Inspection on 26/01/06 for Greenheys Lodge

This inspection was carried out on 26th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Greenheys Lodge 22/06/07

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 Natalie Charnley Unannounced Inspection 26th January 2006 11:00 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 Greenheys Lodge DS0000059312.V283040.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Greenheys Lodge DS0000059312.V283040.R01.S.doc Version 5.1 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 Greenheys Lodge DS0000059312.V283040.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One named person under 65 years old may be accommodated The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 11th November 2005 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. Greenheys Lodge DS0000059312.V283040.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over a period of one day The inspector arrived at the home at 11:00 and left at 14.00 .The inspector spoke with 5 staff, the home manager and 7 residents. One visitor was available at the time of the inspection and made comments to the inspector. The inspector completed the inspection by looking at the homes records, a tour of the building, formal and informal interviews and information from previous inspection reports. The inspector followed an inspection plan written before the start of the inspection to ensure that all areas that needed covering were done so. Feedback was given to the manager during and at the end of the inspection, and again by phone. Not all standards were looked at during this inspection, however all core areas have been covered during the 2005/06 inspection year. What the service does well: What has improved since the last inspection? The home has developed their care plans further to seek the ideas and suggestion of residents and their families. The laundry area is now functioning well and the dumb waiter to the kitchen has been repaired. Greenheys Lodge DS0000059312.V283040.R01.S.doc Version 5.1 Page 6 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. Greenheys Lodge DS0000059312.V283040.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Greenheys Lodge DS0000059312.V283040.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 The statement of purpose and service user guide are well presented and contain a variety of information that residents need to know about living at the home EVIDENCE: Residents commented that they were aware that the home had a statement of purpose and service user guide. One lady commented “ I have a booklet in my room about the home”. Residents are able to read about how they will be treated by staff and what facilities that they can access. If a residents needs support from outside ‘advocates’ details are contained within these guides. The guide is very well presented and easy for residents to understand. Greenheys Lodge DS0000059312.V283040.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,9 and 10 Care planning at the home is based on the individual and details how care is to be given. Residents feel that they are respected by staff and that their privacy is maintained at all times. Staff must make sure that they are familiar with the home medication policy to ensure that medications are given out safely to protect residents. EVIDENCE: Four care plans were looked at during the inspection. The care plans are well organised and simple to use and follow. All residents have an individual plan which they help write, along with staff and family members if needed. The plans are then kept under review by staff on a monthly basis to monitor any changes. Plans include short and long-term goals that residents may try to achieve. The manager has worked hard to develop these plans further to make them clear and easy for residents and staff to understand. Medication records and storage areas were checked and records are awaiting photographs to help staff identify residents. Six entries were handwritten but not double signed by two staff to ensure no mistakes have been made and dose of medication that are variable (when either one or two tablets are to be Greenheys Lodge DS0000059312.V283040.R01.S.doc Version 5.1 Page 10 given) were not recorded correctly. One resident had her medication records crossed out, making records difficult to read. The records for controlled drugs were also checked. This showed that when drugs were being returned to pharmacy, only one signature was being recorded, which leaves records incomplete .The manager must look into this problem as it is a legal requirement. A new controlled drug book needs to be purchased by the home, as the old one is about to run out. Residents at the home all commented that they felt that they had their privacy and dignity maintained. Comments were made such as “we don’t get disturbed unless it is necessary” and “staff are always polite”. Staff were observed knocking on doors before entering and addressing residents in an appropriate way. Residents can see visitors or health workers in private and a resident who lives at the home and is hard of hearing is communicated with using hand gestures, which she prefers. Greenheys Lodge DS0000059312.V283040.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 and 14 Residents can maintain contact with family and friends and are supported by staff to remain independent and make choices for themselves. EVIDENCE: The home has an open visiting policy. Residents stated “ my family can come here at any time and are welcomed in”, another stated “there are no restrictions here”. Visitors were observed at the home, meeting with residents and being involved in the discussions about residents. Residents were able to talk about the decisions and choices that they make on a daily basis. Examples were given regarding what time they go to bed, what activities they join in with and what they have to eat. Staff discussed how they support residents in decision making and help them to maintain their independence as long as possible. Greenheys Lodge DS0000059312.V283040.R01.S.doc Version 5.1 Page 12 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): None of the above standards were assessed in full EVIDENCE: Greenheys Lodge DS0000059312.V283040.R01.S.doc Version 5.1 Page 13 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 Areas of the home are a potential hazard to residents and staff. Staff must ensure the safety of the residents at all times. EVIDENCE: A tour of the home was undertaken. Outside the kitchen, a cleaning trolley was left for a long period of time, which contained cleaning products that could cause harm to residents if they came into contact with them. The trolley also had a mug of hot soup on it, sat beside the cleaning products. The stairwell area opposite toilet number 7 was very cluttered. One mattress, six wheelchair foot plates, five wheelchairs, two large cushions, a selection of wood and a bedside cabinet were stored in this area despite a sign being up stating ‘health and safety risk, wheelchairs not to be stored here’. The door next to this area that has access to the gardens was open, the flowerbeds and paving stones were littered with cigarette ends, despite an ashtray being provided. In the large lounge, the carpet was heavily stained in front of the chairs. There were also three chairs that were had cigarette burns on them and need replacing. The bar area was full of clutter and residents stated that this area is Greenheys Lodge DS0000059312.V283040.R01.S.doc Version 5.1 Page 14 not in use at the moment. The main entrance of the home has a small room in which a drinks machine is kept. The door to this room is a fire door and was found to be wedged open. A strong smell of cigarettes was noted in this area as a member of staff was smoking in an office with the door open. The home may wish to address this, as it does not create a nice environment in which residents can live. Greenheys Lodge DS0000059312.V283040.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 Staffing levels are adequate for staff to support residents. EVIDENCE: Staffing levels at the home during the night shift have been altered since the last inspection by discontinuing the use of a ‘sleepover’ member of staff. The manager and staff reported that this was working well and that the ‘teething’ problems that were first experience had been sorted out. Residents spoke highly about the staff and the care that they provide commenting, “they are very kind” and “we get looked after very well here”. Rotas for the last two weeks were checked and showed that staffing levels are sufficient to meet the needs of the current residents. Greenheys Lodge DS0000059312.V283040.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 and 38 Residents money is kept safe at the home and residents are encouraged to handle small amounts themselves. Safety checks at the home are in place and protect residents from harm. EVIDENCE: Records looked at by the home showed that small amounts of money are held in a safe and given to residents when they ask for it. Residents then sign to say that they have received money. If a build up of money is noted by the manager, this is then returned to head office. Records of these transactions were seen and showed that accurate records had been kept. The contents of the safe were checked during the inspection and all records were in order. Accidents are recorded well at the home, a resident that was identified by the manager as having a lot of falls, had recently been moved to a bedroom downstairs so he could be monitored by staff. All health and safety certificates were checked and found to be in date. Staff stated that they have access to a Greenheys Lodge DS0000059312.V283040.R01.S.doc Version 5.1 Page 17 range of policies in this area and demonstrated a sound understanding of how to prevent accidents. Greenheys Lodge DS0000059312.V283040.R01.S.doc Version 5.1 Page 18 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 4 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 1 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 3 Greenheys Lodge DS0000059312.V283040.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement The registered person must ensure that handwritten entries must are double signed and dated. (remains outstanding from the previous inspection: due 1.1.06) The registered person must ensure that variable doses are accounted for on MAR charts and that entries are not crossed out and remain legible. The registered person must ensure that all entries in the controlled drug registered are double signed. The registered person must ensure that cleaning materials must be stored in a safe manner and away from residents. The registered manager must remove all clutter and combustible items from under the identified stairwell. The registered manager must repair or replace the cigarette burnt chairs and the stained Greenheys Lodge DS0000059312.V283040.R01.S.doc Version 5.1 Page 20 Timescale for action 30/01/06 2 OP19 13(4)(a) 28/02/06 flooring to the main lounge The registered manager must ensure that the practice of wedging fire doors open stops 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 OP8 OP19 Good Practice Recommendations The inspector recommends that the company provide individual homes on site with weighing equipment The inspector recommends that the areas that staff are allowed to smoke be reviewed, with reference to the entrance office and outside the back door. The inspector recommends that the bar area is tidied up and put back in use. Greenheys Lodge DS0000059312.V283040.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Greenheys Lodge DS0000059312.V283040.R01.S.doc Version 5.1 Page 22 - 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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