Inspection on 17/01/06 for Greensleeves

This inspection was carried out on 17th January 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

Greensleeves 17/09/08

Greensleeves 31/10/06

Greensleeves 14/07/05

Greensleeves 25/02/05

Greensleeves 06/05/04

Greensleeves 13/06/03

Greensleeves 05/08/02

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Southfields

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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 Unannounced Inspection 17th January 2006 09:30 Greensleeves DS0000021121.V279161.R01.S.doc Version 5.1 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 Greensleeves DS0000021121.V279161.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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. Greensleeves DS0000021121.V279161.R01.S.doc Version 5.1 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 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) Eastbourne & District Mencap Mr William Barnfield Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Greensleeves DS0000021121.V279161.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of service users to be accommodated is eleven (11). Service users must be aged between forty (40) and sixty-five (65) years on admission. Service users with a learning disability only to be accommodated. A maximum of two service users with a mental disorder in addition to having a learning disability can be accommodated. 14th July 2005 Date of last inspection 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 DS0000021121.V279161.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over four and a half hours in January 2006. It found that all of the National Minimum Standards that were assessed had been met or partially met and the overall quality of care provided was good. Service users and relatives spoken with during the inspection expressed satisfaction with the home, the staff and the service provided. On the day of the inspection there were eleven service users living at the home. The inspection involved a tour of the premises, examination of the home’s records and discussion with the Registered Manager. Two members of staff and five service users were also spoken with. The focus of the inspection was on the quality of life for people who live at the home. In order that a balanced and thorough view of the home is obtained, this report should be read in conjunction with previous inspection reports. What the service does well: Service users at Greensleeves clearly benefit from having an experienced Manager and dedicated staff team who are committed to providing consistent and high quality care. Staff work closely with service users and have developed a sound understanding of their individual care and support needs. The relaxed, homely and welcoming environment has evolved over several years and reflects the stability and commitment within the staff team and the open and inclusive management style. Service users are encouraged and supported to make decisions about their lives. They are involved and regularly consulted on many aspects of life in the home, including menu planning and activities. Communication and consultation with service users’ family members is also effective and ongoing. Relatives have the opportunity to partake in individual assessment, care planning and reviewing processes. Staff receive effective induction and foundation training, regular supervision and are clearly valued and supported by the management team. Greensleeves DS0000021121.V279161.R01.S.doc Version 5.1 Page 6 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. Greensleeves DS0000021121.V279161.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Greensleeves DS0000021121.V279161.R01.S.doc Version 5.1 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 the following standard(s): These standards were not assessed on this occasion. All key standards were assessed during the previous inspection carried out on 14 July 2005. EVIDENCE: Greensleeves DS0000021121.V279161.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 7, 8, 9 & 10 Service users are enabled and supported to take acceptable risks and encouraged to make decisions about their day-to-day living. The systems for service user consultation and participation are good, with a variety of opportunities provided for individuals to be directly involved in many decision making processes and aspects of life within the home. EVIDENCE: The Manager confirmed that independence and individuality are promoted within a risk management framework. Service users are consulted, encouraged and supported in many aspects of their day-to-day living, ranging from selecting colour schemes for their room and communal areas, deciding what clothes to wear, menu planning and choosing recreational and leisure activities, including holidays. Effective communication systems, including monthly staff meetings and regular individual supervision, are in place to ensure that all staff are kept up to date and made aware of service users’ changing care and support needs. Greensleeves DS0000021121.V279161.R01.S.doc Version 5.1 Page 10 Monthly ‘Residents’ Meetings’ are held and minutes are taken. Plans for activities over the Christmas period were discussed during the most recent meeting and it was evident from reading the minutes that the views and choices of service users are listened to and acted upon. They were able to select from a range of social opportunities including a pantomime, a musical and the ballet. Service users’ personal assessments are reviewed annually unless there are any significant changes in the interim. Many of the service users attend the local day services and there is a clear and accessible programme of activities in place in the office. These include: ‘Arts and crafts’; ‘Music’; ‘Drawing and puzzles’ and the popular ‘Reminiscence Session’. During the inspection, a short, impromptu but never the less impressive musical ‘jamming’ session was provided by a service user on the keyboard accompanied by a member of staff on guitar. On their individual weekly ‘Training Day’, each service user remains in the home and has the opportunity for 1:1 time with their key-worker. A variable number of personal and environmental risk assessments were found to be in place for each service user. The Manager confirmed that no service user leaves the home unescorted. Greensleeves DS0000021121.V279161.R01.S.doc Version 5.1 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 the following standard(s): 11, 14, 16 & 17 Family and community links are good and support and enrich service users’ social opportunities. Activities are well managed and are age and culturally appropriate. Service users benefit from menus that are balanced and nutritious and reflect their individual likes and preferences. EVIDENCE: The Manager confirmed that, where appropriate, service users’ family links are encouraged and supported, however not all service users have regular family contact. Service users are encouraged and supported, where appropriate, to participate in the community. Many are accompanied to visit local shops and amenities. Two service users are members of a local theatre group and regularly take part in amateur dramatic productions. They have recently completed a ‘mime’ Greensleeves DS0000021121.V279161.R01.S.doc Version 5.1 Page 12 show, over Christmas, which was well supported and which other service users from Greensleeves went to see and thoroughly enjoyed. Visiting at the home is unrestricted. A service user’s relatives, spoken with during the inspection, confirmed that they were always made very welcome in the home and felt involved and regularly consulted with. They also expressed a high level of satisfaction with the staff and the services provided. A four-week rolling menu has been developed. It was evident that the menus are varied and balanced and based on service users’ identified likes and preferences. An alternative to the main meal is always available and a copy of the menu is displayed in the kitchen. The menu reflects seasonal variations and caters for special dietary needs. Greensleeves DS0000021121.V279161.R01.S.doc Version 5.1 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 the following standard(s): 18, 19 & 20 Staff have developed close and positive relationships with service users and demonstrate a sound understanding of their individual care and support needs. EVIDENCE: As previously documented, Greensleeves operates an effective key worker system and staff were observed working closely and sensitively with service users to meet their identified personal care and support needs. Following consultation with service users, specific guidelines have been developed for all staff, ensuring that support is provided in a structured and consistent manner and in a way that the individual prefers. Staff spoken to during the inspection confirmed that service users are supported to access a range of health care professionals in the community. The home continues to work closely and effectively with the Community Learning Disabilities Team, which provides support and guidance in addressing service users’ psychological healthcare needs. It was noted that a new medication policy and guidelines have recently been introduced, with improved and detailed information regarding the responsibilities of staff in relation to the control, storage, administration and disposal of medicines. Greensleeves DS0000021121.V279161.R01.S.doc Version 5.1 Page 14 The home uses a monitoring dosage system for the administration of prescribed medicines and a local pharmacist continues to carry out quarterly monitoring visit. In house staff training is provided in the control and safe handling of medicines. Controlled drugs are stored and administered appropriately. The Manager confirmed that one service user currently maintains responsibility for controlling and administering their own medication and has a locked drawer in her room. The situation is closely monitored, through the risk assessment process. Greensleeves DS0000021121.V279161.R01.S.doc Version 5.1 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 the following standard(s): These standards were not assessed on this occasion. All key standards were assessed during the previous inspection carried out on 14 July 2005. EVIDENCE: Greensleeves DS0000021121.V279161.R01.S.doc Version 5.1 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 the following standard(s): 24, 25, 26, 27, 28 29 & 30 The service is accessible, safe and clean and remains 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: The physical environment of the home remains largely unchanged and the well maintained décor and good quality furniture and furnishings provide a comfortable, pleasant and homely environment for service users. The Manager confirmed that individuality and independence continue to be promoted within the home, as far as is practicable. This was evident from the personalising of service users’ rooms, which clearly reflects individual tastes, preferences and interests. As with many of the environmental standards, the situation at Greensleeves regarding shared space remains largely unchanged. Adequate communal areas are provided to meet the individual and collective needs of the service users. Outside, access to the ‘Independent Living’ bungalow has been improved by the construction of wooden steps and a decking area. Greensleeves DS0000021121.V279161.R01.S.doc Version 5.1 Page 17 All necessary specialist equipment is made available to meet service users’ assessed support and mobility needs, including an assisted bath, wheelchairs, pressure mattresses and hoists. Since the previous inspection, carpets have been replaced in the lounge and dining room. It was also noted that there is now a new widescreen television and stereo system in the lounge and a new cooker, microwave and fridge in the kitchen. A shower has recently been installed in one service user’s en-suite washroom. Levels of cleanliness and hygiene remain satisfactory throughout. Infection control procedures are in place and closely adhered to. A programme of routine maintenance, renewal and redecoration is in place. Greensleeves DS0000021121.V279161.R01.S.doc Version 5.1 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this occasion. All key standards were assessed during the previous inspection carried out on 14 July 2005. EVIDENCE: Greensleeves DS0000021121.V279161.R01.S.doc Version 5.1 Page 19 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42 Service users and staff benefit from the Manager’s calm, open and approachable style of leadership and clear and positive sense of direction. Service users benefit from up to date policies and procedures relating to health and safety, which staff are aware of and adhere to. EVIDENCE: The established management team continues to maintain a relaxed, open and inclusive atmosphere within the home. Staff and service users, spoken with during the inspection confirmed how approachable and supportive the Manager and the Deputy Manager are. Positive comments from service users’ relatives expressed a high level of satisfaction with the care provided: ‘They all do a wonderful job and I can’t fault any of them’. Greensleeves DS0000021121.V279161.R01.S.doc Version 5.1 Page 20 The Registered Manager has worked in the care industry for over fifteen years and has been in his current post since October 2000. He is experienced, clearly competent to run the home and is keen to keep up to date with recent legislation and training. He already holds a qualification in ‘Advanced Management in Care’ and has recently completed the NVQ level 4 in Management and Care. Effective quality monitoring systems are in place, including satisfaction questionnaires for service users and visitors. Responses from the most recent surveys examined reflect a high level of satisfaction with the home and the services provided. The Manager confirmed that the health, safety and welfare of service users and staff remain of paramount importance within the home. Staff training is provided in many aspects of safe working practices, including moving and handling; food hygiene; fire safety and first aid. All staff training is recorded. Regular fire safety checks, including alarm systems and emergency lighting, are carried out and recorded. COSHH assessments and guidelines are in place. Temperature regulators are fitted to all hot water outlets, accessible to service users. All accidents, incidents and injuries are recorded and reported, as required. Greensleeves DS0000021121.V279161.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 3 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 3 x Greensleeves DS0000021121.V279161.R01.S.doc Version 5.1 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. 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. Refer to Standard Good Practice Recommendations Greensleeves DS0000021121.V279161.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection East Sussex Area Office 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. 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