Inspection on 14/07/05 for Greensleeves

This inspection was carried out on 14th July 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

Greensleeves 17/09/08

Greensleeves 31/10/06

Greensleeves 17/01/06

Greensleeves 25/02/05

Greensleeves 06/05/04

Greensleeves 13/06/03

Greensleeves 05/08/02

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

CARE HOME ADULTS 18-65 Greensleeves Friday Street Eastbourne East Sussex BN23 8AP Lead Inspector Nigel Thompson Announced 14 July 2005 9:30 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Greensleeves H59-H10 S21121 Greensleeves V227356 140705 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Greensleeves Address Friday Street Eastbourne East Sussex BN23 8AP 01323 461560 01323 763723 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Eastbourne and District Mencap Mr William Barnfield Care Home 11 Category(ies) of Learning Disability (LD) 11 registration, with number of places Greensleeves H59-H10 S21121 Greensleeves V227356 140705 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users to be accommodated is eleven (11). 2. Service users must be aged between forty (40) and sixty-five (65) years on admission. 3. Service users with a learning disability only to be accommodated. 4. A maximum of two (2) service users with a mental disorder in addition to having a learning disablity can be accommodated. Date of last inspection 25 February 2005 Brief Description of the Service: Greensleeves is one of three registered care homes for adults with learning disabilities provided by Eastbourne and District Mencap. The home is registered for 11 adults with learning disabilities and service users may remain in the home into old age. The home is a large detached extended bungalow that provides seven single bedrooms and two double bedrooms all with en-suite facilities. There is a chair lift to access the first floor. There is a separate lounge and dining room and a large kitchen that opens onto a patio area and a large rear garden that has recently been landscaped and is now much more accessible and safer for service users. Greensleeves continues to provide a safe and happy environment whereby people can learn to live as independently as their disability will allow. Service users are enabled to access college courses, day centres and a range of leisure activities, both within the home and in the local community. Greensleeves H59-H10 S21121 Greensleeves V227356 140705 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over six hours in July 2005. It found that all of the twenty seven National Minimum Standards that were assessed had been met and the overall quality of care provided was good. Service users and relatives spoken to during the inspection expressed satisfaction with the home, the staff and the service provided. A tour of the premises took place and documentation was inspected, including service user and staff files. In addition to the manger and deputy manager, one of the service users’ relatives, three of the staff on duty and three of the eleven residents were spoken to. What the service does well: What has improved since the last inspection? One of the double bedrooms has recently been redecorated and refurbished and new furniture has also been provided for the lounge. Greensleeves H59-H10 S21121 Greensleeves V227356 140705 stage 4.doc Version 1.30 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. Greensleeves H59-H10 S21121 Greensleeves V227356 140705 stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Greensleeves H59-H10 S21121 Greensleeves V227356 140705 stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 & 5 Documentation, including a comprehensive ‘Statement of Purpose’ and ‘Service Users’ Guide’ ensures that prospective service users and their relatives have sufficient information about the home and the services provided. The thorough admission policy and procedure ensures that service users are admitted only on the basis of a full needs assessment, undertaken by people competent to do so. EVIDENCE: The detailed and informative Statement of Purpose and Service Users Guide provide comprehensive information about the home for the benefit of existing and prospective service users and their relatives. Following a referral to the home, the manager undertakes a full assessment to identify the individual’s needs and ensure that the home is able to meet them. A detailed pre-admission assessment form has been developed and includes information relating to the individual’s personal, medical, social and psychological care and support needs. Prospective service users and their relatives are encouraged to visit the home and have the opportunity to look around and meet with members of staff and existing residents. Greensleeves H59-H10 S21121 Greensleeves V227356 140705 stage 4.doc Version 1.30 Page 9 The manager confirmed that new service users undergo a six month trial period at the home, during which time their suitability and compatibility are assessed and it is established whether their identified care and support needs are able to be met. Greensleeves H59-H10 S21121 Greensleeves V227356 140705 stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 & 8 Service users’ care plans are developed from a comprehensive assessment of an individual’s needs and enable staff to meet such needs in a structured and consistent manner. EVIDENCE: Impressive, high quality care plans have been developed for each service user at Greensleeves. They are detailed, comprehensive and clearly linked to the individual’s assessed needs. Plans that were examined were found to be accurate, well maintained, and up to date. It was evident that service users and, where appropriate, a relative or representative are directly involved in the assessment and individual care planning process. Service users are also involved, with their key-worker, in regular six monthly reviews of their care plan. It was noted that these reviews are recorded and plans are amended to reflect changing needs or circumstances. Service users are consulted regarding many aspects of their day to day living, including menu planning, recreational and leisure activities and holidays. Greensleeves H59-H10 S21121 Greensleeves V227356 140705 stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 , 15 & 17 Social activities and meals are both well managed, creative and provide daily variety and interest for people living in the home. Links with the community are good and support and enrich service users’ social opportunities. EVIDENCE: Service users’ social and recreational interests are assessed and recorded in their individual care plan. The manager confirmed that service users are encouraged and supported to pursue their own identified interests. Regular residents’ meetings are held, with an open agenda, providing opportunity for each service user to raise any issues or concerns that they may have for discussion with staff and other residents. Greensleeves H59-H10 S21121 Greensleeves V227356 140705 stage 4.doc Version 1.30 Page 12 The main talking point over recent meetings has been the ever popular summer holiday. This year the destination was the Isle of Wight and enthusiastic comments from service users included: ‘We all had a grand time. It was one of the best holidays I’ve had’. The home has a communication board that uses Makaton symbols, key words and pictures that enable service users to be informed and involved in the daily routines within their home. Independence is promoted within the home and as previously documented service users are consulted about many aspects of their day-to-day living. Where practicable, they are encouraged and supported to partake in daily routines, including laying the table for meals, cleaning their bedrooms and personal laundry. One service user is involved in meal preparation. Meal times are clearly social events and staff and service users sit down together to eat. The deputy manager confirmed that many of the service users are enabled to be part of the community. With staff support, as required, residents regularly go out and are well known in local shops. Service users’ friends and family links are encouraged and supported. Visiting is unrestricted during the day and visitors are made welcome in the home until 9.00pm. Greensleeves H59-H10 S21121 Greensleeves V227356 140705 stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 & 19 Comprehensive care plans ensure that service users’ individual physical and emotional support needs are provided in structured and consistent manner and in a way they choose. EVIDENCE: Service users’ care plans that were examined were found to contain in depth information, compiled through consultation with and direct involvement of residents and their relatives. The plans were found to contain comprehensive needs assessments and details of staff intervention and action to be taken . Staff spoken to during the inspection confirmed the importance of routine in the lives of service users and this is clearly reflected in the individual care plans and structured daily routines for how personal care is provided. The manager also confirmed that the established and experienced staff work closely and consistently with service users. Knowing each of them well and having a sound understanding of their individual support needs, staff are aware of any changes in a resident’s mood or manner and are therefore able to respond swiftly and effectively. Greensleeves H59-H10 S21121 Greensleeves V227356 140705 stage 4.doc Version 1.30 Page 14 All staff have received training in ‘Care of medicines’. The deputy manager confirmed that one service user currently maintains responsibility for the control of her own medication. She has a lockable facility in her room for storage of the medicines and the situation is closely but discreetly monitored. Greensleeves H59-H10 S21121 Greensleeves V227356 140705 stage 4.doc Version 1.30 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 The open and inclusive atmosphere within the home enables service users, staff and visitors to feel able to express any concerns, confident that they will be listened to. Service users are safeguarded from abuse through robust policies, procedures and relevant staff training. EVIDENCE: A clear and accessible complaints procedure is in place, however, as discussed it is recommended that it be reviewed and amended to include updated contact details of the CSCI. It is also recommended that a copy of the procedure be made accessible to service users’ relatives and other visitors to the home. Service users, their relatives and members of staff spoken with during the inspection confirmed that they would have no hesitation in speaking to the manager or deputy manager or in making a complaint if necessary. Each person was also confident that they would be listened to. Policies and procedures relating to abuse, including whistle blowing are in place and were found to be up to date and well maintained. The manager stated that abuse training is provided for all staff and this was supported by training records and certificates in staff files and confirmed by members of staff themselves. Greensleeves H59-H10 S21121 Greensleeves V227356 140705 stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 28 & 30 The service is accessible, safe and clean and is clearly suitable for it’s stated purpose. Service users benefit from pleasant accommodation that is comfortable, well maintained and decorated to a satisfactory standard. EVIDENCE: Greensleeves has been purpose built to a high specification and clearly meets service users’ individual and collective needs in a safe, comfortable and well maintained environment. As with many of the environmental standards, the situation regarding shared space remains largely unchanged. However the manager did confirm that the garden has been landscaped and significantly improved. An impressive summer house has been erected and the patio area extended. Greensleeves H59-H10 S21121 Greensleeves V227356 140705 stage 4.doc Version 1.30 Page 17 Adequate communal space is provided to meet the individual and collective needs of the service users, including a pleasant dining room and a spacious lounge. All communal areas are decorated and furnished to a high standard. Furniture and lighting throughout the home is domestic in character All necessary specialist equipment is made available to meet service users’ assessed mobility needs, including assisted baths, wheelchairs and hoists. Residents’ bedrooms are fitted with an emergency intercom call system and there are assisted bath seats and call cords are fitted in all en-suite facilities. The home also provides a chair lift and there are grab rails in bathrooms, toilets and corridors. As previously documented, as far as practicable, independence and individuality is promoted within the home and this is evident from the personalising of service users’ private rooms, which clearly reflects individual tastes, interests and personality. Levels of cleanliness and hygiene remain high throughout. Infection control procedures are in place and closely adhered to. A programme of routine maintenance, renewal and redecoration is in place. Greensleeves H59-H10 S21121 Greensleeves V227356 140705 stage 4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 34, 35 & 36 Service users benefit from there being sufficient trained and competent staff on duty at all times to meet their assessed care and support needs. Thorough recruitment procedures help to ensure the safety and protection of service users. EVIDENCE: The stable and dedicated staff team is clearly able to meet the assessed, individual and collective needs of service users within the home. All new employees are provided with a comprehensive job description and staff spoken to had a sound understanding of their individual role and responsibilities. A comprehensive induction and foundation training programme is provided for all new staff and is flexible and compatible with an individual’s level of relevant experience. Mandatory training is ongoing and is recorded in individual staff files. Greensleeves H59-H10 S21121 Greensleeves V227356 140705 stage 4.doc Version 1.30 Page 19 All care staff receive formal supervision every six weeks. Staff spoken to confirmed the support and training they receive. They also acknowledged the personal benefit of effective supervision. Staff files that were examined were found to be well maintained, containing all necessary information, including two written references, proof of identity and satisfactory Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks. The manger confirmed that service users are actively involved in the recruitment and selection process and meet with all prospective members of staff. All new staff are provided with and sign a written contract, including a statement of terms and conditions. Greensleeves H59-H10 S21121 Greensleeves V227356 140705 stage 4.doc Version 1.30 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed on this occasion. EVIDENCE: Greensleeves H59-H10 S21121 Greensleeves V227356 140705 stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 3 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 x 3 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Greensleeves Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x x x x x x x H59-H10 S21121 Greensleeves V227356 140705 stage 4.doc Version 1.30 Page 22 No Are there any outstanding requirements from the last inspection? 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 Regulation Requirement Timescale for action 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 22 Good Practice Recommendations It is recommended that the complaints policy and procedure be reviewed and amended to include updated contact details of the CSCI and that a copy of the procedure be made accessible to service users’ relatives and other visitors to the home. Greensleeves H59-H10 S21121 Greensleeves V227356 140705 stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Ivy House, 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Greensleeves H59-H10 S21121 Greensleeves V227356 140705 stage 4.doc Version 1.30 Page 24 - 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. 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