Inspection on 21/09/05 for Greenmantle

This inspection was carried out on 21st September 2005.

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 19/04/07

Greenmantle 21/02/06

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 Helen Fontaine Unannounced Inspection 21 September 2005 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.V251182.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Greenmantle DS0000025903.V251182.R01.S.doc Version 5.0 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.V251182.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may admit up to 3 people with dementia from the age of 60 years. 26th January 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.V251182.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over one and half hours, as part of the yearly inspection process. The previous unannounced inspection was in December 04 and January 05, where one Requirement was identified. The inspector did a tour of the building and a number of records were looked at. Five residents and one member of staff was spoken to, the Manager was not present for the first part of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Greenmantle DS0000025903.V251182.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Greenmantle DS0000025903.V251182.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 4 All Service Users moving into the home have their needs assessed and have a written contract/statement of terms and conditions. All Carers, representatives and professionals are made aware that the home will meet the Residents needs. EVIDENCE: During the inspection a number of records were looked at, one of the files looked at was a Service Users who had been in the home for three months. There was a full and in-depth assessment, done prior to the admission of the Resident into the home. It was clear from the assessment that the Carer had been very involved and had signed the assessment, as the Service User was unable to. On the file was a copy of the contract and the homes administration assistant was able to produce the statement of terms and conditions. The Manager has developed a newsletter that gave an in-depth description of all the activities and events that have happened in the home, which is sent to everyone connected to the home. Greenmantle DS0000025903.V251182.R01.S.doc Version 5.0 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 10 The Care Plans clearly show all the personal and health care needs, but missed out the cultural and religious needs. The health care needs are fully met and the Service Users feel they are treated with respect. EVIDENCE: A number of Service Users’ care plans were looked at during the inspection and all but one are covered all areas of need. This Residents Care Plan did not reflect their cultural and religious needs that were identified in the initial assessment. All the Service Users files clearly showed that the Residents health care needs were fully met. Service Users spoken to said that they are supported to attend any hospital appointments and one Resident said the home helped them explore all areas of their particular eye problems. Service Users spoken to all said they were treated with respect and one Resident is able to have their cage bird in their room. Staff were observed during the tour of the home giving care and it was noted that this was done in a very professional way. Greenmantle DS0000025903.V251182.R01.S.doc Version 5.0 Page 9 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15 Service Users’ lifestyle in the home matches their expectations, preferences and reflects their social, cultural, religious and recreational needs. Service Users do continue to have contact with family, friends and representatives. Meals at the home are wholesome and appealing in pleasant surroundings and at times convenient to them. EVIDENCE: Service Users spoken to during the inspection said that they have a number of activities and outings if they wished to go. One Resident said that they go out with their family every week and that they had an extra special visit with their family who live abroad. It was noted during the inspection that a Residents meeting was planned for that afternoon, the midday meal was bought forward and Residents spoken to were looking forward to the meeting. A member of staff said that Carers and family members are involved in the meeting as well as the Residents. During the tour of the home, it was noted that the lunch was being prepared. The meal was sufficient and was wholesome and well balanced, the Service Users spoken to said that there is plenty of food. All the Residents spoken to said that they do have a choice and that they do like food they are given. Greenmantle DS0000025903.V251182.R01.S.doc Version 5.0 Page 10 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Complaints are taken seriously and acted on; Service Users are confident that they are listened to. Service Users are protected from abuse, but the home is failing to notify the Commission for Social Care Inspection. EVIDENCE: During the inspection the complaints and incidents books were looked at, a number of complaints were fully investigated. Service Users spoken to said that they are confident that they are listened to and dealt with. During the inspection of the documents it was noted, that although the complaints and incidents were fully investigated the home had not informed the Commission for Social Care Inspection of incidents that affect the Service User. One of the incidents was about a member of staff that had been give a written warning, after a complaint by a Resident. It is important to ensure the safety and protection of Service Users, that any incident that affects the welfare of the Service Users the home informs The Commission for Social Care Inspection. Greenmantle DS0000025903.V251182.R01.S.doc Version 5.0 Page 11 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, 24 and 26 Service Users live in a safe, very well maintained environment, however it was noted a number of doors were held open with either wedges or mobility equipment. The Service Users have access to safe and comfortable indoor and outdoor facilities. Each Resident has a comfortable bedroom with their own possessions around them. The home is very clean, pleasant and hygienic. EVIDENCE: During the inspection there was a tour of the building, a number of bedroom doors were found to be wedged open. Some of the doors had wooden wedges and another was being held open by a walking frame, the home does need to adhere and comply with the requirement of the local fire department. It was noted that the home is very well maintained and during the tour of the home, it was noted that the bathrooms and toilets were being renovated. Service Users were observed accessing various part of the home and Residents spoken to commented on the comfortable indoor and outdoor facilities. Residents each have their own rooms, with their own possessions around them and one Service User had their cage bird in their room. The home was clean Greenmantle DS0000025903.V251182.R01.S.doc Version 5.0 Page 12 and very pleasant, all the Residents spoken to commented particularly about how good it was. Greenmantle DS0000025903.V251182.R01.S.doc Version 5.0 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): 29 and 30 The procedures for the recruitment of staff are not robust; the home does not have two written references. All staff are trained and competent to do their jobs. EVIDENCE: During the inspection staff files were looked at, every member of staff did have a current CRB. However on checking the files it was found that a number of staff did not have two written references. There was a checklist and there were copies of letters requesting references, but these were not chased up and the member of staff was employed. The Manager said that they do everything they can to make sure that this is done and said that they do contact the referee, getting a verbal reference. Staff files looked at showed a number of training certificates, Dementia, Adult Abuse, First Aid and Medication. A member of staff spoken to said that they do receive good training. Greenmantle DS0000025903.V251182.R01.S.doc Version 5.0 Page 14 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): 32 and 33 The Service Users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of the Service Users. EVIDENCE: There is a very clear ethos of leadership and management of the home, the Manager is very committed to the very best care for the Residents and puts a great deal of effort to achieve this. A member of staff spoken to during the inspection said that they had worked in the home for many years. They said at one time they had left, but came back to work in the home because of the care the home gave its Residents and staff. The member of staff commented that the Manager was very supportive and took on board any comments they might make. All the staff members and the Service Users spoken to all commented on the good running of the home. Greenmantle DS0000025903.V251182.R01.S.doc Version 5.0 Page 15 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 3 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 3 X X X 3 X 3 STAFFING Standard No Score 27 X 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 3 X X X X X Greenmantle DS0000025903.V251182.R01.S.doc Version 5.0 Page 16 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 Timescale for action Care Plans must reflect the 15/11/05 cultural and religious needs of service users. The registered person must 15/11/05 submit to the CSCI, a Regulation 37 report for any incidents and accidents, that affects the welfare of the Service User, with the regard to the member of staff receiving a written warning. The registered person must 15/11/05 make sure that no fire doors are wedged open and all fire regulations are observed. The registered person must have 15/11/05 two written references relating to all staff employed in the home. Requirement 2 OP16 37 3 OP19 23(4) 4 OP29 19 Schedule 2 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.V251182.R01.S.doc Version 5.0 Page 17 Greenmantle DS0000025903.V251182.R01.S.doc Version 5.0 Page 18 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.V251182.R01.S.doc Version 5.0 Page 19 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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