Inspection on 19/04/07 for Greenmantle

This inspection was carried out on 19th April 2007.

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

Greenmantle 21/02/06

Greenmantle 21/09/05

Greenmantle 14/12/04

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

CARE HOMES FOR OLDER PEOPLE Greenmantle 20 Mornington Road Woodford Green Essex IG8 0TL Lead Inspector Ms Harina Morzeria Unannounced Inspection 19th April 2007 10:00 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 Greenmantle DS0000025903.V337429.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. Greenmantle DS0000025903.V337429.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greenmantle Address 20 Mornington Road Woodford Green Essex IG8 0TL 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) 020 8506 2301 020 8505 8791 Dr Mohammed Essam El-din Fahim Dr Thanna Abdil Hamid Kandil Dr Mohammed Essam El-din Fahim Care Home 15 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (15) of places Greenmantle DS0000025903.V337429.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may admit up to 3 people with dementia from the age of 60 years. 21st February 2006 Date of last inspection Brief Description of the Service: Greenmantle is a privately run residential care home in Woodford Green, registered to accommodate 15 elderly people, some of whom are suffering from dementia. The house is in a quiet residential area. The accommodation consists of one double bedroom and 13 single rooms which have en-suite facilities. Appropriate communal areas are provided as well as a well-kept garden for the residents’ enjoyment. A lift provides access to the first floor where most of the bedrooms are located. One of the proprietors is also the manager of the home. The proprietors are routinely involved in the day-to-day operation of the service. The Statement of Purpose informs residents, prospective residents and their representatives that the aim of the home is to promote a non-discriminatory service which promotes residents’ dignity, independence, privacy, choice, rights and provides fulfilment. There is evidence that these values are being achieved in the dayto-day operation of the home. A hairdresser visits the home fortnightly, as well as a massage therapist. Staff showed a caring and sensitive attitude towards the residents, which was confirmed by the residents spoken to on the day of the inspection. The Statement of Purpose and the Service User Guide are issued to every prospective resident and both of these documents are displayed in the entrance hall of the home. A copy of the most recent inspection report is also available. A resident or relative/representative could ask for his or her own copy, which the manager would make available. The fees for the home are £500-£525 a week. Greenmantle DS0000025903.V337429.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection visit in the inspection programme for 2007/ 2008. The inspector spoke to residents about their experience of living at the home and a relative whilst visiting the home. Discussions took place with the deputy manager, the senior carer and other staff on duty. Staff were spoken to about care practices and their employment at the home. They were also observed directly and indirectly providing care to residents. A number of staff and residents’ records were examined. What the service does well: What has improved since the last inspection? What they could do better: Although care plans are in place they are of a basic nature. A person centered plan of care needs to be drawn up, setting out in detail the action which needs to be taken by the care staff to ensure that all aspects of the health, personal and social care needs of the person using the service are met. The plan must be drawn up with the involvement of the person using the service or his/her representative and signed by them. Greenmantle DS0000025903.V337429.R01.S.doc Version 5.2 Page 6 Individual risk assessments must be carried out for each person who uses the service which is linked to a care plan, in order to eliminate any unnecessary risks to the health or safety of people using the service. All care staff must receive formal supervision at least six times a year which must be evidenced. The registered person is required to ensure that all staff working in the care home receive appropriate training in the care of people with dementia. The registered person should develop ‘End of Life’ care plans for all residents. The manager and staff team should consider how they can achieve the highest standards of care as set out in the Commission’s Key Lines of Regulatory Assessment. 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. Greenmantle DS0000025903.V337429.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 Greenmantle DS0000025903.V337429.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): 1,2,3 4 and 5 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents and their relatives have detailed information about the home to enable them to make an informed choice about moving into the home. A detailed pre-admission assessment is undertaken of all prospective residents, this will ensure that their identified needs can be appropriately met by the home. Prospective residents and their relatives are able to visit the home prior to their admission and obtain a copy of the service user guide, to help inform their decision about admission to Greenmantle. Intermediate care is not provided in this home. EVIDENCE: Greenmantle DS0000025903.V337429.R01.S.doc Version 5.2 Page 9 The Statement of Purpose clearly sets out the objectives and philosophy of the service. The Service User Guide is informative and written in plain English, a copy of this document is given to all residents. When requested the service can provide a copy of the Statement of Purpose and guide in a format which will meet the capacity of the resident. A quarterly newsletter is compiled which includes photographs of celebrations, special events, activities, outings and meetings to inform prospective residents and relatives as well as visitors about all the activities that take place in the home. The files of two new residents were looked at. A pre-admission assessment by the manager and an assessment from the local authority had been undertaken, as well as obtaining other background information from the family. Admissions only take place if the service is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident. Residents and relatives are able to visit the home prior to a resident moving in. This was confirmed by the new residents spoken to. Prospective residents are given the opportunity to spend time in the home. New residents are provided with a statement of Statement of Terms and Conditions/Contract, which sets out in detail what is included in the fee, the role and responsibility of the provider, and the rights and obligations of the individual. The manager actively promotes opportunity for discussion and clarification. Greenmantle DS0000025903.V337429.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 and 10 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents have basic individual plans of care in place reflecting their current needs, to ensure their health care needs are met. Residents are protected by the home’s medication policies and procedures which staff follow. Residents are treated with respect and the arrangements for their personal care ensure that their right to privacy is upheld. EVIDENCE: Each individual has a care plan but the practice of involving people who use the service in the development and review of the plan is variable. The plan includes basic information necessary to deliver the residents’ care but is not detailed or person centred. All residents had a care plan but some were more detailed than others. Several residents have challenging behaviour due to their dementia, but the care plans are not specific as to the strategies to be Greenmantle DS0000025903.V337429.R01.S.doc Version 5.2 Page 11 implemented to ensure good care for these residents, and to safeguard other residents. The care plan is not used as a working document and does not consistently reflect the care being delivered, as daily logs only reflect routine day to day tasks carried out for the residents. All residents living with dementia will have specific individual needs, and these must be reflected in the care plans. Care plans are reviewed and updated as required by the National Minimum Standards. People who use the service are aware that they have a care plan but there was no evidence to show that they are actively encouraged to be involved in its review or development. However evidence was seen that relatives/ representatives are invited to attend the annual reviews carried out by social services. The home’s procedures described the arrangements for providing key workers to support individual residents but the staff have a very limited role in practice and do not actively contribute to the care plan in place. Risk assessments are completed but these mainly focus on lifting and handling techniques for each resident. Risk assessments are not individual and are not linked to care plans. There was no evidence to show that decisions are agreed with the individual or that the risk assessments are reviewed and updated regularly. For example, a safety risk assessment had not been undertaken for one resident who has suicidal tendencies. The care plans must be comprehensive, identifying the residents’ personal, social and health care needs and how these should be met. They should be aimed at identifying what a person can do and how staff can work with the person to encourage them to continue to achieve their level of independence, resulting in a person centred plan, such as ‘X is able to shave by himself, staff to assist by setting up the shaver and place a mirror by his bedside table to enable him to carry out the task by himself’, ‘Y is able to undress by herself, staff to allow her to do this as far as she can before intervening.’ Residents’ health needs are identified as part of their care plan and record how these needs are to be met. Records indicate that health professionals such as chiropodists, dentists, GPs, community nurses have seen residents and staff support residents to attend hospital out patient appointments. Other written evidence includes residents being weighed monthly as well as fluid and bowel charts in place for those residents who require closer monitoring. There are policies and procedures for the handling and recording of medicines which support and inform practice. A random sample of Medication Administration Record (MAR) charts were examined which are routinely completed. Only senior staff are responsible for administering medication. Medication records are seen as key to the efficient management of health care matters, the home keeps them up to date. Staff responsible for administering medication have the required accredited training. Greenmantle DS0000025903.V337429.R01.S.doc Version 5.2 Page 12 Staff treat residents in a respectful and sensitive manner. Staff are aware of the need to communicate with residents when carrying out any tasks for them such as feeding or delivering personal care. All staff understand the need to respect residents’ dignity and knock on bedroom and bathroom doors before entering. All the residents spoken to stated that the staff are very good, caring and look after them well. Greenmantle DS0000025903.V337429.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 and 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The activities programme at the home meets the current needs of residents. Visiting times are flexible and people are made to feel welcome, this ensures that residents are able to maintain contact with relatives and friends. Residents have choice and control over their lives and are consulted via residents’ meetings. The meals in the home are well presented and nutritionally balanced. They offer both choice and variety to residents. EVIDENCE: There is an activity programme in place. Residents and relatives spoken to confirmed that a variety of activities are on offer both within the home and day trips are planned outside during fine weather. Entertainers including musicians Greenmantle DS0000025903.V337429.R01.S.doc Version 5.2 Page 14 are invited to the home to play old-time songs, which are thoroughly enjoyed by the residents. Residents confirmed that they do a number of activities inside and outside the home including outings, lunches, and walks as well as going out with their families. However, two relatives commented as follows, “I am concerned that my husband does not have any fresh air, such as sitting for a short while in the garden”, “my mum ... should have an opportunity to go out once a week just to see the outside world and to keep in touch with it. It is quite an effort for staff to do so and I feel it is the one and only weakness in Greenmantle.” There must be more consideration given to the specialist needs of people living with dementia. For instance more individual activities, including the use of life histories, and small group activities focusing on the individual’s needs and cognitive functioning, and adapting activities to relate to the individual’s likes, dislikes, past and present and concentration span. All staff must recognise the important part that they can play in the encouragement and motivation of residents living with dementia. Residents’ meetings take place showing that the residents are consulted about their choices and preferences around activities. However, this is only reflective of those residents who are able to express an opinion and as stated above, more effort needs to be made to include the views, wishes and expectations of people suffering from dementia. Some residents attend church on a Sunday morning whilst some others receive communion at the home. A hairdresser and manicurist attend regularly. One visitor spoken to said that they are encouraged to come and see their relative and are always made to feel welcome by the staff. There is an adjoining dining area where most residents have their breakfast and lunches. Mealtimes are flexible and relaxed. Residents confirmed that the food was good and they have a choice of food from the menu at mealtimes. The menus were seen to be nutritionally balanced and special diets are catered for. Staff support residents who require assistance with their meals. Comment received regarding food and cleanliness in the kitchen are as follows, “in all my visits the kitchen is always spotless”, “when I have made requests about diet, her care or changes they have always fully implemented these”, “ they take into account individual preferences for example, they always give my mother wholemeal bread.” Greenmantle DS0000025903.V337429.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents and their relatives can be confident that their complaints will be listened to and acted upon. The staff have undertaken training in adult protection/abuse awareness to ensure that there is an appropriate response to any allegations of abuse. EVIDENCE: The home has a clear complaints procedure, which is displayed around the home and is available in the Service User Guide. Both residents and relatives say that the manager is always available to them and that they are clear how to make a complaint or raise a concern. From discussion and comment, it is clear that residents in the home are comfortable with raising any concerns and are happy to speak their minds on anything that is an issue for them. The documentation was reviewed and a complaint log is kept. There is evidence that the majority of complaints are minor and that the manager lists all levels of concern, which shows good reporting. Records show that concerns are dealt with promptly and dates are noted. The records of complaints and compliments were examined. All complaints are logged. Complaints clearly Greenmantle DS0000025903.V337429.R01.S.doc Version 5.2 Page 16 indicate details of the complainant, the nature of the complaint and the outcome. Two residents were asked ‘if you were unhappy about anything in the home, who would you talk to’? They said they would talk to the manager or staff. A comment received reflects this, “my concerns are always dealt with sympathetically and professionally”. A large number of compliments have also been received by the manager about the high level of care and attention given to the residents at Greenmantle which have been reflected in various sections of this report. There is a written policy and procedure for dealing with allegations of abuse and whistle blowing. The home also has copies of all the local authority procedures on adult protection. Training on adult protection/abuse awareness is an ongoing programme that is attended by all staff. The inspector spoke to staff who confirmed that they had received in house training. The inspector recommends that the manager consults with the Redbridge learning collaborative regarding a full, informative and up to date adult protection training course which is accessible to staff. Greenmantle DS0000025903.V337429.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, 20,21,22,23, 24,25,26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is clean and spacious with access to indoor and outdoor facilities. There are sufficient and suitable toilets and bathrooms for the number of residents. The atmosphere in the home is welcoming. Each resident has their own bedroom and they are encouraged to personalise them with their own possessions. EVIDENCE: The home has a welcoming and homely atmosphere. A tour of the home was undertaken and it was clear that the home provides a physical environment that is appropriate to the specific needs of the people who live there. Residents were seen either participating in activities or listening to music. There is a through lounge leading through to the dining room and a conservatory at the back which leads to a small garden. This means that Greenmantle DS0000025903.V337429.R01.S.doc Version 5.2 Page 18 people using the service have a choice of place to sit quietly, meet with family and friends or be actively engaged with other people who use the service. The home is fully accessible throughout to the residents. The manager is monitoring areas in the home that need routine maintenance and renewal of fabric. The bedrooms vary in size, shape and facilities. All have en-suite toilets and a vanity unit. The bedrooms are appropriately furnished and are personalised by having photographs, pictures, radios and televisions that residents have brought from their own homes. A new bed has been purchased for a resident to maximise his comfort. The home is cleaned on a daily basis and throughout the inspection all areas of the home were found to be clean, tidy and smelt fresh. The following comment was received from one relative, “ I just knocked on the door one day and was totally impressed by the cleanliness of Greenmantle. This has never changed in the seven years my mum has been a resident.” There are sufficient toilets and bathrooms for the needs of the residents. Adaptations and equipment are in situ which are capable of meeting the needs of all residents. A new electronically operated Oxford mini hoist was purchased. The kitchen was visited by the inspector and was found to be clean and tidy and food was being stored and labelled appropriately. The kitchen equipment was fully upgraded with two new fridges, two freezers and a new gas cooker. All kitchen doors were replaced with new ones. An environmental health inspection and a health and safety visit were carried out in January and March 2007 respectively, which were both satisfactory. A full fire risk assessment has also been carried out. Greenmantle DS0000025903.V337429.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 and 30. People who use the service experience quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing levels are satisfactory and there are sufficient trained staff on duty to meet the individual assessed needs of the residents. The procedures for the recruitment of staff are robust and provide safeguards for people living in the home. EVIDENCE: The home has a relatively stable staff team with some staff having worked at the home for several years. The staff team are very committed and understand and fully support the main aims and values of the home. During the day there are three care staff on each shift, at least one of the care staff is a senior and one waking night staff plus one carer sleeping in and on call, which is sufficient to meet the current needs of the residents. There is a wide ethnic diversity in the staff team reflecting the diversity of the Borough of Redbridge. People using the service consistently report that their needs are being well met by the staff team. The home also employ two part time cooks and two domestic staff. Greenmantle DS0000025903.V337429.R01.S.doc Version 5.2 Page 20 Where possible residents were asked to give their views on the service and the care they were receiving. Written feedback was also received. One resident commented: “I am very happy here, staff are kind to me”. Other comments included: “Everyone is friendly”. “ They look after us well”. There are enough qualified, competent and experienced after meet the health and welfare of people using the service. Staff rotas take into account the needs and routines of the people using the service. The service recognises the importance of training, and tries to deliver a program that needs any statutory requirements and the national minimum standards. The manager is aware that there are some gaps in the training programme and plans to deal with this. Staff had received training in essential areas such as moving and handling, first aid, fire safety and medication awareness and administration. The deputy manager cascades information from a range of sources to keep staff up to date regarding care practices. The inspector recommends that the manager consults with the Redbridge learning collaborative regarding the range of training courses that are now available to residential care staff. Staff should be encouraged to access training from external sources which could be challenging and stimulating for them. The home is registered to provide care to people with dementia. However, the staff have only completed basic dementia awareness training. This issue was discussed with the manager as all staff must be trained and competent to deliver the care required by the particular group of residents they look after. The manager is required to ensure that all staff working in the home undertake the full accredited training in dementia care, in order to ensure that they are able to understand and fully meet the needs of residents suffering from dementia. All ancillary staff must also undertake basic dementia awareness training. Most of the care staff are qualified to NVQ level 2 except one staff who has enrolled on the course. A random sample of personnel files including the most recently recruited staff were inspected. These were found to be in good order with necessary references; criminal records bureau disclosures and application forms duly completed. Induction is provided to all new members of staff as confirmed by them and the manager, however the inspector was unable to see the document used in practice as the carer interviewed was unable to produce it. Greenmantle DS0000025903.V337429.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): 31,32,33, 34,35,36,37,38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from living in a home which is run by a qualified and experienced manager. The staff team work well together but must receive regular formal, individual supervision which must be evidenced, to make sure that residents are safe and secure whilst living at the home. Residents’ rights and best interests are safeguarded by the home’s recordkeeping policies and procedures. Residents’ and staff’ health, safety and welfare are promoted and protected. EVIDENCE: The manager has the required qualifications and experience and is competent to run the home and meet its stated aims and objectives. He is supported by a Greenmantle DS0000025903.V337429.R01.S.doc Version 5.2 Page 22 qualified and experienced deputy manager. Feedback from both the residents and staff was positive about the way in which the home is run. The deputy manager trains and develops a staff team who were generally competent and knowledgeable to take care for the people who use the service. The service generally works in partnership with families of people who use the service and professionals. The manager is improving and developing systems that monitor practice and compliance with the plans, policies and procedures of the home. More work is needed in this area. The manager is aware of the need to promote safeguarding and has developed a health and safety policy that generally meet health and safety requirements and legislation. However there are areas where they need to make improvements such as developing individual risk assessments for each resident which are linked to individual care plans. The manager needs to evidence a sound understanding and application of ‘best practise’ operational systems, particularly in relation to continuous improvement, customer satisfaction, and quality assurance. A quality assurance survey to seek satisfaction levels amongst the residents and relatives is undertaken by the manager showing that the registered manager is monitoring the service provided in the home. The inspector is notified of any significant events and developments in the home. The manager ensures that staff follow the policies and procedures of the home. However greater effort needs to be made to ensure that staff receive regular formal supervision which is evidenced. Practice and performance may be topics for discussion during supervision, staff training and team meetings. The home has appropriate policies and procedures regarding safeguarding residents’ finances. If they wish and are able to, residents are helped to take responsibility for managing their own money. They are provided with facilities to keep their valuables and money safe. Where the home is responsible for residents’ money it maintains clear records that are routinely kept up-to-date and can be used to track an individual resident’s finances. The manager adheres to keeping records up to date. The home has carried out all health and safety checks. The fire safety officer and environmental health officers have visited the home to carry out annual checks. The proprietor is aware of the need to follow up any recommendations made. Greenmantle DS0000025903.V337429.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 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 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 3 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 3 3 3 2 3 3 Greenmantle DS0000025903.V337429.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15(1) Requirement Existing care plans must set out in detail the action which needs to be taken by the care staff to ensure that all aspects of the health, personal and social care needs of the person using the service are met. Evidence must be in place to show the involvement of the person using the service or his/ her representative and signed by them. Individual risk assessments must be carried out for each person who uses the service which is linked to a care plan, in order to eliminate any unnecessary risks to the health or safety of people using the service. All staff working in the care home must receive appropriate training in the care of people with dementia. All of care staff must receive formal supervision at least six times a year which must be evidenced. Timescale for action 30/08/07 2 OP7 13(4) 30/08/07 3 OP30 18 30/08/07 4 OP36 18(2) 30/08/07 Greenmantle DS0000025903.V337429.R01.S.doc Version 5.2 Page 25 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 OP11 Good Practice Recommendations ‘End of Life’ care plans should be developed for all residents Greenmantle DS0000025903.V337429.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 Greenmantle DS0000025903.V337429.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!