residents from Greenheys Lodge and residents from the other homes within the complex were consulted. During the visit the inspector observed a meal of fish, chip, peas and bread and butter being served which was followed by sponge and custard. The meal looked appetising. Five people stated that they always liked the meals at the home, six people stated that they usually did, three stated that they sometimes did and one person said that they never liked the meals at the home. Two people wrote that the food was “always cold” and another person wrote “could be better.” One resident wrote “meals very good.” Care Plans contained individual ‘catering information forms’ that gave the opportunity to record people specific dietary requirements relating to their health, religion, likes and dislikes. One resident wrote “meals very good.” However, three people commented about the temperature of the food they received, one person wrote “could be hotter”, and two people wrote “always cold.” It is essential that food is served at an appropriate temperature. DS0000059312.V342694.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are comfortable about using the homes complaints procedure. EVIDENCE: A clear and easy to use complaints procedure was available at the home. The home had received one complaint about the service since the previous inspection which was being managed by a representative of European Wellcare Homes Ltd. No complaints had been received by the Commission for Social Care Inspection about the home. All residents who responded to the service user questionnaires and all residents who were spoken to during the visits stated that they knew how to make a complaint about the service. Copies of Liverpool City Council and Sefton Council Safeguarding Adults procedures were available at the home along with an in-house policy and procedure. The in-house policy contained detailed information about the company’s procedure on responding to adult protection concerns with clear guidance on who is responsible for completing the company’s alert form. Although the policy refers to local authority’s adult protection procedures, it does not identify the local authority procedures that would be specific to Greenheys Lodge. DS0000059312.V342694.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The layout, facilities and location of the home are suitable for the residents who live there. The home is safe and clean, however, some carpets and chairs would benefit from refurbishment. EVIDENCE: The home is accessible to all. The front door has level access and a passenger lift enables people to access both floors of the building. Residents are able to access a level garden/patio area at rear of the building. Since the last inspection took place staff had decorated one of the lounges on the ground floor. A decorator had recently been employed by the company and was scheduled to spend a period of four weeks in every six monthly period decorating Greenheys Lodge. During the visit decoration was taking place of the corridors on the ground floor of the home. DS0000059312.V342694.R01.S.doc Version 5.2 Page 16 A tour of several areas of the home took place. An open space underneath a downstairs stairwell near to an external fire exit was very cluttered with equipment including wheelchairs, foot plates from wheelchairs, several ‘zimmer’ frames, a broken dining room chair and a commode. The manager stated that she would deal with the situation that day. Several bedrooms were visited and it was evident that people had been encouraged to bring their personal effects and with them into the home. People’s bedrooms were personalised with photographs of loved ones and other personal effects. Residents were able to access four lounges around the home, two of which were designated smoking lounges. Several areas of carpeting and chairs contained cigarette burns and were in need of refurbishment/renewing. Plans were in place at the home to ensure that the ‘No Smoking’ legislation scheduled to come into force on the 1st July 2007 would be adhered to. One smoking room had been identified as a resident only smoking room. The home was clean and tidy and generally free from odour. One bedroom had a strong odour of urine and the manager explained that several products were being tried to manage the odour. Fourteen people stated that the home was always fresh and clean, one person stated that it usually was and one person stated that the home was sometimes fresh and clean. DS0000059312.V342694.R01.S.doc Version 5.2 Page 17 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, 27, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff need to have regular updated training for their role to ensure that they can meet the needs of residents safely at all times. EVIDENCE: Fifteen care staff were employed at the home along with twelve other people who manage the domestic, laundry and catering needs of the residents. The home had a vacancy for a senior member of care staff. Two care staff and the deputy manager were on duty at the time of arrival for the visit. Rotas demonstrated that generally there was a minimum of three care staff on duty at this time. The deputy manager explained that they had been unable to cover the shift. An off duty member of staff arrived later in the morning to cover the shift and a member of staff from another home joined the team in the afternoon to cover the late shift. It was evident that for the period of time when there were only two care staff on duty that those staff were put under a great deal of pressure to ensure that residents needs were met. It is essential that an appropriate number of staff are on duty at all times to ensure that have the time to meet individuals needs. The home had a recruitment procedure and there was evidence on staff files that the appropriate Criminal Record Bureau checks had been completed. Staff DS0000059312.V342694.R01.S.doc Version 5.2 Page 18 files also contained application forms and information relating to the staff members interview. One file did not contained two written references and another had two written references addressed ‘to whom it may concern’. Dates when staff commenced their employment were not available on some files. The manager stated that she recognised that some information was not available on some files and was in the process of auditing and updating the information. Five staff had enrolled to undertake a National Vocational Award (NVQ) level 2 and once they have completed their course all but two staff will have achieved their NVQ award. The manager stated that staff receive a minimum of six supervisions a year and an annual appraisal. There was evidence on staff files that supervision were taking place. The manager demonstrated that several sources were used to access and update training. These included the Skill for Care Website for personal care and professional guidance from the Commission for Social Care Inspection (CSCI). There was evidence that some staff had awareness training in infection control and fire awareness using company in-house policies and procedures packs. The manager stated that senior staff had received in-house medication training which included guidance and information from the Commission for Social Care Inspection (CSCI), National Institute of Clinical Excellence (NICE) and the Nursing and Midwifery Council (NMC). All staff were in the process of completing a distance learning course on the subject of dementia developed by the The Alzheimers Society. Training records demonstrated that all staff required updated training in moving and handling and food hygiene. Nine people stated that always received the care and support they need, four people said that they usually do and two people said that they sometimes received the care and support they needed. Twelve people stated that staff listen and act upon what they said. Three people stated that staff do not listen and act upon what they said. Five people stated that staff were always available when they needed them, five people stated that they usually were and five people stated that staff were sometimes available when you needed them. Positive comments were received about the staff team working in the home, these included “I’ve never been happier, the staff are very good”, “I’ve been in several homes but non have been as good as this” and “staff are very good.” DS0000059312.V342694.R01.S.doc Version 5.2 Page 19 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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed in a manner that promotes peoples individuality. The health, safety and wellbeing of residents and staff is promoted by policies and procedures. However, attention needs to be given to fire safety procedures within the home. EVIDENCE: The home manager has several years experience in working and managing a social care service. The manager demonstrated a detailed awareness of the needs and wishes of the residents living at the home and a good awareness of community services that can be accessed for advice and support for individual residents. DS0000059312.V342694.R01.S.doc Version 5.2 Page 20 Information supplied by the manager prior to the inspection demonstrated that resident’s meeting are being held on a regular basis and that the home produces a quarterly newsletter. A copy of the most recent newsletter was available on the resident’s notice board. Questionnaires from the company titled ‘let us know’ are periodically sent to residents to ask their views on the service. The manager stated that she intends to develop a further questionnaire to gain the opinions of people who stay at Greenheys Lodge for short respite breaks. The manager stated that she also plans to introduce a suggestion box in the near future for people to post any suggestions they may have about the service. The home has a procedure for the management and safe keeping of people’s money and money is given to the resident on their request. All transactions are recorded appropriately. Comprehensive policies and procedures relating to health and safety are available within the home. These policies were last reviewed in March 2007. Information supplied by the manager demonstrated that regular servicing and testing took place of appliances within the home. The home has access to a ‘handy person’ who regularly checks the hot water temperatures and the fire alert and detection system. The procedure in the home and records demonstrated that generally these checks were carried out on a monthly basis. However, records demonstrated that the most recent recorded test to ensure that the fire detection alarm bells were operational had been carried out on the 17th April 2007. The inspector requested that the fire detection alarm bells were tested immediately to ensure that they were operational. The ‘handy person’ was not available in the building and it was of serious concern that there appeared to be nobody in the building able to tests the alarm system. The ‘handy person’ was contacted and came and tested the alarm system. A discussion took place between the ‘handy person’ and the manager regarding the need for several staff to be trained and made competent to carry out the test to ensure that appropriate testing of the fire system could take place at all times. During a telephone conversation with the home manager on 16.07.07 the manager stated that the procedure for testing the fire detection system had been changed and was now done on a Tuesday on a weekly basis. The manager and the deputy manager have also been instructed on how to carry out the testing for when the ‘handy person’ is not available. DS0000059312.V342694.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 DS0000059312.V342694.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? no 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 OP19 Regulation 13(4)(a) Requirement So residents can live in a comfortable environment, chairs and carpets with cigarette burns in them must be repaired or replaced. Timescale for action 10/08/07 2. OP27 18 (1) (a) 3. OP30 18 (1) (c) 4. OP38 23 (4) (c) This requirement remains outstanding from 28.02.06 The staffing rota must be 03/08/07 reviewed on a regular basis to ensure that sufficient staff are on duty throughout the day to meet the needs of the residents. All staff must receive training on 10/08/07 a regular basis in all mandatory areas including moving and handling and food hygiene to ensure that care and support is delivered in a safe manner at all times. Regular testing of all fire 03/08/07 detection systems must take place on a weekly basis to ensure that in order to protect residents the equipment will activate in the event of a fire. DS0000059312.V342694.R01.S.doc Version 5.2 Page 23 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. Refer to Standard OP7 OP9 Good Practice Recommendations It is strongly recommended that daily records that reflect resident’s day to day living need to be legible and written in a manner that respects each person. It is strongly recommended that a thermometer is placed in the medication storage room and the temperature is regularly monitored to ensure that mediation is being stored with the manufacturers guidelines. It is strongly recommended that activities provided in the home should be reviewed on a regular basis to ensure that all resident have access to regular stimulation and the use of the sensory room is promoted. It is strongly recommended that the temperature of food served is regularly reviewed to ensure that residents are served meals at the temperature of their choice. It is strongly recommended that the in house adult protection policy be reviewed and updated so that it contains contact details specific to Greenheys Lodge. 3. OP12 4. 5. OP15 OP19 DS0000059312.V342694.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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