Inspection on 27/09/05 for Greenside House

This inspection was carried out on 27th September 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Greenside House 26/02/09

Greenside House 23/11/06

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 Jayne Barnett-Middleton. Unannounced Inspection 27th September 2005 09:40 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.V251148.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. Greenside House DS0000038615.V251148.R01.S.doc Version 5.0 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 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.V251148.R01.S.doc Version 5.0 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 availlable. 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 eg 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. 15th June 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. Greenside House DS0000038615.V251148.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out from 9.40 am to 2.45 pm. Most of the service users were seen during the inspection. Eight service users, six staff and the registered manager were spoken to. A sample of records was examined and a partial inspection of the building was carried out. Throughout the inspection positive and professional relationships were observed between staff and service users. The inspector wishes to thank the registered manager, staff and service users for their time and co-operation throughout the inspection process. What the service does well: What has improved since the last inspection? Care plans for long stay service users had been reviewed. Some work was still needed to ensure that they met the required standard. However, information checked was much improved and information easier to track. The procedure for recording the administration of medication had been reviewed and a new medication administration record was soon to be introduced. Staff were receiving refresher training appropriate to their job role. Greenside House DS0000038615.V251148.R01.S.doc Version 5.0 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.V251148.R01.S.doc Version 5.0 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.V251148.R01.S.doc Version 5.0 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): 3 and 6. Prospective service users and their relatives were provided with the information that they needed, to enable them to make an informed decision about moving into the home. Service users were not admitted to the home without their needs being assessed. Service users admitted solely for intermediate care were provided with the appropriate facilities to maximise their independence and return home. EVIDENCE: A full needs assessment was carried out for all service users prior to their admission, which confirmed that the service was appropriate for the service user, and provided staff with the information to formulate an individual plan of care. Greenside House DS0000038615.V251148.R01.S.doc Version 5.0 Page 9 Intermediate care was provided, which provided service users with short term intensive rehabilitation to enable them to return home. Service users requiring intermediate care were accommodated in dedicated areas of the home. Specialist health staff including physiotherapists and occupational therapists supported Service users. All service users spoke positively about the care that they were receiving and were confident that due to the support they would be able to return home to live independently. Greenside House DS0000038615.V251148.R01.S.doc Version 5.0 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. Service users individual needs were assessed. Care plans for long stay service users were in need of some amendments to ensure that they met the required standard. Service users had good access to health care services, which met their assessed needs. A policy and procedure to ensure that staff adhered to the safe administration of medication was in place. Service users privacy and dignity was respected EVIDENCE: Three Care plans set out in detail the action that was required by staff to ensure that all aspects of service users care needs were met. One care plan checked for a service user receiving intermediate care contained excellent detail of service users care needs and rehabilitation programmes. The care plan had been reviewed on a regular basis to ensure that it reflected the progress and changing needs of the service user. Greenside House DS0000038615.V251148.R01.S.doc Version 5.0 Page 11 The care plan format for service users in need of long term care had been reviewed to a good standard and information was easier to track. The manager confirmed that care plans were reviewed on a monthly basis to reflect the changing care needs of the service user, however records checked did not evidence that care reviews were taking place on a regular basis. Service users preferred funeral arrangements were not recorded, to ensure that their wishes following their death could be respected. Service users said that their healthcare needs were met and spoke positively about the care and rehabilitation that they were receiving. All staff felt that the service worked well and that they worked consistently with the occupational and physiotherapy team. There was no record in one care plan checked for a service user receiving longterm care to evidence that they were receiving regular health care visits. There was a policy and procedure to ensure that staff adhered to safe practices regarding medication and the protection of service users. The recording and storage of medication was checked on a sample basis. Medication had been administered appropriately. Staff had received medication training, which promoted the safe administration of medication. Service users were observed to be receiving personal care in a manner that respected their privacy and dignity. Greenside House DS0000038615.V251148.R01.S.doc Version 5.0 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. The daily routines within the home were flexible and promoted service user choice. Service users were encouraged to maintain contact with their family, friends and the local community as they wished. Service users were encouraged to make informed decisions with regards to their daily lives. A good choice of menu was offered and special dietary needs were catered for. EVIDENCE: Service users said that their daily routines were flexible “I can do what I want”. Several service users were observed to be spending time in the lounges whilst others had chosen to spend their time in the privacy of their bedroom. Service users were observed to be following their preferred routines and said that they were “pleasantly surprised” as to how the staff team respected and encouraged them to spend their day as they pleased. Two activity coordinators were employed and a good range of activities was provided. Activities such as crafts, bingo, outings and Coffee mornings were held on a regular basis. A baking session was taking place and service users were observed to be thoroughly enjoying this activity. Greenside House DS0000038615.V251148.R01.S.doc Version 5.0 Page 13 Service users confirmed that they maintained good links with their family and friends and that they were welcome to visit them at any reasonable time. A good choice of menu was offered and special dietary needs were catered for. Menu boards were provided in all dining rooms that informed service users of the choice of food that was available. All Service users said that they enjoyed their meals and described the food as “good”, “good choice” and “nice”. Greenside House DS0000038615.V251148.R01.S.doc Version 5.0 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. The complaints procedure was clear and accessible. Complaints made by service users and their relatives were listened to and action was taken to deal with complaints promptly. There was an adult protection procedure and all staff had received adult protection training. EVIDENCE: The complaints procedure ensured that service users and their relatives were aware of how to make a complaint and who would deal with them. Discussions with Service users confirmed that they had nothing to complain about and were happy with the care that was being provided. There was an adult protection policy and procedure that promoted the protection of service users from harm or abuse. All staff had received adult protection training. Greenside House DS0000038615.V251148.R01.S.doc Version 5.0 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): 19,20,23,24 and 26. 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 divided into flats and each had sufficient sitting and dining space. Outdoor space and all areas of the home were safe and accessible to people in wheelchairs. There were sufficient toilet, washing and bathing facilities, which were close to service users bedrooms and communal areas. The manager said that there were domestic vacancies and that she was in the process of recruiting new staff. The home was clean and tidy, which promoted a comfortable and homely environment. Several bedrooms were checked and all were clean and well decorated. Service users in long term care had been encouraged to personalise their bedrooms with photographs and mementoes, which encouraged service users to retain their own identity. Greenside House DS0000038615.V251148.R01.S.doc Version 5.0 Page 16 Service users said that they were happy with the accommodation provided and described the home as “very friendly” and “the home is always clean”. Greenside House DS0000038615.V251148.R01.S.doc Version 5.0 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. A training and development programme was in place. Staff received regular training, which enabled them to meet the needs of service users. The home operated a recruitment procedure. However, staff files were currently not kept at the home to confirm that the required standard was being met. Staffing levels did not meet the Residential Forum Staffing levels, which is a condition of the homes registration. EVIDENCE: All service users spoke positively about the staff team and described them as “friendly”, “caring” and “helpful”. Several staff felt that at times there was not enough staff on duty to provide service users with the level of care that they required. All service users spoke positively about the care that they were receiving and were confident that due to the support they would be able to return home to live independently. The staff rota identified that there were occasions when staffing levels did not meet the Residential Forum Staffing levels, which is a condition of the homes registration. Staff rotas checked demonstrated that the manager was planning the staff rota to ensure the required minimum of staff was provided, however short-term sickness was creating a shortfall. Greenside House DS0000038615.V251148.R01.S.doc Version 5.0 Page 18 A training and induction programme for staff was in place to enable them to meet the assessed and changing needs of service users. Staff confirmed that they had attended various training courses that included food hygiene, fire, moving and handling, infection control and first aid. A training matrix was in place, which clearly demonstrated the training that staff had attended and identified any individual training requirements. Over 50 of the staff team held a level 2 or 3 National Vocational Qualification in Care, which developed the skills and competence of staff, to enable them to meet the changing needs of residents. The manager confirmed that robust recruitment procedures were in place to promote the protection of service users. However, staff files were currently not kept at the home to confirm that the required standard was being met. Greenside House DS0000038615.V251148.R01.S.doc Version 5.0 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): 31,33,36 and 38. The home was managed in the best interests of service users; positive comments were made about the service and the care that service users received. The health, safety and welfare of service users were promoted. EVIDENCE: The manager is a Registered General Nurse and has recently completed a NVQ level 4 qualification in care. All service users spoke positively about the home and described the service as “very good”. There was a relaxed and friendly atmosphere within the home. Service users were comfortable to talk about the care that they received. Greenside House DS0000038615.V251148.R01.S.doc Version 5.0 Page 20 Staff received regular supervision that gave them the opportunity to focus on care practices and to identify any training and development needs. Detailed Records of accidents and injuries were maintained to ensure that service users were provided with the appropriate observation and supervision required. A handyman was employed at the home and a routine programme of maintenance was in place. Areas throughout the home were on the well maintained which promoted a safe environment. The staff had received regular training, which promoted safe working practices and the health, safety and welfare of service users and their colleagues. Greenside House DS0000038615.V251148.R01.S.doc Version 5.0 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 X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 2 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 X X 3 3 X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 3 X x Greenside House DS0000038615.V251148.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? Yes 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 12,15 Timescale for action Care staff must review all service 30/11/05 users care plans at least once per month. (Timescale of 31st July 2005 not met.) Service users preferences 30/11/05 regarding funeral arrangements must be recorded on their care plan. Records of healthcare visits to 30/11/05 service users must be maintained. Sufficient Care staff must be 01/11/05 employed in such numbers to meet the needs of service users, in line with the homes condition of registration. Staff files must include 30/11/05 documents as required under schedules 2 and 4 of the regulations. Requirement 2 OP11OP7 12,13 3 4 OP8 OP27 12,13 13,18 5 OP29 2,19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Greenside House DS0000038615.V251148.R01.S.doc Version 5.0 Page 23 No. 1 . Refer to Standard None Good Practice Recommendations Greenside House DS0000038615.V251148.R01.S.doc Version 5.0 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. 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