Inspection on 17/03/06 for Greenhive House

This inspection was carried out on 17th March 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Greenhive House 16/02/07

Greenhive House 12/08/05

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 Duncan Paterson Unannounced Inspection 10:00 17 March 2006 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 DS0000030684.V271203.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.V271203.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 0207 639 8423 connie.oppong@anchor.org.uk 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.V271203.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th August 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. The home is purpose built and was opened in 2001. The home is arranged into four group living units, each with its own living room and dining room. All of the bedrooms are single and have en-suite facilities. There is a large garden to the rear. The home is in Peckham, within a reasonable distance of the shopping centre and public transport routes. Anchor plan to make a change to the service to include registration to provide dementia care services and to reduce the registered numbers to 48. The plan involves one unit being leased to SLAM who aim to provide part of their services from Greenhive. This plan is currently subject to a registration application being considered by CSCI. On the day of the inspection there were 47 service users present. One of the units was empty in preparation for the change. DS0000030684.V271203.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 took place on 17 March 2006. Time was spent in each of the three units including time spent talking with service users, staff and visiting relatives. Observation also took place as well as use of case tracking methods to assess care provision. Time was spent at the start and end of the inspection with the manager and deputy manager. What the service does well: 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. DS0000030684.V271203.R01.S.doc Version 5.0 Page 6 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.V271203.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&4 The service is good at drawing up a range of assessment information. Staff are knowledgeable about individual service users and both service users and relatives value the work staff do. EVIDENCE: Five service user’s care plans were inspected in order to consider the assessment and care planning arrangements. The deputy manager said that each service user is referred via Southwark social services department and a care assessment is completed as part of the referral process. Copies of assessments are retained at the home. The assessment process for service users is clear and well organised. Assessment information from local authority social workers is backed up by a range of assessment information drawn up by staff at the home. This includes an individual lifestyle agreement for each service user. The inspector spoke with service users as well as visiting relatives. Feedback was positive with one set of relatives identifying communication as a strong point. “They talk to you. That’s good”, the relative said. Service users generally gave positive feedback DS0000030684.V271203.R01.S.doc Version 5.0 Page 8 about the staff and the help they were given. Two service users raised individual concerns which the inspector was able to feedback to the manager and deputy manager. Staff demonstrated a good understanding of service user’s needs as well as the needs of the service user’s whom they provided a keywork service to. DS0000030684.V271203.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): 7, 8,9 & 10 Care planning documentation is detailed and varied but needs to link, in more detail, assessed needs with objectives for care provision. Staff work well to meet service users needs and are aware of their responsibilities. EVIDENCE: Case tracking methods were used to assess the care planning arrangements and how care to individual service users was being delivered. Five service user plans were inspected and four of the service users were spoken with. In general the care planning documentation is detailed and provides a variety of reviews, assessments and records relating to the care provided to service users. Health matters were well documented with links to services provided by health care professionals such as district nurses. Service users spoken with in the main gave positive feedback about the care provided and the work of staff. Only relatively minor maters were raised with the inspector. Staff demonstrated a good knowledge of service user’s and their needs as well as a good understanding of their responsibilities and the home’s systems. DS0000030684.V271203.R01.S.doc Version 5.0 Page 10 One area that needs development is linking service user’s assessed needs to care plan objectives. The care plans seen had objectives but these did not detail entirely what service user’s needs are. A recommendation is given about this. The manager told the inspector that the Anchor care planning documentation is currently under review with a new care planning format due out in the summer of 2006. Medication is stored and records kept on each unit. The storage and records were inspected for two of these units. The arrangements were clear with records being kept properly. DS0000030684.V271203.R01.S.doc Version 5.0 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): 12, 13, 14 & 15 There is a relaxed, informal feel to the home with staff enabling service users to choose activities and ways to spend their time. Food arrangements are good with many of the service users reporting that food provided is good. EVIDENCE: On the day of the inspection staff organised a St Patrick’s Day party for service users which was well attended. Currently, staff are responsible for organising activities as there is no activities organiser. The planned change to the service includes the appointment of an activities organiser. The inspector spoke with service users during the morning. Some service users spend time in their bedrooms and others in the unit lounges. One service user said she was bored but others said they were happy with activities provided and life at the home. Staff have been able to create a relaxed, friendly environment for service users with service users having some joint activities as well as quiet time in their own bedrooms or in the lounge areas. The deputy manager said that priests and church ministers visit regularly to provide religious services. Service users had visitors throughout the day. The inspector observed the serving of lunch. Meals are served in each of the three units. Heated trolleys are used to bring the meals from the kitchen. DS0000030684.V271203.R01.S.doc Version 5.0 Page 12 There are kitchens with dishwashers on each unit thereby assisting with the provision of a small homely feel to each unit. The meal was attractively served and looked tasty. Many of the service users said that the food was good and that they enjoyed it. A choice of meal was provided. DS0000030684.V271203.R01.S.doc Version 5.0 Page 13 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 The complaints recording system is clear and well organised. EVIDENCE: The complaints records were inspected. There had been eight complaints recorded since the last inspection. The majority of these were relatively minor in nature although one complaint is ongoing. There is a simple recording system with complaints cross referenced and with sections to report on the investigation, outcome and any action taken. DS0000030684.V271203.R01.S.doc Version 5.0 Page 14 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, 20, 21, 22, 23, 24, 25 & 26 An attractive, comfortable and homely environment is provided for service users. EVIDENCE: The home is attractively decorated and comfortable. The inspector visited all four units within the home. As discussed above, one unit was empty in preparation for the forthcoming change of use. The inspector visited three service users in their bedrooms and was shown a number of the home’s bathrooms by staff. The facilities provided for service users are very good. Each bedroom is single with en suite facilities including a shower. Service users had been able to either furnish or decorate their bedrooms to their own taste. The standard furnishings provided are of good quality. The layout of the home, with separate units for 16 service users each, allows a homely feel to develop within each unit. Each unit has a kitchen, lounge and DS0000030684.V271203.R01.S.doc Version 5.0 Page 15 dining area and there is plenty of space for service users. There are also rooms which can be used for activities for all service users to get together. DS0000030684.V271203.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, 28, 29 & 30 Staffing numbers are currently sufficient for the needs of service users. Recruitment is good with a clear and comprehensive recruitment process being followed. Staff are provided with a range of training although training certificates are needed on staff files to confirm that the training has been received. EVIDENCE: The inspector assessed these standards through an examination of the staff rota, a sample of staff recruitment files and staff training records as well as discussions with staff and the manager and deputy manager. There are separate staff for each unit. Staffing levels include three staff on one unit with three staff in the morning for the other two units. There is a duty senior worker on all day as well as either the deputy manager or manager. In addition, there are domestic, catering and administrative staff. Proposed staffing levels for the change of service have been submitted as part of the registration application to CSCI and will be assessed as part of the application. Currently, the staffing levels in use are adequate although on the day of the inspection there were some changes to the staffing rota with one worker not being available for duty and another arriving late. Staff recruitment is robust with evidence provided of a comprehensive recruitment process. The inspector looked at a sample of five staff files. Each file contained the required recruitment information with the exception of one file which did not have evidence that a Criminal Records Bureau (CRB) DS0000030684.V271203.R01.S.doc Version 5.0 Page 17 certificate had been obtained. The CRB process followed was discussed with the deputy manager who undertook to look for the missing CRB evidence. Training records were shown to the inspector. There is a training profile which has been drawn up for each member of staff. The profile states that there has been recent training with many staff having undertaken dementia care and care planning training. The deputy manager said that approximately 50 of staff have completed NVQ2 training. Although the deputy manager said that there were training certificates to back up the training profiles these were not on file and available to show the inspector. A requirement is given for these training certificates to be placed on file. This should not be a difficult task and will assist both the manager and deputy manager with planning and CSCI with an overview of what training staff have had. DS0000030684.V271203.R01.S.doc Version 5.0 Page 18 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, 32, 35 & 36 Service users benefit from clear management arrangements and effective leadership for staff. EVIDENCE: The manager and deputy manager have been able to provide clear, well organised direction for staff. This benefits service users as staff understand their responsibilities and the expectations upon them. The manager and deputy know both staff and service users well and have developed some good management systems to monitor care provision. A caring, friendly atmosphere has been created. Staff supervision arrangements involve the responsibility for supervision being delegated to senior staff. Some of the staff supervision records were shown to the inspector. These provided evidence that staff supervision is carried out regularly and that it is detailed. Staff spoken to confirmed that they had DS0000030684.V271203.R01.S.doc Version 5.0 Page 19 supervision. However, not all the records were available and the manager will need to ensure that delegated staff are carrying out staff supervision consistently. The inspector spoke with the home’s administrator about the arrangements made to look after service user’s money. A new Anchor system is being introduced later in 2006 which will involve more use of computer systems. The current arrangements are detailed and involve cross checking safeguards. A sample of service user records were inspected as part of the assessment. There is a service user’s account where all service user’s money looked after is placed. One service user has in excess of £1000 in this account and therefore is losing out on interest. A recommendation is given to liaise with social services and / or relatives to explore whether an interest bearing account can be set up. There was not sufficient time available at this inspection to assess the quality assurance arrangements. However, the manager said that there had been a recent assessment of the home against the Hospitality Assured quality system. A report will be available later in 2006 and future regulatory work will involve the study of this report DS0000030684.V271203.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 x x 3 3 x x DS0000030684.V271203.R01.S.doc Version 5.0 Page 21 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 OP30 Regulation 18 (1) (a) (i) Requirement The registered person must ensure that copies of staff training certificates are placed on staff files and are available for inspection. Timescale for action 01/06/06 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 OP35 Good Practice Recommendations The registered person should ensure that communication takes place with relatives and /or social services about the setting up of individual interest bearing bank accounts for service users. The registered person should ensure that service user’s assessed needs are linked in more detail to care plan objectives. 2 OP7 DS0000030684.V271203.R01.S.doc Version 5.0 Page 22 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.V271203.R01.S.doc Version 5.0 Page 23 - 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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