Inspection on 23/11/06 for Greenside House

This inspection was carried out on 23rd November 2006.

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

Greenside House 26/02/09

Greenside House 27/09/05

Greenside House 15/06/05

Greenside House 11/08/04

Greenside House 12/05/04

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

CARE HOMES FOR OLDER PEOPLE Greenside House Greenside Avenue Mapplewell Barnsley S75 6BB Lead Inspector Christine Rolt Key Unannounced Inspection 23rd November 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Greenside House DS0000038615.V314915.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. Greenside House DS0000038615.V314915.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greenside House Address Greenside Avenue Mapplewell Barnsley S75 6BB 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) 01226 386600 01226 391332 none Barnsley PCT Miss Joanne Sharp Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38) of places Greenside House DS0000038615.V314915.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The two single bedrooms with a partition screen in Flat 3 (bedroom 2 & 3) must be used as one double bedroom. The occupants of this double room must be given the option to move to single bedrooms when available. The bedrooms allowed occupancy is as follows: Flat 1 - 7 Bedrooms all single occupancy Flat 2 - 7 Bedrooms all single occupancy Flat 3 - 6 Bedrooms all single occupancy and 1 double bedroom Flat 4 - 6 Bedrooms all single occupancy and 1 double bedroom Flat 5 - 6 Bedrooms all single occupancy and 1 double bedroom Staffing levels must be maintained at or above the levels required by the April 2002 Residential Forum, Care Staffing in Care Homes for Older People. Where additional services are provided e.g. day care, staffing for this must be over and above that required by condition 3. Three of the places are registered for either OP Old Age; not falling within any other category, OR PD Physical Disability for people aged 55 years to 64 years inclusive. 27th September 2005 2. 3. 4. 5. Date of last inspection Brief Description of the Service: Greenside House is a purpose built home, which, provides a range of residential and day care services for older people. It stands in its own grounds in a residential area and is close to the centre of Mapplewell village. Adequate car parking space is provided. The home is divided into five wings that are called flats. There are four flats on the ground floor and one flat on the first floor. The home has a passenger lift. Each flat comprises seven bedrooms, a lounge/dining room, a kitchenette and sufficient toilet and bathing facilities. Information supplied in the Pre-Inspection Questionnaire received November 2006 stated that the weekly fee was from £nil for intermediate care to £291.83 for short stay care. Hairdressing, private chiropody, newspapers toiletries and some transport were not included in the weekly fee and were charged separately. The home’s Statement of Purpose was displayed in the entrance foyer. Service User Guide was available in each bedroom. The Greenside House DS0000038615.V314915.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 inspection and comprised information already received from or about the home and a site visit. The site visit was from 9:30 am to 5.00 pm rd The registered manager Ms. Joanne Sharpe was on 23 November 2006. present and provided assistance throughout the day. The majority of the residents were seen and chatted with. Residents’ Surveys were sent to 12 residents and 9 were completed and returned. One resident and three relatives were also asked detailed questions about the home during the site visit. Five residents were tracked throughout the inspection. A sample of records was examined and a partial inspection of the building was carried out. The inspector wishes to thank the registered manager, staff, residents and relatives for their assistance and co-operation. What the service does well: What has improved since the last inspection? Reviews for the remaining permanent residents were carried out at least once per month in consultation with the resident or their representative. Weekly reviews were held for short-term residents. Residents’ wishes regarding terminal care and arrangements after death were recorded on their files. Greenside House DS0000038615.V314915.R01.S.doc Version 5.2 Page 6 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. Greenside House DS0000038615.V314915.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 Greenside House DS0000038615.V314915.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 6. Quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service. Residents had their needs assessed and were issued with contracts/statements of terms and conditions. Residents assessed and referred solely for intermediate care were helped to maximise their independence and return home. EVIDENCE: All residents were issued with contracts/terms and conditions and had their needs assessed. Residents who came for regular respite care had their care plans reviewed and updated each time they were admitted to the home. Copies of all the documents were available on residents’ files. Residents who required intermediate care were accommodated in designated wings of the home where specific and intensive rehabilitation programmes were provided to enable the residents to regain skills and return home. Greenside House DS0000038615.V314915.R01.S.doc Version 5.2 Page 9 Health therapists, including physiotherapists and occupational therapists, formed part of the staff team. Greenside House DS0000038615.V314915.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. Quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service. Residents care needs were set out in individual plans of care. Health care needs were generally met. Residents who were judged capable were selfmedicating. Residents were generally protected by the home’s medication practices and procedures but could be improved. Residents were treated with respect and their right to privacy was upheld. EVIDENCE: The files for five residents were checked. These were for two residents on respite care, one permanent resident, one rehabilitation resident and one rapid response resident. Files contained residents’ contracts/terms and conditions, full needs assessments, care plans, risk assessments, medication records, personal inventories and daily records. Three of the residents did not have weight charts or the charts had not been completed. This was discussed with the manager. Visits by GPs were recorded by the GP directly onto the care plan. However, there were no other records of visiting health professionals. Greenside House DS0000038615.V314915.R01.S.doc Version 5.2 Page 11 Cross references from the daily records to other aspects of the care plan including a historical list of visits by health professionals would provide an audit trail of how residents’ needs were met. This was discussed with the manager. Reviews were carried out at least once a month in consultation with the permanent resident and their family. Weekly reviews were carried out for short stay residents. Residents considered that their care needs and health needs were met. Residents’ and relatives’ comments were “Incredibly impressed with record keeping, communication and joined up thinking”, “Yes, they took him to hospital for appointment” “Definitely” (receives the medical support they need), “Seen by consultant at Mount Vernon on 2nd Day” and “For first time I feel that she is treated as a woman and not as individual ailments”. In the Pre-inspection Questionnaire it was stated that there had been eight admissions to A & E, four deaths within home and two deaths in hospital. However, the home had failed to notify the CSCI of any of these incidents or any other incidents that affected the health and welfare of resident. This was discussed with the manager during the site visit. Medication was suitably stored in the medication room. The area was clean and tidy. Medication that required refrigeration was stored in a locked medication refrigerator and the temperature was monitored. Controlled medication was correctly stored and the correct procedure for recording was noted. There was written evidence that the manager carried out medication audits. The home’s medication records were handwritten and were not countersigned. The margin for error of handwritten entries was discussed with the manager and it was strongly recommended that handwritten entries were countersigned. Medication for two residents was checked. There was a discrepancy with one of the medications. The manager noted this. Residents who were capable, dealt with their own medications and had lockable storage facilities and this was evidenced during the site visit. Residents were treated with respect and dignity and addressed by their preferred name. Privacy was respected and residents who were considered capable had keys to their bedroom doors. Information relating to this was recorded in residents’ care plans. Information regarding residents’ wishes concerning terminal care and arrangements after death was now included in care plans. Comments received about the staff were “Nice and friendly”, “All staff kind and helpful”, “I think staff here are great and they can’t do enough to please you” and “Compliments and gratitude to the staff”. Greenside House DS0000038615.V314915.R01.S.doc Version 5.2 Page 12 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, 14 and 15. Quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service. Residents’ lifestyle in the home matched their expectations and preferences. They were encouraged to maintain contact with their family and friends and had choice and control over their lives. A good choice of menu was offered and special dietary needs were catered for. EVIDENCE: The Pre-inspection Questionnaire stated that the home had a handicraft instructor and an activity co-ordinator and there were also activities in the day centre. Residents and their families confirmed that activities took place. Residents followed their preferred routines and during the site visit, several were noted to be enjoying a pre-lunch sherry. Comments were “Play bingo which I haven’t been able to do for years”, “Enjoy a sherry”, “Happy enough”, and “Go to Day Centre”. Residents said that they could choose how and where to spend their time and there were no restrictions on the time they got up or went to bed. Some preferred to sit in the lounges whilst others spent time in their bedrooms. Greenside House DS0000038615.V314915.R01.S.doc Version 5.2 Page 13 Contacts with families were maintained and visitors were seen coming and going throughout the day of the site visit. Those spoken to said that they were made welcome and kept informed. The food was good and there were choices at all meals. Specialist diets were provided. The manager said that they were currently working on menus to provide a better range of options for specialist diets. All comments about the food were positive “Could have eaten it myself – very good”, “Enjoy pudding particularly”, “Dad’s not complained”, “Great” and “Choice, service and consideration excellent”. The manager said that since they had started peeling and slicing fruit and offering it with the afternoon drinks, more residents were choosing to eat it. A variety was offered including fresh figs, mango and other tropical fruit but some fruits were more popular than others. Greenside House DS0000038615.V314915.R01.S.doc Version 5.2 Page 14 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. Quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service. Residents and their relatives were confident that their complaints would be listened to and acted upon. Residents were protected from abuse. EVIDENCE: The home had a complaints procedure and this was displayed. Also, the manager said that all residents had a copy of the complaints procedure in their bedrooms. The home had a Complaints and Compliments Book which was seen during the site visit. There were no complaints but many compliments. Residents and their relatives said that they had no cause for complaint but if they had, they would tell the manager and were confident that it would be dealt with to their satisfaction. The home had the Barnsley Multi Agency Adult Protection Policy and Procedures and also the local PCT procedures for reporting abuse. There were no allegations of abuse. All staff had undertaken some level of adult protection training but were also undertaking further training with Barnsley Council. Greenside House DS0000038615.V314915.R01.S.doc Version 5.2 Page 15 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 and 26. Quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service. The home was clean, comfortable and well maintained. Service users were provided with an environment that was safe, accessible and homely. EVIDENCE: The home was clean and there were no offensive odours. One relative said that this had come as a pleasant surprise to her as she was expecting to be met by some odours. The home was well decorated and residents liked their bedrooms. Bathrooms were clean and tidy. The home had only one ‘Standaid’ whereas it normally had two. The manager explained that another ‘Standaid’ was on order and delivery was expected. Greenside House DS0000038615.V314915.R01.S.doc Version 5.2 Page 16 Comments about the environment and facilities were all positive and included “”Pleasant, clean and nicely decorated”, “Very good”, “Very adequate”, “Fine” and “Would like to stay here”. Greenside House DS0000038615.V314915.R01.S.doc Version 5.2 Page 17 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 and 30. Quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visit to this service. Residents’ needs were generally met by the numbers and skill mix of staff, but were not fully supported and protected by the home’s recruitment practices. Staff were trained and competent to do their jobs. EVIDENCE: There were sufficient carers on duty and health professionals supplemented these. Staff had the time to meet residents’ needs and residents were not rushed. The majority of residents considered that there were always or usually sufficient staff on duty but one resident felt that there was a shortage. Staff said that it could sometimes be a problem when staff went off sick, however they managed to cope at these times. According to the Preinspection Questionnaire 75 of staff had attained NVQ Level 2 or above. However, it was noted that two of the assistant managers had been undertaking NVQ Level 2 for quite some time and had not yet achieved this qualification, whilst some carers had achieved NVQ Levels 2 and 3. The need to ensure that suitably qualified, competent and experienced persons were working at the care home, especially where they were left in charge of the home, was discussed with the manager. Greenside House DS0000038615.V314915.R01.S.doc Version 5.2 Page 18 Staff files were stored centrally. The inspector asked for six staff files to be sent to the home. These staff files were for both PCT and Barnsley MBC employees. Three of the files had no information about CRB disclosures or POVA checks. The three remaining files contained letters that said that CRB disclosures had been received but did not state the level of check carried out. The manager was able to produce a CRB disclosure for one of these three members of staff to show that the CRB had been carried out at the correct level. She explained that this was the member of staff’s personal copy. Five of the six files had no documents to verify the persons’ identities. Skills training was promoted and included Catheter Care, Urinary Tract Infection, Defibrillation, Oral Care, Food Supplements and Wound Care. Greenside House DS0000038615.V314915.R01.S.doc Version 5.2 Page 19 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, 33, 35, 37 and 38. Quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service. Residents lived in a home that was run and managed by a person who was fit to be in charge and the home was run in the best interests of residents. Residents’ finances were safeguarded. The health, safety and welfare of residents and staff were promoted and protected. EVIDENCE: The registered manager has been in post for approximately three years and improvements have been made to meet standards and ensure the best interests of residents. Greenside House DS0000038615.V314915.R01.S.doc Version 5.2 Page 20 The home had a good quality assurance monitoring system, which included checks of the environment, residents’ finances, medication, accidents, staff training and complaints. In addition to this ‘Housekeeping Services’ also carried out monthly checks. Residents’ meeting were held regularly and a poster was displayed to inform residents and invite their relatives. Minutes of meetings were kept and these were seen during the site visit. Staff meetings and Assistant Managers’ Meetings were also held and minutes of the Assistant Managers’ Meetings were also seen during the site visit. Questionnaires were included in the Service User Guide. Visits by the Registered Provider’s representative were undertaken and reports of these visits were available at the home. Residents’ finances were stored safely. Only one of the three residents who were tracked throughout the inspection had their money looked after by the home. Therefore the money for this resident and another resident chosen at random was checked. Cash tallied with the records. Staff training, including mandatory health and safety training, was ongoing, and records were available of the training undertaken by staff. The Pre-Inspection Questionnaire provided information of the dates that equipment and systems within the home had been serviced and maintained Greenside House DS0000038615.V314915.R01.S.doc Version 5.2 Page 21 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 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 3 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 X X X X X x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X x 3 Greenside House DS0000038615.V314915.R01.S.doc Version 5.2 Page 22 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. 2. Standard OP8 OP8 Regulation 12, 13 37 Requirement Residents’ health needs must be monitored i.e. up to date weight charts The CSCI must be notified of all incidents as listed under Regulation 37 of the Care Home Regulations. Staff dealing with medication must ensure that the correct procedures are followed and that medication tallies with the records Staff files must include documents as required under schedules 2 and 4 of the regulations. (Previous timescale of 30th November 2005 not met) Timescale for action 21/01/07 21/01/07 3. OP9 13 21/01/07 6. OP29 2,19 21/01/07 Greenside House DS0000038615.V314915.R01.S.doc Version 5.2 Page 23 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 OP8 Good Practice Recommendations A list of visits by health professionals should be kept on each resident’s care plan to provide a historical record of each resident’s health care needs. The list should cross reference to daily records to provide an audit trail. It is strongly recommended that hand written entries of medication details are countersigned to reduce the margin for error. Staff left in charge of the home should have NVQ or equivalent qualification 2 3 OP9 OP28 Greenside House DS0000038615.V314915.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Greenside House DS0000038615.V314915.R01.S.doc Version 5.2 Page 25 - 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. 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