Inspection on 21/02/06 for Greenmantle

This inspection was carried out on 21st February 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 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 19/04/07

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 21st February 2006 11.00a 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.V284482.R01.S.doc Version 5.1 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.V284482.R01.S.doc Version 5.1 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.V284482.R01.S.doc Version 5.1 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 September 2005 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 13 single and one double bedroom. There is a well-kept garden. A lift provides access to the first floor. 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. Greenmantle DS0000025903.V284482.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second statutory inspection visit in the inspection programme for 2005/06. Over the course of the two visits, all core standards have now been assessed. Four requirements were set at the previous inspection and the registered person has complied with all the required action. This inspection was unannounced and started at 11am. The inspector spoke to four residents during the inspection as well as the senior person on duty and the manager. Staff files, medication records as well as residents’ files were checked. What the service does well: What has improved since the last inspection? Greenmantle DS0000025903.V284482.R01.S.doc Version 5.1 Page 6 The registered person ensures that the home operate a through recruitment procedure, including confirmation of staff in post only after a satisfactory CRB check has been undertaken and two references received. Care plans reflect the residents’ cultural and religious needs. The manager is aware that a Regulation 37 notification must be sent to the CSCI of any incident that may affect the welfare of residents in the home. The latest fire safety inspection carried out by the fire service was satisfactory. 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. Greenmantle DS0000025903.V284482.R01.S.doc Version 5.1 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.V284482.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not tested on this visit. However evidence from the last inspection was that the statement of purpose and service users guide provide the information that prospective residents need to make an informed choice about where to live. All residents have a written contract with the home. A comprehensive pre-admission assessment is undertaken for all residents prior to their admission to the home. Residents and their representatives are invited to visit the home so that they know that the home they enter will have the knowledge to meet their needs. EVIDENCE: The above standards were not specifically tested on this visit, as there were no outstanding requirements in relation to the standards. At the time of the last inspection, all of the core standards were assessed as met. Greenmantle DS0000025903.V284482.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 Residents’ medication is administered safely and regularly, however the registered person must follow the home’s procedure for handling unused and out of date medication. EVIDENCE: All the senior staff have completed the medication administration training and therefore have the competence to administer medication. All medication administered is appropriately logged on the MAR charts. None of the residents are responsible for administering their own medication. However, upon examining the contents of the medication trolley the inspector noted that there were a number of out of date medicines, creams and homely remedies stored here. The registered person is required to return any unused and out of date items to the pharmacist. See requirement. Greenmantle DS0000025903.V284482.R01.S.doc Version 5.1 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14, 15 Residents are offered choice in as far as they are able to contribute to making decisions about matters that affect their lives. Residents receive a wholesome, appealing and well-balanced diet in pleasant surroundings. Both the care and catering staff make every effort to ensure that their nutritional needs are met on a daily basis. EVIDENCE: On the day of the inspection a number of residents were observed enjoying listening to music, reading, knitting or doing other activities with staff. They confirmed that a variety of activities are arranged and they are free to choose if they wish to participate. Many residents said that if they did not want to join in the activities, then the staff respect this. The residents spoken to said that the food is always good and they are given choices from the planned menu. Menus were inspected and found to be balanced and interesting and mealtime arrangements are flexible enough to accommodate individual preferences. Most of the residents spoken to said how much they enjoyed the food in the home. Greenmantle DS0000025903.V284482.R01.S.doc Version 5.1 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not tested on this visit. However evidence from the last inspection was that complaints are taken seriously and acted upon. Residents are protected from abuse. EVIDENCE: The above standards were not specifically tested on this visit, as there were no outstanding requirements in relation to the standards. At the time of the last inspection, all of the outcome standards were assessed as met. Greenmantle DS0000025903.V284482.R01.S.doc Version 5.1 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,26 The standard of the environment within the home is very good, providing residents with a clean, attractive, safe and comfortable place in which to live. EVIDENCE: The decor, furnishing and fittings in the home are maintained to a good standard. There is an ongoing programme of refurbishment and redecoration. The external areas of the home are well maintained and secure. Residents said that they were very pleased with their individual bedrooms and communal facilities. There were no unpleasant odours in the home. The home was found to be clean and hygienic. Comments from residents and relatives indicated that they considered a very good standard was being achieved in this area. Greenmantle DS0000025903.V284482.R01.S.doc Version 5.1 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Staffing levels are satisfactory and there are sufficient staff on duty to meet the individual assessed needs of the residents. Residents benefit from a committed and experienced team of staff who have the skills and training to meet their needs. The procedures for staff recruitment are followed and provide the safeguards to offer protection to people living in the home. EVIDENCE: A good deal of positive feedback about the staff at the home was received from the residents and their relatives. A typical comment being “the staff are very kind and caring.” Most of the staff have worked in the home for a number of years and have built up a good knowledge and understanding of the needs of the residents. The staff rota showed that staffing levels for both care and domestic staff were sufficient to ensure the residents’ needs continue to be met. Staff files showed that they have done training in essential areas, such as food hygiene, health and safety, administering medication, adult protection and first aid. A comprehensive training programme is in place, a lot of which is provided internally with the deputy manager continuing to discuss the “ policy of the week”. On the day of inspection an external trainer had been invited to discuss residents’ dietary needs and how to meet these. Greenmantle DS0000025903.V284482.R01.S.doc Version 5.1 Page 14 Most staff are in the process of completing their NVQ level 2 and level 3 courses. Greenmantle DS0000025903.V284482.R01.S.doc Version 5.1 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37,38 The leadership, guidance and direction to staff ensures that residents receive consistent quality care. The home is good at making sure that residents are kept safe and secure whilst living at Greenmantle. The registered person ensures that residents’ finances are handled appropriately and safeguarded. EVIDENCE: The manager and deputy manager work closely together to achieve high standards for the home. Feedback from residents was positive about the way in which the home is run. The home is well maintained and provides a safe environment for residents and staff. Greenmantle DS0000025903.V284482.R01.S.doc Version 5.1 Page 16 Evidence was seen that care staff receive supervision on a regular basis from the deputy manager. Staff meetings occur on a monthly basis. A number of statutory records were inspected, which are up-to-date and accurate. Individual records are secure and used in accordance with the Data Protection Act 1998. The inspector was informed that most of the residents’ finances are handled by their family members and the manager handles residents’ personal allowances. The manager keeps a clear record of all monies received and expenditures providing receipts for all purchases. The manager and staff work together to achieve high standards for the home. Feedback from residents was positive about the way in which the home is run. Greenmantle DS0000025903.V284482.R01.S.doc Version 5.1 Page 17 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 3 X X X X X 3 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 3 3 3 3 3 3 3 Greenmantle DS0000025903.V284482.R01.S.doc Version 5.1 Page 18 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 OP9 Regulation 13 (2) Requirement The registered person must ensure that the storage of medication is closely monitored and any unused and out of date medication is returned to the pharmacist. Timescale for action 31/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Greenmantle DS0000025903.V284482.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Greenmantle DS0000025903.V284482.R01.S.doc Version 5.1 Page 20 - 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!