Inspection on 06/02/06 for Greenhill Lodge

This inspection was carried out on 6th February 2006.

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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Greenhill Lodge 05/07/06

Greenhill Lodge 17/08/05

Greenhill Lodge 31/03/05

Greenhill Lodge 05/08/04

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

CARE HOME ADULTS 18-65 Greenhill Lodge 22-24 Alexandra Road Watford Hertfordshire WD17 4QY Lead Inspector Tom Cooper Unannounced Inspection 6th February 2006 3:45 Greenhill Lodge DS0000019416.V282494.R01.S.doc Version 5.1 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 Greenhill Lodge DS0000019416.V282494.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 Adults 18-65. 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. Greenhill Lodge DS0000019416.V282494.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Greenhill Lodge Address 22-24 Alexandra Road Watford Hertfordshire WD17 4QY 01923 241 957 01923 229 236 greenhilllodge-londoneast@muca.org.uk 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) The Mental Aftercare Association John Warner Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10), Physical disability (10) of places Greenhill Lodge DS0000019416.V282494.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. This home may accommodate 10 people with a mental disorder or physical disability (when associated with mental disorder). The manager must complete the Registered Managers Award and NVQ Care Level 4, or equivalent, within 18 months of registration. 17th August 2005 Date of last inspection Brief Description of the Service: Greenhill Lodge is a home offering accommodation to up to 10 people with long-term mental illness. It is situated in a pleasant residential street in Watford within easy walking distance of the town centre, with all the community life that offers. The residents live relatively independent lives but with staff support always available when they require it and to monitor their general state of health and wellbeing. The home also has two flats for more independent service users but these are excluded from the registered provision. Greenhill Lodge DS0000019416.V282494.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection for the current inspection year and took place on a weekday in the late afternoon and evening. The main focus of the inspection was to evaluate the service users’ experience of living in the home and to check compliance with the statutory requirement and any action taken in respect of the recommendation made at the last inspection. Discussions were held with the registered manager, the deputy manager and two support workers on duty and most of the service users in residence. Documentation checked included a service user’s care plan, risk assessments, medication and complaints records and two personnel files. A brief tour was made of the premises and two service users showed the inspector their bedrooms. The staff and residents were very friendly and welcoming. The inspection indicated that the home was running well with the service users expressing general satisfaction with their lives in the home and enjoying positive relationships with staff. Statutory requirements have been made in respect of risk assessments and staff records. What the service does well: The home provides a safe and supportive environment where the service users can feel safe and at home, with assistance available at all times should they need it. Service users reported general satisfaction with the home, saying that their opinions and preferences were taken seriously, staff were helpful and constructive and the personal support provided was consistently good. All those spoken with felt they were able to exercise a fair degree of personal autonomy. Two were looking forward to taking holidays abroad this year supported by staff. Good assessment information is documented, with clear details of the personal circumstances and goals set by and for of each individual, the current agreed approach to be taken and good progress notes. Members of staff spoken with said they enjoyed working at the home and rated communications and teamwork as strong. They felt they had good support from senior colleagues and received regular individual supervision. Staff have a good rapport with the service users and understand their individual needs and aspirations well. The home has a detailed medication policy and sound procedures are operated for the obtaining, storage, administration and recording of medication. Greenhill Lodge DS0000019416.V282494.R01.S.doc Version 5.1 Page 6 The premises are safe, comfortable and well maintained and provide a suitable domestic environment for the service users. The communal rooms are well furnished and decorated. The kitchen is modern and well equipped, and there are adequate bathroom and toilet facilities. The enclosed garden has been much improved in recent years and provides an excellent extra space to use in fair weather. A reasonable standard of cleanliness was found in all areas inspected. Greenhill Lodge DS0000019416.V282494.R01.S.doc Version 5.1 Page 7 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. Greenhill Lodge DS0000019416.V282494.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Greenhill Lodge DS0000019416.V282494.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 Adequate information about the philosophy of care and operation of the home is available to prospective and current residents. Admissions are made on the basis of detailed assessments of the individuals’ needs and aspirations so that it is clear that the home can provide a suitable service. The home also has good arrangements to enable new residents to familiarise themselves with the home prior to moving in. EVIDENCE: The home has a suitable statement of purpose and service user’s guide. Copies are given to each service user. All admissions are made subject to the home’s pre-admission process, involving an assessment carried out by a senior member of staff. Admissions are decided by a multi-disciplinary referrals panel. Prospective residents are sent an introductory letter and information pack containing the statement of purpose and service user’s guide. The manager or deputy manager makes a formal needs assessment based on observations, discussion and practical exercises. This usually takes place at the person’s current place of residence with the social worker or other representative present. The individual is always invited to visit the home to see it in operation prior to admission and individual moves may be arranged swiftly or over several visits, gradually extended until the move becomes permanent. Greenhill Lodge DS0000019416.V282494.R01.S.doc Version 5.1 Page 10 The home has a number of external professionals supporting the care of the residents. This includes CPNs, Psychiatrists, GPs, and other relevant medical support. Each service user signs a licence agreement with the provider upon admission. This details the terms and conditions of occupancy at the home, including charges. A representative (normally a social worker or advocate) may sign on behalf of the service user if necessary due to incapacity. Residents are also given a copy of the Tenant’s Charter. Greenhill Lodge DS0000019416.V282494.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Detailed assessments are in place for each service user, including risk assessments and the agreed level of support is identified in their care plans. Good interaction between staff and service users was noted. Staff consult service users about their lives and support them to make decisions and choices, including taking responsible risks. This enables them to maintain a good degree of independence in a safe environment. However further work must be done to ensure all relevant risks have been addressed. Confidential information is handled appropriately. EVIDENCE: Each service user has a care plan, drawn up by staff in conjunction with the service user, who signs the finished document. Risk assessments are also completed, including information from the CPA. Good assessment information is documented, conveying a clear sense of individual status and the relevant care priorities, including the personal goals of the service user. However, a recommendation was made to produce more specific risk assessments for service users relating to spending time away from the home (especially overnight stays) and a requirement in respect of self-medication. Greenhill Lodge DS0000019416.V282494.R01.S.doc Version 5.1 Page 12 Service users said that staff consulted them about all aspects of their lives and they felt they had a reasonable level of personal control. Each resident has a keyworker to provide extra individual attention and this arrangement was felt to be effective. All the residents at Greenhill Lodge have serious mental health problems. Nevertheless they lead largely independent lifestyles, are able to access the community alone and enjoy considerable opportunity to make their own decisions. The level of individual care and support required varies from individual to individual. Staff are aware of the particular circumstances and behaviour patterns of each service user and strive to balance unobtrusive support with encouragement to maintain acceptable minimum standards of room tidiness and personal hygiene, adapting the care delivered accordingly, on a day to day basis if necessary. Service users spoken with confirmed that staff consulted them over the running of the home, and there were regular house meetings that provide a forum for expressing views. One such meeting took place during the inspection. The company has a confidentiality policy that staff are aware of and all personal information about service users is handled appropriately. Greenhill Lodge DS0000019416.V282494.R01.S.doc Version 5.1 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14, 16, 17 Service users are supported and encouraged by staff to lead the lifestyles they choose. They live as part of the local community and engage in social and leisure activities that suit them, using public services and amenities in the ordinary way. Staff encourage service users to maintain adequate motivation and to take personal responsibility where possible. Service users have a reasonable diet and staff encourage healthy eating. EVIDENCE: Service users spoken with said that they were mostly satisfied with their lifestyles and felt that staff were constructive and helpful. Motivation is often a problem with this client group therefore staff have to balance the residents’ right to privacy and self-determination with the need for adequate stimulation and positive experiences as well as shouldering some personal responsibility. The service users generally follow their own pursuits, spending much of their time sitting in the communal areas smoking and watching television or talking to each other and staff. Very little in the way of social or leisure activities take place within the home, but this is how the current service users prefer it. Staff occasionally arrange day trips out to destinations such as Brighton, which are Greenhill Lodge DS0000019416.V282494.R01.S.doc Version 5.1 Page 14 popular and well attended. Two service users were looking forward to taking trips abroad later this year with staff support. One service user had recently inherited a large number of DVDs which he had donated to the home and the residents watch these regularly in the living room. All the residents access the local community in the ordinary way, using local shops, hairdressers, GPs, pubs, etc. A number of residents attend local churches. One resident is Sikh but chooses not to practise his religion. The service users have a reasonable diet, with individual preferences well known to staff and reflected in menu planning. Those asked said the food provided was good. Staff encourage healthy eating habits where possible. For example, they negotiate with one service user to restrict his caffeine consumption within tolerable limits and this need is recorded in his care plan. Residents help out with the washing up. They have unrestricted access to the kitchen. Service users prepare lunch and breakfast themselves from food that is supplied on the premises. Staff remain in the kitchen at these times to monitor safety and assist when needed. Greenhill Lodge DS0000019416.V282494.R01.S.doc Version 5.1 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 ,21 Staff treat service users with respect and dignity. They encourage service users to attend to their personal care and maintain a reasonable standard of physical presentation. Service users’ physical and emotional healthcare needs are well documented in their personal files. The home operates sound procedures for the safe handling of medication that protect service users’ interests. Staff have consulted service users over their requirements relating to illness and death and these are recorded. Therefore service users know their wishes will be respected. EVIDENCE: The service users’ principal care needs are to do with managing their mental health problems. The varying levels of support required for each individual are well documented in their care plans. Service users asked said that they had confidence in staff and felt well supported without being harassed or coerced. Staff appeared to have good insight into individual needs and a measured approach. Greenhill Lodge DS0000019416.V282494.R01.S.doc Version 5.1 Page 16 The home operates the Boots Monitored Dosage System of medication dispensed in individual blister packs. Only trained staff handle medication and a double check system is used to minimise mistakes. The pharmacist visits every three months to monitor performance. No recording errors were found on checking the current medication administration record (MAR) sheets. One resident was self-managing some of his medication, which is a positive example of the home promoting independence. However no risk assessment had been made in respect of this (see requirements) and it is recommended that outside approval be sought from the GP or psychiatrist and recorded to demonstrate a multi-disciplinary approach. Staff have tactfully consulted individual service users over their requirements for dealing with illness and death and these are noted on their care plans. Greenhill Lodge DS0000019416.V282494.R01.S.doc Version 5.1 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Residents are encouraged and enabled to make their views and concerns known. They are aware of the complaint procedure. Policies and procedures are in place to ensure that service users are protected from abuse and neglect. EVIDENCE: Service users asked said that they knew how to go about making a complaint and felt they would be taken seriously by the manager. The home has a complaint procedure that contains all the elements to meet the standard. No complaints had been recorded in the complaints file since the last inspection. However the manager has introduced a new book for the recording of informal ‘grumbles’ that contained several entries, with details of the action taken in response. This indicates a commitment to resolving matters at an early stage. The home has a copy of the Hertfordshire inter-agency adult protection procedure in the office and staff spoken with were aware of the home’s whistle blowing policy. Greenhill Lodge DS0000019416.V282494.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 The premises are well maintained and decorated, providing a safe and comfortable environment for the service users. Staff assist service users to maintain adequate standards of cleanliness and hygiene. EVIDENCE: The deputy manager reported that the dining room and one service user’s bedroom had been redecorated since the last inspection. A schedule of planned maintenance is kept that indicates progress made. Service users commented that the premises were pleasant and suited them quite well. They also expressed satisfaction with their bedrooms. All areas seen on this occasion were attractively decorated and furnished to a fair standard. Due to the habits of some of the residents caused by their mental health problems there is always a high rate of wear and tear in this home and therefore the renewals budget needs to be sufficient to allow the manager to maintain proper standards. The communal rooms are all decorated in bright colours and provide a homely living environment in which service users can relax and feel at home. However nearly all the residents smoke cigarettes and inevitably the Greenhill Lodge DS0000019416.V282494.R01.S.doc Version 5.1 Page 19 atmosphere in the communal areas reflects this. Because of the force of the habit it would be impractical to attempt to enforce a separate smoking area in the home. Despite this all areas seen, including two bedrooms and bathrooms were acceptably clean and tidy. Equipment such as fire extinguishers had been serviced within the last year. No special mobility aids are required at present. The home has no lift therefore only fully mobile residents can live at the home. The neatly arranged garden provides an excellent alternative space for residents that they use a lot, especially in fair weather. In addition to the flowerbeds there is a patio and a summerhouse. Staff tend the garden, and occasionally residents help. Greenhill Lodge DS0000019416.V282494.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 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, 32, 33, 34, 35, 36 Staff understand and support the home’s aims and their roles in delivering the service promised in the statement of purpose. Staffing numbers from day to day are adequate to meet the needs of the current group of service users. Staff are confident and knowledgeable about service users’ individual needs and agreed programmes and relate well to them, providing support and guidance. The company has rigorous recruitment policies and procedures that should protect the interests of service users. However evidence of staff identity and CRB disclosure must be kept in the home for each member of staff. The company provides regular relevant training for staff that ensures they are well equipped to assist service users to lead safe and fulfilled lives in accordance with the home’s statement of purpose. Staff are well supported and supervised by senior colleagues to deliver consistent care for the service users. Greenhill Lodge DS0000019416.V282494.R01.S.doc Version 5.1 Page 21 EVIDENCE: Staff spoken with had a good understanding of the aims of the home as detailed statement of purpose. Communications and teamwork were rated as good so that they felt able to act consistently to care for the service users. Staff know their limitations and obtain advice and support from outside health professional when necessary. Service users said that staff were good listeners and this was evident watching staff and residents interacting during the inspection. All the current support workers are undertaking the NVQ3 qualification and the deputy has started the NVQ4 course. Therefore the home will soon be able to meet the 50 qualification standard, which is positive. At the time of the inspection two members of staff plus the manager were on duty. There are generally at least two members of staff on each day shift, plus the manager. At night one member of staff is provided. Additional staff are deployed if necessary, for example to accompany residents to hospital appointments, outings etc. The staff team is well balanced, with a good range of experience and skills. Service users spoken with expressed satisfaction with the current staffing arrangements. There were currently two vacant posts but cover was being provided by three relief workers and agency workers very familiar with the home. The manager said that fresh agency staff unused to the home were rarely used. This promotes continuity and minimises disturbance to the service users. Team meetings take place regularly. The company has rigorous recruitment procedures that involve thorough vetting of applicants. The records of two staff were examined and found to contain photographs of the person, application forms, two positive references and detailed interview notes. However in one case there was no identity evidence and no evidence of a CRB disclosure taken up by the company (although the individual concerned said this had been done) the company. A requirement has been made to obtain all the necessary information and documents for all staff. All new staff receive structured induction and foundation training and the company provides good access to training according to individual training schedules. Staff said they received regular one to one supervision from the manager and session notes were on file. Staff said they really enjoyed working at the home and felt well supported by senior colleagues. Greenhill Lodge DS0000019416.V282494.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41, 42 The home is well run, with service users benefiting from the support and guidance of the manager and empathetic and experienced staff team. The manager is experienced and qualified and provides strong leadership. The home is operated so that staff support and encourage service users to lead safe and reasonably fulfilling lives with a large degree of personal choice. Record keeping is of a generally high standard, although more attention must be paid to risk assessments relating to service users’ day to day actions. The home is safe to live and work in, with appropriate health and safety procedures followed. Greenhill Lodge DS0000019416.V282494.R01.S.doc Version 5.1 Page 23 EVIDENCE: The manager is very experienced in working with people with mental illnesses and has recently achieved the NVQ4 qualification in management and care. He is awaiting the Registered Manager’s Award. He is focused and calm and provides effective leadership to the team, promoting an open and inclusive atmosphere in the home. He is readily available to staff and residents. In addition to the monthly proprietor’s representative’s reports on the conduct of the home, the company has now introduced a new quality monitoring and assurance system that includes canvassing the views of service users and their representatives and assessment of the home’s performance against the national minimum standards. Actions to be taken to address any shortfalls identified are determined and recorded. This is a positive development that should enhance the quality of the service from year to year. Most records seen including care plans, complaints, medication and supervision/appraisal notes were well organised and diligently compiled. However, as reported above more attention must be paid to risk assessments and staff vetting records. Sound procedures are in place for the storage and recording of residents’ money held for safekeeping. Equipment checked such as the fire extinguishers had been serviced within the last year and all kitchen and laundry equipment was in good order. The bathrooms were suitable for the residents as they do not have mobility problems. The gardens were safe and accessible and all floor coverings seen were secure and safe. No hazards were noted during a brief tour of the premises, which were relatively uncluttered and tidy. Greenhill Lodge DS0000019416.V282494.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 3 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 X 2 3 x Greenhill Lodge DS0000019416.V282494.R01.S.doc Version 5.1 Page 25 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 YA34YA41 Regulation 17(2) & 19 Requirement Evidence of identity (such as a copy of the person’s birth certificate) and a Criminal Records Bureau disclosure must be obtained and kept in the home on file for any member of staff working at the home. Risk assessments must be made in respect of all service users who self-manage medication. Timescale for action 31/03/06 2. YA20 13(4)(c) 10/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA9 YA20 Good Practice Recommendations Risk assessments should be made with appropriate control measures identified in respect of service users spending time away from the home, especially overnight stays. Outside approval of self-medication by individual service users should be obtained from the GP or psychiatrist and recorded to demonstrate a multi-disciplinary approach. Greenhill Lodge DS0000019416.V282494.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 Greenhill Lodge DS0000019416.V282494.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!