Inspection on 05/12/06 for Greenlands

This inspection was carried out on 5th December 2006.

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

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

Other inspections for this house

Greenlands 19/09/07

Greenlands 25/04/06

Greenlands 07/11/05

Greenlands 10/05/05

Greenlands 24/01/05

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

CARE HOMES FOR OLDER PEOPLE Greenlands 46 Green Lane Bolton Lancashire BL3 2EF Lead Inspector Lucy Burgess Unannounced Inspection 5th December 2006 09:30 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 Greenlands DS0000061961.V320461.R01.S.doc Version 5.2 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. Greenlands DS0000061961.V320461.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greenlands Address 46 Green Lane Bolton Lancashire BL3 2EF 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) 01204 531691 Mrs Asma Ali Khan Mrs Shagufta Parveen Rasul Hussain Mrs Shagufta Parveen Rasul Hussain Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Greenlands DS0000061961.V320461.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service should employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection. 25th April 2006 Date of last inspection Brief Description of the Service: Greenlands is a private residential care home registered to provide care for up to 28 older people. Placements made at the home are made from the local authority or through private referral. Fees range from £315.00 to £350.00. This is dependant on single or shared accommodation. The property is detached and set in its own well-maintained gardens. There is also parking to the rear. The Home is situated close to all local amenities and easily accessible for local transport to Bolton. The Home comprises of four single bedrooms and twelve double rooms. They are individually decorated and furnished and include a wash hand basin and a nurse call system. There are no en-suite facilities. The Home offers the choice of two lounges and a separate dining room. The standard of cleanliness is good. There has been an on-going programme of maintenance and re-decoration to enhance the environment. Greenlands provides comfortable accommodation for the residents living there. Greenlands DS0000061961.V320461.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and carried out over two days for a period of 14 hours. The inspector spent some time looking around the home, examining records as well as talking with residents and staff. Observations were made of meal times. Discussion and feedback was also held with the Providers, one of who is the Registered Manager. The home is registered to provide accommodation for 28 people, however the occupancy level at the time of the inspection was 20. Although the inspection was unannounced the completion of a pre-inspection questionnaire was requested. Feedback surveys had not been made available to residents and their families prior to the visit therefore were not completed. Feedback surveys were received from 2 GP’s and 2 Social Workers. Comments have been added to the report. All the key standards were looked at during this inspection visits. What the service does well: Several areas of training have been provided for staff with further plans for the forthcoming year providing staff with the knowledge and skills they need to support the residents living at the home. The Management are also looking at ways in which they can further improve areas within the home and the service that they provide. Generally there have been little changes with the staff team and residents living at the home. Residents appeared settled and were looking forward to the festivities. Observations found that residents interacted well with each other as well as the staff. One resident stated that, ‘I’m happy at Greenlands, I’m being looked after’. Cards and letters have been received from relatives expressing their gratitude for the care and support provided to their relative whilst living at Greenlands. Greenlands DS0000061961.V320461.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can Greenlands DS0000061961.V320461.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. Greenlands DS0000061961.V320461.R01.S.doc Version 5.2 Page 8 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 Greenlands DS0000061961.V320461.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information regarding the home, it’s facilities and what the residents should expect have been developed however they are not routinely given out. Without this information individuals are not able to make an informed decision regarding the suitability of the home and if their needs can/are being met. Relevant information had been gathered with regards to the assessed needs of prospective residents. This enables the home to make a decision about the suitability of the placement prior to the person moving in. EVIDENCE: The home has developed a Statement of Purpose and Service User Guide. A copy is also held in large print should this be required. Minor amendments are required to the documents due to the changes within the staff team and structure. Greenlands DS0000061961.V320461.R01.S.doc Version 5.2 Page 10 From discussion with the Manager these are not routinely handed out but a copy is accessible on request. The Manager is advised to provide additional copies so the prospective residents and/or their representatives can take them away when considering a move into the home. The home has also developed individual contracts in line with the standard. Information also identified the room to be occupies and fess payable. Copies have been distributed to residents or their representative where appropriate and signed by all relevant parties. Three files were examined for the newest residents. Each had been placed at the home by a funding authority and information into their assessed needs had been provided, such as the initial assessment, risk assessment and service specification. Information was detailed and outlined the emotional, physical and medical needs and the support they required as well as any aids needed. Further details included areas of risk, health screening, finances and mental health. Where individuals had been discharged to the home from hospital details were provided of current medication. This information provided a good over view into the needs of residents and whether they could be met by the home. Through discussion with one of the Owners, arrangements had also been made to visited prospective residents in hospital as part of the referral and resettlement process. Standard 6 does not apply to Greenlands, as they do not provide Intermediate Care Services. Greenlands DS0000061961.V320461.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Whilst residents’ care needs and assessments are in place, information needs to be developed and monitored so that records fully reflect the changing needs of residents ensuring their safety and well-being is addressed. A safe system of storing medication was in place. Further improvements are needed to records ensuring the system is safe and residents are protected. EVIDENCE: Care files were examined for three residents who had moved into the home following the last inspection visit. Files were orderly and included information such as a service specification, generic risk assessment, assessment and placement agreement. Care files also included a care plan and risk assessments in relation to moving and handling, nutrition and pressure care. Some of the records need to be expanded upon. One resident with moving and handling needs had mixed information recorded on file. Whilst some areas stated unable to walk, another documents stated Greenlands DS0000061961.V320461.R01.S.doc Version 5.2 Page 12 needs support with transferring and walking and a further entry stating walking improved. Information needs to be accurate so that staff are clear about the level of support and assistance residents require. This will prevent any accident or injury to both residents and staff. Another resident was being monitored due to having diabetes. Clear information needs to be detailed on the file showing how this is to be monitored and what action should be taken if there were any concerns. Further areas that needed to be fully assessed included areas where residents have had changes in behaviour, sleep pattern and have been wandering. Further documents are held and include daily diaries, monthly weight records, professional visits, such as GP’s, social workers, dentist, hearing checks, dentist and district nurse etc. With regards to weight records it was clear that the Manager had monitored these where changes had occurred. Suitable arrangements had been made for those individuals requiring supplement and nutritional assessments had been completed. The home has also purchased chair scales so that accurate weights can be recorded. It was noted within records that a number of accidents and incidents had occurred involving residents. Information was checked to see if it corresponded with details recorded within the accident book. The Manager must ensure that where an accident or incident has occurred, which may affect the well-being of a resident that information is clearly recorded within the accident and that written notification is forwarded to CSCI inline with Regulation 37. This will allow for issues related to residents to be monitored. For example on resident who was ‘tracked’ through the visit had fallen 7 times within a nine week period. There was no information on file to show that this was being explored. This should be clearly evidenced on the care plan. The medication system was examined. Medication continues to be supplied by BOOTS pharmacy. Records are made of item received and retuned by the home. An error was found with regards to some controlled drugs, which had been received. Whilst they hade been stored appropriately they had not been recorded. All medication is now stored within two secured trolleys away from the heating boiler. On examination of the stock it was found that several items had been taken from the box they had been dispensed in and placed lose within the trolley. A bottle of liquid medication was also found without a label. The Manager must ensure that all medication is clearly labelled and only administered to those for who it has been prescribed. Those items where Greenlands DS0000061961.V320461.R01.S.doc Version 5.2 Page 13 boxes or labels have been lost or are unable to be read must be returned to the supplying pharmacy. On examination of records, information is recorded within regards to blood checks, which have been carried out for those residents who take warfrin. However where changes have been made to the sheets or additional medication has commenced, written records should be signed, dated and then countersigned to ensure that the information recorded is correct. Time was spent both observing and speaking with residents. Observations found that residents interacted well with each other as well as the staff. One resident stated that, ‘I’m happy at Greenlands, I’m being looked after’. Another resident hadn’t settled at the home, as she had wanted to remain in Blackburn where she had lived. The Manager was following up on this request and had made contact with the Social Worker involved. Feedback was also received from 2 visiting GP’s and 2 Social Workers. The majority expressed that they were satisfied with the overall care of the residents however one did not. Other comments included that they were able to see residents in private, that was always a senior member of staff on duty and that the home communicated clearly and worked in partnership. Greenlands DS0000061961.V320461.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12 to 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Suitable arrangements regarding activities are in place offering choice and stimulation however this area could be explored. The dietary needs of the residents were also catered offering choice. EVIDENCE: Some improvements have been made in this area. Since the last visit arrangements have been made for residents to go on day trips, meals out and a theatre trip. This has included; Cleveleys, Morecombe, Blackpool, Illuminations, Smithles Coaching House and The King and I at Bolton Albert Halls. Other activities are advertised for those being provided within the home. These include exercises, sing-a-long and nail care. The home also has a lady who visits who offers massage and hairdressing as well as clothes parties and an occasional entertainer. Arrangements were also being made for the forthcoming Christmas party, which was being planned for residents and their families and included a raffle. Greenlands DS0000061961.V320461.R01.S.doc Version 5.2 Page 15 Whilst finance records showed that residents had been paying for hairdressing and massage no other records including the daily diaries showed that residents had been involved in other activities. Where this has been provided this should be documented. One of the residents is Asian and arrangements are in place for her to attend the Asian Elders Centre as well as having a volunteer. This enables her to access the wider community as well as socialising with other people from her own religion and culture. Adequate arrangements are made within the home with regards to providing a Halal diet and festivals are observed. With regards to meals, lunchtime on one of the days was observed. The main meal is served at lunchtime and comprised of roast lamb, potatoes, vegetables, grave and mint sauce. Desert was home made rice pudding. Residents were asked if they would like second helping, which they did. There was little waste. Several of the residents required a soft pureed diet. Food had been processed together and therefore did not appear very appealing. Where this is required by residents, items should be blended separately so that the meal is more attractive. Both cooks are experienced caterers and have worked within homes for many years. Items such as pies, deserts, cakes etc are homemade. At present the cooks are making the Christmas cake for the home. One resident commented that the previous day the cook had made egg custard, which she had really enjoyed and had eaten 3 pieces. Other residents commented that the food was good and that they were full when leaving the table. Where the diets of some residents are poor, supplements are provided. Additional monitoring is also done of residents’ weights, these are carried out on a monthly basis and reviewed any the Manager to see if there have been any changes. As stated further within the report the home has had an inspection by the food hygiene inspector. Action identified is being addressed. Training has also been completed by the relevant staff with regards to the new legislation. Greenlands DS0000061961.V320461.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements are in place in relation to the protection of service users as well as responding to their concerns. The majority of staff have completed training ensuring they are fully aware of the procedure to follow ensuring the residents are protected. EVIDENCE: A copy of the homes complaints procedure is displayed within the home. From observations made residents feel able to openly speak about the likes and dislikes within the home. Cards and letters have been received from relatives expressing their gratitude for the care and support provided to their relative whilst living at Greenlands. Since the last inspection visit no concerns or complaints have been received by the home or CSCI. Issues were raised with the inspector by one staff member. Discussion with the staff member was then held with one of the owners. It is suggested that when staff raise issues that they receive feedback about the action being taken and will therefore feel that the matter is being addressed as opposed to ignored. The Manager is also advised to put in place a formal complaints/concerns book and where issues are brought to her attention they are recorded detailing what action has been taken. Greenlands DS0000061961.V320461.R01.S.doc Version 5.2 Page 17 Information in relation to adult protection procedures are also held within the home and available to staff. In relation to Adult Protection training, this has been provided to members of the team. Further arrangements are being made for the new employees to attend. Greenlands DS0000061961.V320461.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Greenlands provides a clean comfortable, homely environment for the residents. Further redecoration and refurbishment have been identified to enhance the environment. Additional aids and adaptations have been provided to meet the needs of older people. EVIDENCE: Further work has been carried out in relation to facilities provided within bathrooms, which meet the needs of residents. One of the bathrooms has been fitted with a new bath a chair hoist, 2 of the shower rooms now have walk-in showers, which provide easy access and space so that support can be provided safely. One bedroom has also been fitted with a new vanity unit and a salon washbasin has been fitted in the downstairs bathroom for the hairdresser. Greenlands DS0000061961.V320461.R01.S.doc Version 5.2 Page 19 The Owners are aware that further work is required to the environment including the redecoration of the new bathrooms now the work has been completed as well as a replacement carpet for the hall stairs and landings. This has been identified within the improvement plan for 2007. On-going issues have been raised with regards to the heating of the home. Servicing has taken place with regards to the boilers however due to the age of part of the system some of radiators need to be regularly bled. This is carried out by the handyman and needs to be monitored. The home has also been experiencing problems with the clothes drier. This has caused difficulties in ensuring that items are dried properly. The Manager is to explore suitable arrangements for items to be dried until the machine is repaired. It is advised that items are not placed on the radiators throughout the home as this will affect the heating of rooms for residents. The home employs two domestic staff that are in the main responsible for the cleaning of the home, however some tasks are completed by care staff. The home was found to be clean and tidy. Supplies of cleaning materials were also available. The Manager must ensure that adequate hand-washing soap, paper towels and protective clothing are available at all times where personal care is provided to prevent cross infection particularly as 3 residents have been discharged from hospital with E-Coli. Greenlands DS0000061961.V320461.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27 to 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Sufficient staffing levels and training are provided. Some improvements are need to staff recruitment files to ensure the safety and protection of the service users. EVIDENCE: At present the home is supporting 20 residents. Staffing throughout the day generally comprises of 3 day staff including the Manager, a cook and a domestic. Evenings are covered by 3 staff with 2 wake-in staff throughout the night. The home also has a person on a work placement scheme that helps once or twice a week with lunchtimes and serving drinks. Staff are allocated tasks each shift for which they are responsible for completing. Through discussion with a number of staff members, it was felt that some staff did not always ‘pull their weight’ and left work for others to do. As the team is relatively small all staff need to work as a team to ensure that residents are supported fully. The Manager should explore this with the team. Since the last visit three new staff have been employed by the home in the role of carer and domestics. The personnel files were examined for the new staff and the work placement worker. Information included an application form including health declaration, CV, written references, copies of identification, photograph, POVA check and CRB. Minor shortfalls were found Greenlands DS0000061961.V320461.R01.S.doc Version 5.2 Page 21 with regards to 2 written references being available, a complete application form and gaps in employment. In relation to the placement worker a criminal record check had also been completed along with a risk assessment in relation to her role and responsibilities. In relation to training, a variety of courses have been made available. These have included adult protection, infection control, fire safety, moving and handling, care of the dying, dementia and medication. Arrangements are being made for the newest members of the team to complete the relevant courses. Further training was identified with regards to incontinence care and diabetes. During the inspection this was followed up and arrangements are to be made with a suitable training provider in the New Year. Copies of certificates had been placed on file to evidence their attendance. Further training has been offered with regards to NVQ with some funding being made available for Level 2 and 3. The Manager anticipates completing her NVQ level 4 and Registered Managers Award by March 2007. Greenlands DS0000061961.V320461.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Relationships and communication have improved within the team. Arrangements need to be in place for the reviewing of the service provisions to ensure that the home delivers a quality service. Adequate arrangements continue to be in place to safeguard service user finances. Improvements are needed to ensure the health, safety and welfare of residents is maintained. EVIDENCE: The current owners took over the home approximately 2 years ago. Whilst initially there were some difficulties, which resulted in staff leaving, this now appears to have settled. Staff spoken with felt that morale within the home had improved and that improvements had been made. Greenlands DS0000061961.V320461.R01.S.doc Version 5.2 Page 23 With regards to quality monitoring, the home does not complete the Regulation monthly reports as they are on site several days each week, therefore have regular contact with residents, staff and visitors. Discussion and feedback is also sought from staff through supervisions and team meetings. The home also has a resident’s feedback questionnaire however these have not been distributed for sometime. The Manager is advised to explore this area and consider seeking feedback from other people who are known to them, for example, Social Workers, GP’s, and District Nurses etc. Information gathered can also be used to inform the development of the home improvement plan. As outlined earlier within the report cards and letters had been received from 3 relatives expressing their gratitude for the care and support provided to family members. Records were checked with regards to resident’s finances. In the main residents finances are managed by an appointed representative. A bank account has been opened for 1 resident who requires assistance. Personal allowances were also held for several other residents. A random check was carried out with regards to money held. This corresponded with the records held. With regards to health and safety, checks had been carried out be external professional in relation to hoists, passenger lift, fire equipment, gas, emergency lighting and call bells, small appliances and electric. Checks are also made in relation to fire safety and a recent risk assessment and training as been completed by an external provider. Records were seen for water temperatures. It was noted that a majority of reading were between 48 and 49oC. These should be adjusted and maintained at around 43oC. The Manager expressed that she would discuss this with the handyman. Information was provided within the pre-inspection questionnaire with regards to accidents admissions to hospital. The details provided stated did not correspond with the records held within the home or information, which had been forwarded to CSCI. On inspection of the diary notes it was found that further incidents had arisen however had not been documented within the accident book. Where residents have attended or been admitted to hospital this too needs to be recorded on the Regulation 37 forms and forwarded to CSCI. As already stated the home has also been inspected by the Food Safety Inspector. Action identified was being addressed. Training had also been completed in relation to the new legislation that has been implemented in this area. Greenlands DS0000061961.V320461.R01.S.doc Version 5.2 Page 24 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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Greenlands DS0000061961.V320461.R01.S.doc Version 5.2 Page 25 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 OP1 Regulation 4&5 Requirement The Registered person must ensure that copies of the Statement of Purpose and Service User Guide are made available to service users or their representatives. Timescale for action 30/01/07 2. OP7 13 The Registered Person must 30/01/07 ensure that accurate information is recorded within the care plan with regards to the support required by residents when being supported with moving and handling. The Registered Person must ensure that the care plans are signed to evidence that they have been agreed by the service users and/or their appropriate representative (outstanding requirement). The Registered Person must ensure that relevant training is undertaken so that staff are able to offer safe support to residents with diabetes. DS0000061961.V320461.R01.S.doc 3. OP7 15 30/03/07 4. OP8 13/12 30/03/07 Greenlands Version 5.2 Page 26 5. OP8 12 The Registered Person must ensure that residents are monitored in relation to falls and action taken to address any/all concerns. (Outstanding requirement) The Registered Person must ensure that medication is dispensed from the labelled box ensuring it is administered to the person it was prescribed for. The Registered Person must ensure that medication, which is unlabelled, is returned to the supplying pharmacy. The Registered Person must ensure that when controlled drugs are received by the home that appropriate records are maintained. The Registered Person must ensure that all staff personnel files are available for inspection and all information as required under schedule 2 is in place prior to commencing employment. (Outstanding requirement) The Registered Person must ensure that water temperatures are maintained at 43oC. The Registered Person must ensure that accurate records are maintained with regards to accident and incidents involving residents. The Registered Person must ensure that incident which may affect the well-being of residents and notified to the CSCI in line with the regulation. DS0000061961.V320461.R01.S.doc 30/01/07 6. OP9 13(2) 30/01/07 7. OP9 13(2) 30/01/07 8. OP9 13(2) 30/01/07 9. OP29 19 30/03/07 11. OP38 23 30/01/07 12. OP38 13 30/01/07 13. OP38 37 30/01/07 Greenlands Version 5.2 Page 27 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. 3. 4. 5. 6. 7. 8. 9. Refer to Standard OP9 OP12 OP15 OP16 OP26 OP26 OP27 OP31 OP33 Good Practice Recommendations The Registered Person should ensure that handwritten entries on the mar sheets are signed, dated and counter signed to ensure that information is accurate. The Registered Person must ensure that service users are consulted with in relation to activities within the home. The Registered Person must make arrangements for those residents who require a pureed diet, that meals are presented nicely and not mixed together. The Registered Person must have a complaints record in place for the recording of any issues brought to her attention along with action taken. The Registered Person must ensure that the heating is monitored ensuring the home is adequately heated for the residents. The Registered Person must ensure that adequate provisions are available for staff with regards to managing cross infection. The Registered Person should explore feedback received from staff with regards to the delegation on completion of tasks within the home. The Registered Person must ensure that communication between management and staff continues to improve ensuring continuity of care. The Registered Person should consult with other parties and feedback included within the homes development programme. Greenlands DS0000061961.V320461.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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