Inspection on 05/12/07 for Greenleigh

This inspection was carried out on 5th December 2007.

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 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

Greenleigh 18/03/09

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

CARE HOMES FOR OLDER PEOPLE Greenleigh 219 Wolverhampton Road Dudley Sedgley West Midlands DY3 1QR Lead Inspector Mandy Beck Key Unannounced Inspection 5th December 2007 08:30 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 Greenleigh DS0000070930.V355976.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. Greenleigh DS0000070930.V355976.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greenleigh Address 219 Wolverhampton Road Dudley Sedgley West Midlands DY3 1QR 01902 664 023 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) Select Health Care (2006) Limited Elizabeth Naylor Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36), Physical disability (6) of places Greenleigh DS0000070930.V355976.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home with Nursing (N) to service users of the following gender: Either Whose Primary care needs on admission to the home are within the following categories: Old age (OP) 36 Physical Disability (PD) 6 The maximum number of service users to be accommodated is 36 2. Date of last inspection New service Brief Description of the Service: Greenleigh is a purpose built nursing home registered to provide care to a maximum of 36 people. The home provides both personal and nursing care for older people. A qualified nurse is on duty at all times and is assisted by a team of care staff. The home has two floors. Bedrooms, bathrooms and toilets are situated on both floors, communal areas, lounges, conservatory and the dining area on the ground floor. Kitchen and laundry facilities are also provided on site. The home has parking facilities to the front and side of the property. The home is situated on the A459 Wolverhampton Road and is on a main bus route between Dudley and Wolverhampton. The home does not currently list the cost of fees in the Statement of Purpose or the Service User Guide. Some items that will not be covered by the weekly fee include hairdressing, non NHS chiropody, toiletries and newspapers. Greenleigh DS0000070930.V355976.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. since its registration in November 2007. The inspection lasted a day and was completed by one inspector. To help us make the judgements in this report we have used information given to us by the home in their Annual Quality Assurance Assessment (AQAA). We have also asked the people who live in this home and their relatives to comment on their care in our surveys. Additionally we have looked a people’s care using our case tracking process. This process gives us the opportunity to look at some people’s care in depth and to be able to make decisions about whether or not the home is meeting their needs. We also spoke to staff about their experiences of working in the home and looked at staff files to make sure that the home continues to recruit new workers safely. We looked around the home to make sure that it continues to be a clean and comfortable place to live. What the service does well: The home is clean and fresh, it is generally well maintained and people told us it was a nice place to live. They said “its always clean and fresh”. Each person will have an assessment of their needs before they agree to move in. Everyone has an identified key worker who will talk to them when planning and reviewing their care. This is then written into a monthly key worker report. All the people we spoke to and who answered our surveys agreed that meals are very nice. They enjoy a choice of home cooked nutritious food in pleasant surroundings. “you can have what you want to eat” The home has an Activity Organiser who has a monthly plan of activities which people can choose to take part in. The home has systems in place to make sure that it is run in the best interests of the people who live there. It consults regularly with them and acts upon their ideas. Greenleigh DS0000070930.V355976.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 be made available in other formats on request. Greenleigh DS0000070930.V355976.R01.S.doc Version 5.2 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 Greenleigh DS0000070930.V355976.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4,5 Quality in this outcome area is adequate. People who need to make a choice about living at this home will have enough information to help them make a decision. Their needs will be assessed although improvements could be made. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a statement of purpose and service user guide that gives prospective service users enough information to help them make an informed choice whether the home will be suitable for them. Each person will have an assessment of their needs before they move in. We looked at three people’s assessments as part of our case tracking process. The manager told us that new documentation had recently been introduced and staff were trying to get used to using it. This was evident when looking at some people’s assessments. We found that there were gaps in information Greenleigh DS0000070930.V355976.R01.S.doc Version 5.2 Page 9 and in one case less than half of the assessment had been completed. This lack of information could lead to difficulties when staff begin to plan care. Once the decision has been made to move into the home people are given a contract and terms and conditions of employment. The manager will also write to people informing them that the home is able to meet their needs once they move in. This home does not provide intermediate care services. Greenleigh DS0000070930.V355976.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is adequate. People who live in this home will have their healthcare needs met but improvements are needed to medication systems to make sure that people are protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the care files for three people. Residents have a plan of care that generally details their health and social needs. Care plans are developed whenever possible with their involvement and are reviewed monthly. Key workers also complete a monthly report which summarises the residents life at the home from the previous month. Care plans we looked at did not include all needs, for instance those people who have short-term health care problems such as a chest infection or a urine infection. In one person’s assessment staff have recorded that they need help with oral care but there was no care plan to show how staff were going to do this. Greenleigh DS0000070930.V355976.R01.S.doc Version 5.2 Page 11 We saw that each person had in their assessment, risk assessments for moving and handling, falls, nutrition and pressure sore risk development. We then found the same risk assessments repeated in the care plans. In some cases despite the risk assessments being the same the score was different even though it had been completed on the same day. This could lead to people being very confused and at worst residents not receiving the care they need because their care documentation is too repetitive and not consistent in all cases. For example one person had two nutritional risk assessments both with different scores. It was also concerning to find that this person had only one recorded weight in October 2007 despite being admitted in August 2007 and had been identified as being at risk. Another person had two pressure sore risk assessments both had different scores. One had indicated that the person was at low risk the other stating high risk. We found that some people required bed rails to keep them safe when they are in bed. It was pleasing to see that the home had completed a risk assessment for this but they must make sure that they review it on a regular basis. Although there were shortfalls in the home’s documentation it was pleasing to hear from staff that they were aware of the needs of the residents. When we spoke to them they were able to tell us the care needs of the residents. They also told us that they acted as Key workers for residents and because of this had a more in depth knowledge of those residents. Residents are appropriately referred to and have visits from health professionals such as GPs, specialist nurses, opticians and chiropodists although they have not recently had a visit form a dentist although this is being organised. Visitors spoken to said that they felt that they were informed of any changes in their relative’s health. Residents said “they always call the doctor if I am ill”. Medication practices in the home must be improved in order to safeguard residents well being. We found that the home does not always record on the Medication Administration Record (MAR) when medication has been received. We saw that some people’s medication had been dispensed into a medicine tot but was kept in the trolley. This is poor practice and must stop in order to reduce the risk of medication errors occurring and to keep residents safe. We found evidence to suggest that people are not being given their medication as it is prescribed. For instance one person still had antibiotics in the store cupboard that had not been dispensed. Another person needs an injection every three months, we found three ampoules of this medicine still in the medication cupboard. If the person had received the injection as they have been prescribed it then there should be no ampoules left at all. We also saw medication in the trolley with no residents name on it, the manager was asked to remove it. Similarly 5 blisters of Adcal tablets were in Greenleigh DS0000070930.V355976.R01.S.doc Version 5.2 Page 12 the trolley without names, without a box. This means that staff cannot be sure who this medicine belongs to. Another person was prescribed medication on an “as required” basis. When medication is prescribed this way a care plan should be in place that clearly identifies the circumstances of when the medication should be administered. If a person is found to be taking this “as required” medication on a regular basis then a review of this medication should be sought from the Doctor and the MAR sheet amended where necessary. The manager told us that she does not do a monthly medication audit at present but does plan to do this in the future. It is strongly recommended that this process begin sooner rather than later in order to protect residents from poor medication practices. The people living in this home told us that staff treat them with respect and dignity at all times. Staff we able to give examples of how they meet residents needs and how they respect their choices such as what time they like to go to bed and when they like to get up. The manager will need to do further work on the End of Life care planning for each person. It is acknowledged that this can be a sensitive subject to discuss with residents and where appropriate their families. However in all of the care plans we looked at each one was blank. In one case staff had written, “not appropriate”. This area of care planning must be improved. Greenleigh DS0000070930.V355976.R01.S.doc Version 5.2 Page 13 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): 12,13,14,15 Quality in this outcome area is adequate. People who live in this home are supported to lead an active life but improvements could be made. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home does provide some activities for people to take part in. On the day of the inspection the home was preparing for a pantomime, which was to be performed in the home. The activites are displayed on the notice boards in the reception and the main corridor. Staff told us “we could do more to get the residents out and about but there’s never the time”, “we try hard to sort things out for them to do, we are getting better”. Residents said, “I’d like to go out more and to use the garden”. “Apart from joining in singing when keyboard player visits there are no other activities that suit”. Relatives said, “I feel that there might be more effort made to stimulate them mentally”. Relatives and visitors are encouraged to come to the home at any time but the manager would ask that visitors give consideration to people’s needs. This is especially pertinent around mealtimes and bed time. Greenleigh DS0000070930.V355976.R01.S.doc Version 5.2 Page 14 The home provides details of advocacy services and they are on display on the notice board. The manager told us that none of the staff have received training around the Mental Capacity Act 2005. This is recommended so that staff understand their role in supporting people who may lack capacity to make some decisions for themselves. When looking at one person’s file we noticed that staff had documented “able to make own decisions” a further note in this person’s file said “all consent forms given to family to sign”. The home must make sure that if someone is able to make their own decisions they are included in this process. It is strongly recommended that the consent forms are kept under regular review to make sure that they continue to represent the wishes of service users. Meals are provided on a four weekly menu. We observed breakfast and lunchtime meals. It was pleasing to see that residents enjoyed their meals, they said “you can have what you want, nothing to much trouble”. Breakfast is served in two courses. People can have cereals and toast and a full English breakfast if they want one. All meals are a good size and presented nicely. The dining room is pleasantly decorated and makes meal times relaxing. It was however noted that the home stores all of its wheelchairs in the dining room when they are not in use, there are so many this takes up almost one third of the room. The manager said that there is no where else for them to be stored at this time Greenleigh DS0000070930.V355976.R01.S.doc Version 5.2 Page 15 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): 16,18 Quality in this outcome area is good. People who use this service can feel confident that the home will listen to and act upon their views and protect them from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a detailed complaints procedure that is displayed in the reception area of the home and is also in the service user guide. Since the last inspection the home has received only one complaint that was appropriately investigated by the manager. People told us that they were confident about raising concerns and that the home would address them. They said “I speak to the lady in the office and matters are dealt with”. We spoke to some of the staff about how they would protect the people living in the home from abuse. They told us, “I would report any bad practices straight away to the manager”, “we have a policy called Whistleblowing that we can use to report any concerns without others knowing”. “I would make sure that the resident is safe and then report to the nurse in charge immediately”. The home has appropriate policies and procedures for the protection of vulnerable adults. It also has an ongoing training programme for its staff to ensure that their knowledge is updated and they are confident of what to do if an allegation of abuse is made to them. There were some staff who said that they had not received any training but were able to give good Greenleigh DS0000070930.V355976.R01.S.doc Version 5.2 Page 16 examples of what to do if an allegation had been made to them or they had witnessed poor practice. Greenleigh DS0000070930.V355976.R01.S.doc Version 5.2 Page 17 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): 19,22,24,25,26 Quality in this outcome area is adequate. People who live in this home live in a well maintained, clean and comfortable environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is clean and well maintained with an ongoing refurbishment plan. The new bedroom curtains and throws are lovely and make people’s bedrooms very homely. People are also encouraged to bring treasured items with them when they come to live at the home. The lounges and dining room have all been decorated and are very comfortable. The additional heating of the conservatory enable it to be used throughout the year and gives resident’s additional choice of where to spend their day. The home has a variety of aids and adaptations such as grab rails assisted baths and a wheel in shower available for those who are more dependant. Greenleigh DS0000070930.V355976.R01.S.doc Version 5.2 Page 18 When we spoke to staff they told us that some more equipment would help them with their work. “an extra hoist would be good, then the residents may not have to wait for so long”. New chairs have been ordered for more dependent residents as current chairs are not suitable and put them at increased risk of pressure sores and look uncomfortable. The chairs are torn and look unsightly; the manger told us that it will be 6 weeks before the new chairs arrive. It was also noted that all three of the toilets on the ground floor next to the dining room did not have a sufficient supply of hot water. The cold water tap in one of these toilet’s was not working. One member of staff said “they’ve always been like this, its off and on you never know”. We checked people’s bedrooms upstairs and the hot water supply did not appear to be sufficient in all bedrooms. Staff told us “sometimes we put the plug in the sink and it takes ages to fill even then its not hot enough so we borrow some from the room next door”. The home is recording the hot water temperatures but they do not seem to reflect the findings on the day of inspection. The home must make sure that there is hot running water to all of the hot water taps in the home. The main garden is situated at the back of the home and is planted with shrubs and trees and mainly consists of a large patio area. Changes to access from the conservatory now enable all residents including those in a wheelchair to access the garden. The manager said that the home has recently been awarded a grant that will enable them to develop the garden area further in the spring. They plan to make it more of sensory experience for the people who live there. The home was found to be clean and generally free from any offensive odour. The home’s infection control practices are satisfactory with gloves, aprons and hand disinfecting gel available around the home. There are some improvements to be made for instance making sure that the underside of all the bath hoists, commodes and shower chairs have been thoroughly cleaned in order to reduce the risks of cross infection. Staff should also be encouraged to use the lids to the commode pots when transporting them from people’s bedrooms to the sluice. Greenleigh DS0000070930.V355976.R01.S.doc Version 5.2 Page 19 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): 27,28,29,30 Quality in this outcome area is good. The home generally provides enough staff to meet the needs of the people who live there. Staff are recruited safely and people are safeguarded as a result. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There appears to be enough staff on duty to meet the needs of the people living there. The manager has three days supernumery in order to “manage the home”. Other days she is counted in the staffing numbers. This can prove problematical at times when management issues arise and she is the only trained nurse on duty. We spoke to staff about what it was like working in the home they said “we are all working well together now, things are getting a bit more stable”, “when we have five staff in the morning providing the team all work well together then I feel that the residents needs are met”. The people who live in the home said “the staff here are lovely, they are really helpful and they work very hard for not much money, it’s a shame when they do such a good job”. Care staff are supported by the home in completing their National Vocational Qualifications (NVQ’s). Currently 26 out of the current care staff group of 30 have achieved their NVQ level 2. Greenleigh DS0000070930.V355976.R01.S.doc Version 5.2 Page 20 Staff files were also looked at during this inspection to make sure the home continues to recruit in a safe manner. Apart from some minor omissions generally staff had been recruited safely and appropriate checks undertaken before staff are allowed to start employment. The home supports new staff through an structured induction. Staff said “they showed me round when I started made me feel welcome and I had lots of training”. Greenleigh DS0000070930.V355976.R01.S.doc Version 5.2 Page 21 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): 31,33,35,38 Quality in this outcome area is good. The home is effectively managed and is generally run in the best interests of the service users whilst also ensuring that they are protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Greenleigh DS0000070930.V355976.R01.S.doc Version 5.2 Page 22 Since the last inspection the Manager has completed the Registration process with the Commission for Social Care Inspection. Mrs Naylor is now the Registered Manager for the home and runs the home in the best interests of the people who live there. A quality plan is available for the home that aims to improve and develop the home to meet people’s needs. Residents, relatives and placing officers satisfaction questionnaires are undertaken on a regular basis to obtain their views of the home. There is a monthly report of key areas such as accidents falls and complaints. All policies and procedures are reviewed annually. The process of auditing accidents and falls may be further developed by producing an action plan at the end of each audit to show how the home is going to further reduce risks to the people who live there. The majority of people living in the home have their finances managed by their families or by the Court of Protection. The home’s staff do not manage the finances of any residents. There secure facilities for the safe keeping of service users personal money and valuables if required. Written records are available for all transactions which detail the reason for the withdrawal and two signatures, receipts are available as proof of purchases. Some of the residents money stored in the safe was randomly checked and was satisfactory. The Manager has introduced regular supervision for all staff. Records seen show that the manager has an appropriate system in place to review the performance of all staff. Procedures to protect service users include regular checks on the fire alarm, emergency lighting, fire extinguishers, nurse call points and hot water. There were concerns raised about the hot water temperatures and the manager has been asked to deal with this. Records identify that staff regularly attend mandatory training in fire safety, moving and handling, food hygiene and health and safety. We found that some of the bank staff the home employs had no training records at all. The manager was asked to make sure that bank staff in particular receives fire training and a fire drill that is specific to the home to ensure that all staff would know what to do in the event of a fire. The manager said some bank staff have told her they have received mandatory training elsewhere but there were no training records to support this. The manager has been asked to make sure that all her bank staff have appropriate training to ensure that residents are not placed at risk by inadequately trained staff. Greenleigh DS0000070930.V355976.R01.S.doc Version 5.2 Page 23 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 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 1 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 2 X X X x 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Greenleigh DS0000070930.V355976.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? New service 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 OP3 Regulation 14(1) (a) Requirement Each person must have an assessment that details all their needs so that they can feel confident their needs will be met by the home. Risk assessments must be kept up to date and be consistent so that people are not placed at unnecessary risk. When people are assessed by the home as being at risk of malnutrition they must make sure that they record that person’s weight as directed in their care plan. The home must make sure that each person has a care plan for short term health problems when they occur, such as chest infections and urine infections. Each person must have their medication given to them as it has been prescribed. Staff must not dispense medication into tots and leave them in the trolley to be given to residents at a later time. Timescale for action 01/01/08 2 OP7 13 (4) 01/01/08 3 OP7 13 (4) 01/01/08 4 OP8 15 01/01/08 5 OP9 13(2) 01/01/08 Greenleigh DS0000070930.V355976.R01.S.doc Version 5.2 Page 25 When residents need medication on an “as required” basis a care plan must be in place that details the circumstances for administration. When administration of “as required” medication has taken place this must be clearly recorded in the residents MAR sheet. When residents are given “as required” medication regularly this must be reviewed by the resident’s own doctor. There must be no gaps on the MAR sheet all omissions must be accounted for. The manager must make sure that all medication in the home is clearly labelled, those medicines without labelled must not be used and disposed of. There must be a consistent supply of hot water throughout the home. This includes the three toilets on the ground floor. Residents must be able to awash their hands in warm water after having used the toilet. Residents must not be placed at risk by bank staff that have not received fire training or a fire drill that is pertinent to the home. 6 OP21 23(j) 01/01/08 7 OP38 23 (4) (e) 30/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Greenleigh DS0000070930.V355976.R01.S.doc Version 5.2 Page 26 1 2 3 4 OP1 OP7 OP11 OP14 5 6 OP21 OP26 It is recommended that the Statement of Purpose and Service User Guide be updated to include information about fees It is recommended that the home considers reducing the duplication of risk assessments in order to reduce the risk of errors and possible risk to residents. It is recommended that the manager begins to work with residents by discussing and planning their end of life care. It is recommended that all staff have training around the Mental Capacity Act 2005 to make sure that they are aware of their roles and accountability towards the residents they care for. It is recommended that the home records when it has disinfected the shower heads as part of its legionella risk reducing process. It is recommended that the underside of bath hoists, shower chairs and commodes are given a deep clean in order to reduce the risk of cross infection to residents. Greenleigh DS0000070930.V355976.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 77 Paradise Circus Queensway Birmingham B1 2TD 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. Extracts may not be used or reproduced without the express permission of CSCI Greenleigh DS0000070930.V355976.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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