Inspection on 12/08/05 for Greenhive House

This inspection was carried out on 12th August 2005.

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

Other inspections for this house

Greenhive House 16/02/07

Greenhive House 17/03/06

Greenhive House 22/03/05

Greenhive House 01/10/04

Greenhive House 12/02/04

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

CARE HOMES FOR OLDER PEOPLE Greenhive House Greenhive House 50 Brayards Road London SE15 2BQ Lead Inspector Alison Pritchard Unannounced Inspection 12th August 2005 2.45pm 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 DS0000030684.V254363.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. DS0000030684.V254363.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Greenhive House Address Greenhive House 50 Brayards Road London SE15 2BQ 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) 0207 740 9880 Anchor Trust Ms Connie Oppong Care Home 64 Category(ies) of Old age, not falling within any other category registration, with number (0) of places DS0000030684.V254363.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd March 2005 Brief Description of the Service: Greenhive House is a care home run by Anchor Homes, providing personal care and accommodation for 64 people who are over the age of 65 years. At the time of the inspection there was one vacancy. The home is purpose built and was opened in March 2002. The facilities are over two floors and a lift is available to allow access. The home is arranged into four group living units, each with its own living room and dining room. All of the bedrooms are singe and have en-suite facilities. There is a large car park to the front of the home and gardens to the side and rear. The home is situated in Peckham, within a reasonable distance of the shopping centre and public transport routes. DS0000030684.V254363.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection was unannounced and carried out over an afternoon and early evening in mid August 2005 and lasted approximately 5 hours. The Inspection methods included discussion with approximately seven residents, observation of care practices, informal discussions with staff, discussion with the manager, examination of records and a partial tour of the building. What the service does well: What has improved since the last inspection? What they could do better: As at the inspection of October 2005 it was found that notes are not always made daily on residents’ care files. One of the files seen had an incomplete record of residents’ property. The manager stated that an audit system is to be introduced and this should help senior staff to monitor recording practices. Although most aspects of health and safety were well looked after the call bell system needs to be tested each week to make sure that it is working properly and the fire risk assessment needs to be reviewed each year. DS0000030684.V254363.R01.S.doc Version 5.0 Page 6 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. DS0000030684.V254363.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 DS0000030684.V254363.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): 1,3 and 5. The information available for potential residents allows them to make a decision about whether Greenhive is suitable for their needs. Information about potential residents is gathered by the home so that they can be sure that they can meet their needs. Wherever possible, visits are made to the home before a person is admitted. EVIDENCE: The statement of purpose contains the required information. There is a ‘Welcome Pack’ for new and potential residents which contains useful information about the home in an accessible style. The file for two residents who had come to live at the home five weeks before the inspection contained assessment documents. The manager informed the inspector that the admissions were made in emergency circumstances which were beyond the control of the home. Nevertheless the home had gathered information about the residents’ needs and the manager had visited them in hospital on the day of their admission. One of these residents told the inspector that she is happy with the way that the home cares for her. The DS0000030684.V254363.R01.S.doc Version 5.0 Page 9 usual procedure of the home would be for, wherever possible, prospective residents, their family and friends to be invited to visit the home. DS0000030684.V254363.R01.S.doc Version 5.0 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, 10, The residents will benefit from the planned introduction of an audit system to make sure that the care plans include all of the residents’ needs and how they will be met. Residents’ health care needs are met and the home makes sure that they see health care professionals when they need to do so. Residents are treated in a kindly and respectful way by staff. EVIDENCE: The home draws up a document called an ‘Individual Lifestyle Agreement’ (ILA) for each resident. The document contains information about the care a resident should receive and forms the individual plan of care. One of the ‘ILA’ s seen was signed by the resident and they had been involved in discussions about the plan. Reviews of care plans had taken place. It was noted that there was a variation in the quality of the ILAs. Whereas one contained information that was relevant and detailed, another contained little information. This was discussed with the manager who stated that a files audit system is to be used as part of the supervision system. This will ensure that DS0000030684.V254363.R01.S.doc Version 5.0 Page 11 key workers are given any necessary guidance in their care planning work. This will benefit residents by ensuring that the care plans accurately and fully reflect their care needs. Some of the daily notes were completed only sparsely with little information and on some days entries were not made. This should be improved so that there is a daily record kept with a view to ensuring that residents’ conditions are monitored. The files showed that residents are referred to health care services such as dental, optical, podiatry, physiotherapy and occupational therapy services. Health visitors come to the home to carry out procedures such as injections. In addition there is regular contact with the GP and notes showed that referrals are made appropriately in response to concerns about residents’ health. The home’s medication procedures and practices were inspected fully by a Pharmacy Inspector in March 2005. One recommendation was made as a result of that inspection. The recommended action has been taken. The management of medication will be inspected on the next visit to the home. Residents reported that if they wish to spend time alone in their rooms then staff respect their privacy at these times. Observation of staff and residents’ interaction showed that staff are kind, patient and warm when they are assisting residents. This was confirmed by residents whose comments about staff included: “They are kind and look after you” and “ [they are] very caring”. All of the residents seen were well dressed and groomed indicating that staff take care to make sure that residents’ appearance gives them dignity and respect. DS0000030684.V254363.R01.S.doc Version 5.0 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 The residents have the opportunity to take part in a good range of activities which take account of their religious and cultural needs. They are also supported to maintain contact with family and friends. The residents are generally satisfied with the meals provided and there are feedback systems to make sure that the meals reflect their preferences and needs. EVIDENCE: A programme of summer activities included a garden party, trips to the coast and a visit to a local park. A garden party with the theme of ‘One World’ was planned for early September. A Roman Catholic Priest and a Minister from the Church of England each visit the home each month. Other activities which take place in the home include bingo competitions, art and craft classes and a visiting library. Residents are able to order a daily newspaper. The residents asked about this issue said that they were satisfied with the activities available to them. Visitors are able to come to the home at all reasonable times and residents confirmed that their visitors are welcomed to the home. There is a visitor’s room in the home so that private visits can take place. The room has a bed settee and en-suite facilities. Information about advocacy services is displayed in the home. DS0000030684.V254363.R01.S.doc Version 5.0 Page 13 The ethos of the home as described in the statement of purpose, includes ‘seeking to give each resident or their advocate a real say in the running of the home’. The home continues to hold formal meetings for residents each month and there is regular informal contact between the manager and residents, as well as with the care staff. The residents spoken to during the inspection said that they had enjoyed the fish and chips provided for lunch that day. They reported that if they do not like the main dish then alternative meals are available. During the inspection two residents said that they found the chicken served for the evening meal rather too spicy. This was taken seriously by a member of staff who said that she would inform the catering staff. In addition menu comment books are kept so that staff can record comments about the food and the cook can use the records in menu planning. The cook attends residents meetings regularly so that she can receive comments directly. DS0000030684.V254363.R01.S.doc Version 5.0 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 and 18 There are effective systems in place to ensure that residents’ views and concerns are addressed and that they are protected from abuse. Property lists should be completed and kept up to date so that the residents’ interests are promoted. EVIDENCE: The residents receive information about the complaints procedure in their ‘welcome pack’. Residents said that if they were unhappy with anything about the home that they could raise it with the staff or the manager and that they felt confident concerns would be dealt with. The manager reminds residents about the complaints procedure at the residents’ meetings and there are notices throughout the building which give details about the variety of ways in which concerns can be raised. One of these is the Anchor ‘Care Line’ – a telephone service for reporting complaints. There are also notices displayed for staff about the whistle-blowing procedure which they may use to report concerns. It was noted on residents’ files that in one case the property list held was incomplete. An audit should be carried out to make sure that the lists are complete as this contributes to the protection of residents’ interests. DS0000030684.V254363.R01.S.doc Version 5.0 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): 19, 23, 24, 25 The residents benefit from a clean and homely environment which is safe and assists them to maintain their independence. EVIDENCE: The building was very clean and tidy when the inspector visited. Several residents said that they liked their bedrooms, and were particularly pleased that there are en-suite facilities provided. Residents are able to bring items of their own furniture to their rooms and to personalise their rooms as they wish. Adaptations are made throughout the building to aid mobility and independence. These include hand and grab rails, raised WC seats and a passenger lift. There is ample communal space and it is comfortable and suitable for its purpose. Each of the four units has a lounge-dining room which has a television and in addition there is a large lounge on each floor. Some of the residents like to sit together in the hallway of the home where they enjoy seeing the visitors come and go and chatting with them and with each other. DS0000030684.V254363.R01.S.doc Version 5.0 Page 16 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 There are enough staff on duty to make sure that residents’ needs for care and support are met. EVIDENCE: The staffing levels are for there to be nine care staff to be on duty in the mornings, two on each unit, with an additional worker to provide care where there is the greatest need. In the afternoon there are eight care staff on duty. Senior staff are on duty between 8am and 10pm. At night time there are four staff on duty, one of whom is a senior member of staff in overall charge. Between 8am and 5pm on weekdays there is a manager on duty in the home. The observation during the inspection was that the staffing was adequate for the numbers and needs of the residents. DS0000030684.V254363.R01.S.doc Version 5.0 Page 17 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, 38 The residents benefit from a competent and appropriately qualified manager. The residents and staff are protected through the health and safety arrangements but a system needs to be devised to ensure that call bells are tested regularly and the fire risk assessment is reviewed. EVIDENCE: The Registered Manager is appropriately qualified and experienced for the role. A range of records relating to the health and safety in the home were inspected. The records showed that regular health and safety inspections take place, tests of electrical appliances had been undertaken, fire drills take place regularly and weekly tests of the fire detection systems are conducted. Areas identified as needing improvements were to ensure that regular checks of the call bell systems are made and recorded and that the fire risk assessment is reviewed annually. DS0000030684.V254363.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 3 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x x x 3 3 3 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 3 x x x x x x 2 DS0000030684.V254363.R01.S.doc Version 5.0 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 OP7 Regulation 15(1) Requirement Timescale for action 01/11/05 2. OP18 17(2) Sch 4 para 10 3. OP38 23(2)(c) 4. OP38 23(4)(v) The Registered Provider must ensure that improvements to care plans are made by ensuring that notes in files are made each day and contain an appropriate level of detail. (Previous timescale of 1/1/05 not met). The Registered Provider must 01/11/05 ensure that an audit is conducted to ensure that the residents’ property lists are complete. The Registered Provider must 10/10/05 ensure that tests of the call bell system are made each week and recorded. The Registered Provider must 01/11/05 ensure that the fire risk assessment is reviewed annually. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. DS0000030684.V254363.R01.S.doc Version 5.0 Page 20 No. Refer to Standard Good Practice Recommendations DS0000030684.V254363.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 DS0000030684.V254363.R01.S.doc Version 5.0 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. 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