CARE HOMES FOR OLDER PEOPLE
Greenhill Park 24 Greenhill Park Road Evesham Worcestershire WR11 4NL Lead Inspector
C Presley Unannounced Inspection 11.00 29 December 2005
th 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 Greenhill Park DS0000063333.V272471.R01.S.doc Version 5.0 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. Greenhill Park DS0000063333.V272471.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Greenhill Park Address 24 Greenhill Park Road Evesham Worcestershire WR11 4NL 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) 01386 40836 Mrs Maria Bayliss Mr Michael Francis Cole Mrs Maria Bayliss Care Home 24 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (24), of places Physical disability over 65 years of age (24) Greenhill Park DS0000063333.V272471.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 19th July 2005 Brief Description of the Service: Greenhill Park is a residential home situated in a quiet residential area of Evesham close to the town centre and provides care and accommodation for a maximum of 24 older people. There is an area of landscaped gardens with two attractive patio areas for the residents to enjoy and there are extensive views over the Vale of Evesham and the Cotswold Hills. Accommodation is provided over two floors and comprises of 18 single rooms, 12 of which are en-suite and 3 shared rooms. A passenger lift provides access to first floor rooms. Greenhill Park DS0000063333.V272471.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 11.00am. This inspection concentrated on standards not inspected during the last inspection and requirements from that report. A number of residents were spoken to during the inspection and time was spent with the registered manager/owner of the home. What the service does well: What has improved since the last inspection? What they could do better:
Staff had not received infection control training and infection control policies and procedures were not in place to ensure residents were protected from cross infection. Greenhill Park DS0000063333.V272471.R01.S.doc Version 5.0 Page 6 The registered manager should ensure all staff receive induction training and progress to either a foundation training package or NVQ training; residents would benefit from staff undertaking NVQ training. A Legionella risk assessment should be developed. Staff would benefit from regular supervision sessions with the registered manager. 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 Park DS0000063333.V272471.R01.S.doc Version 5.0 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 Greenhill Park DS0000063333.V272471.R01.S.doc Version 5.0 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): None of the standards in this section of the report were inspected at this visit for further information please refer to previous inspection report. EVIDENCE: Greenhill Park DS0000063333.V272471.R01.S.doc Version 5.0 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): None of the standards in this section of the report were inspected fully during this visit for further information please refer to previous report. EVIDENCE: Care records were inspected during the visit and there was evidence of a daily record for each resident. Monthly reviews reflected changing needs of residents. Further plans to develop care records are being discussed with senior staff. The home and Boots the chemist audit medication records. Residents are treated with respect. Greenhill Park DS0000063333.V272471.R01.S.doc Version 5.0 Page 10 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): None of the standards in this section of the report were inspected fully during this visit for further information please refer to previous report. EVIDENCE: Visitors were observed during the morning visiting family and taking them out. The home has a relaxed atmosphere and residents feel it is their home. Greenhill Park DS0000063333.V272471.R01.S.doc Version 5.0 Page 11 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 standards in this section of the report were inspected at this visit for further information please refer to previous report. EVIDENCE: There have been no complaints to the Commission or the home since the last inspection. Greenhill Park DS0000063333.V272471.R01.S.doc Version 5.0 Page 12 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, 21, 22, 23, 24, 25 & 26 The standard and cleanliness of the home is excellent; infection control procedures are not robust and staff require training in this field. EVIDENCE: The home is clean, warm, well presented and bedrooms are individually furnished. Residents have access to the gardens weather permitting. There are two lounges one of which is designated a quiet lounge. Bathrooms are well maintained and staff record bath temperatures in individual care plans. These temperatures appeared low in some cases. During the tour of the premises it was noted there were a number of toiletries left in bathrooms following the morning bathing of residents. Staff were not adhering to infection control policies and procedures and appropriate infection control measures for foul laundry are not in place.
Greenhill Park DS0000063333.V272471.R01.S.doc Version 5.0 Page 13 There were a number of worn flannels and towels in resident’s bedrooms and the linen cupboard; discussion with the registered manager took place and she said she had replaced some and would purchase more. The laundry room was unlocked and contained a number of hazardous products that were not kept secure Greenhill Park DS0000063333.V272471.R01.S.doc Version 5.0 Page 14 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): 28, 29 & 30 Recruitment procedures are robust and ensure staff are safe to work with vulnerable adults. Induction and foundation programmes require further development. EVIDENCE: Staff files inspected evidenced the home has a robust employment procedure in place and all staff have a POVA first and criminal record check at enhanced level before commencing work in the home. A recent member of staff had not had an induction-training period and was observed carrying out a procedure, which conflicted with infection control procedures; the registered manager said she was aware of this shortfall and would be addressing it immediately. The home did not have a foundationtraining programme in place. There were thirteen care staff employed in the home, of these two were NVQ trained and four had commenced training. The registered manager said she had plans for all staff to commence NVQ training but this would take time to implement. All staff had a first aid certificate to an appointed person level. Training programmes, which enable staff to develop, continue to be a strength in the home. Greenhill Park DS0000063333.V272471.R01.S.doc Version 5.0 Page 15 Greenhill Park DS0000063333.V272471.R01.S.doc Version 5.0 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): 33 & 36 There is no formal quality assurance programme in the home and staff are not receiving regular formal supervision. EVIDENCE: Quality assurance is an ongoing process in the home and residents are give every opportunity to discuss any concerns they may have, these are not formalised into an annual report and do not take into consideration views of the multidisciplinary team and other visitors to the home. Staff do not receive regular formalised supervision sessions and the registered manager is aware this is a shortfall. Since the last inspection the accident book has been audited regularly and records are kept secure.
Greenhill Park DS0000063333.V272471.R01.S.doc Version 5.0 Page 17 It was noted the serving hatch through to the dining room did not have a fire proof cover in place this was considered an unacceptable risk to residents in the home and there is a requirement of this report to fit one within one month. Greenhill Park DS0000063333.V272471.R01.S.doc Version 5.0 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 x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 3 3 2 3 3 3 3 2 STAFFING Standard No Score 27 x 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 2 x x 2 x x Greenhill Park DS0000063333.V272471.R01.S.doc Version 5.0 Page 19 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 OP21 Regulation 13 Requirement Staff must ensure when residents are bathed the temperature of the bath is suitable. Infection control policies and procedures must be adhered to and staff must receive training in this field Foul laundry must be appropriately bagged and laundered Worn flannels and towels must be replaced Substances considered hazardous must be appropriately stored All staff must receive induction training to National Training Organisation specification within 6 weeks of appointment of their posts All staff must receive foundation training to National Training Organisation specification within 6 months of appointment of their posts A quality assurance programme system must be introduced in accordance with the
DS0000063333.V272471.R01.S.doc Timescale for action 29/12/05 2 OP26 13 31/01/06 3 4 5 6 OP26 OP21 OP26 OP30 13 23 13 12,18 29/12/05 31/01/06 29/12/05 29/12/05 7 OP30 12,18 30/03/06 8 OP33 24 30/06/06 Greenhill Park Version 5.0 Page 20 9 10 OP36 OP38 18 23 requirements of Regulation 24 and Standard 33. Care staff must receive formal supervision at least six times a year A fire resistant hatch that complies with fire safety must be fitted to the serving hatch between the kitchen and the dining room 30/03/06 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP28 Good Practice Recommendations Arrangements should be made for staff to receive training which will enable a minimum of 50 of the care staff to attain a qualification at NVQ level 2. Greenhill Park DS0000063333.V272471.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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