Inspection on 24/06/05 for Greensleeves

This inspection was carried out on 24th June 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

Greensleeves 17/03/10

Greensleeves 28/01/10

Greensleeves 07/07/09

Greensleeves 08/07/08

Greensleeves 02/05/06

Greensleeves 28/09/05

Greensleeves 28/09/04

Greensleeves 19/04/04

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

CARE HOMES FOR OLDER PEOPLE Greensleeves 19 Perryfield Road Southgate Crawley, West Sussex RH11 8AA Lead Inspector Ms V Khan Unannounced Friday 24 June 2005 V222869 th 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 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. Greensleeves H60 H11 S14541 Greensleeves V222869 120505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Greensleeves Address 19 Perryfield Road, Southgate, Crawley, West Sussex, RH11 8AA 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) 01293 511394 Mrs Jean Thompson Kennedy Gisbey Mrs Jean Thompson Kennedy Gisbey Care Home 41 Category(ies) of Dementia - over 65 years of age (DE(E)) registration, with number 41 Female places of places Greensleeves H60 H11 S14541 Greensleeves V222869 120505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 28th September 2004 Brief Description of the Service: Greensleeves is a care home providing personal care and accommodation for up to fourty one older people with dementia. The home accommodates only female residents. The owner and manager is Mrs Jean Gisbey. The home is siuated in a residential area of Crawley, being close to the town centre, local amenities and transport links. Greensleeves consists of two linked houses and a large purpose built extension. The home is comprised of two units, largely based upon the needs of residents. Both units have their own lounges, dining areas and gardens. Bedrooms are on two floors, with a lift serving most rooms on the first floor. The home is spacious, clean, tidy and comfortable. The gardens have many interesting features for residents to enjoy. There is off-road car parking for staff and visitors. Greensleeves H60 H11 S14541 Greensleeves V222869 120505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this unannounced inspection. Due to the residents’ mental frailty, a large part of the inspection focused upon observation. Good interaction was seen between staff and residents, and residents appeared content. Time was also spent speaking to the manager, staff on duty and one visitor. Records were read, all rooms in the home were entered and the garden explored. Although the home is registered for forty-one residents, at the time of the inspection, there were thirty-five residents living there. Comments from one visiting relative included “Staff are very caring with a good sense of humour. “ What the service does well: What has improved since the last inspection? What they could do better: Residents’ contracts need to quote current legislation. Staff would benefit from attending adult protection training. Staff should be receiving formal supervision at least six times a year and annual appraisals. Greensleeves H60 H11 S14541 Greensleeves V222869 120505 Stage 4.doc Version 1.30 Page 6 Training attended by staff needs to be reviewed, in order that all staff receive necessary training relevant to their roles. 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 H60 H11 S14541 Greensleeves V222869 120505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Greensleeves H60 H11 S14541 Greensleeves V222869 120505 Stage 4.doc Version 1.30 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 standard(s) 2, 3, 6 Residents’ contracts are comprehensive, but quote obsolete legislation. Residents’ needs are assessed before moving in to the home to ensure they will be met. The home does not provide an intermediate care service. EVIDENCE: At the last inspection, it was noted that residents’ contracts and terms and conditions of residency quoted obsolete legislation, and Mrs Gisbey was required to amend this. This is still outstanding and it is recommended that this be altered. In order to ensure that the home can meet residents’ needs, they are assessed as part of the care management process by health and social care professionals before moving in. The home then completes basic assessments and long-term assessments, which include residents’ likes and dislikes. All residents move into Greensleeves on a long-term basis. Greensleeves H60 H11 S14541 Greensleeves V222869 120505 Stage 4.doc Version 1.30 Page 9 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 standard(s) EVIDENCE: Greensleeves H60 H11 S14541 Greensleeves V222869 120505 Stage 4.doc Version 1.30 Page 10 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 standard(s) 13, 14, 15 Contact is promoted and visitors are made welcome. Residents are supported in exercising as much choice and control as they are able. Residents receive wholesome food. EVIDENCE: Visiting is restricted during mealtimes and bedtimes and a notice is displayed informing visitors of this. A visiting relative said that she was a frequent unannounced visitor to the home and that she was always welcomed. Preparations were in hand for a family and friends garden party, which was due to take place two days after the inspection. Residents’ finances are managed by their families or power of attorneys. A policy is held and a general helpline number is on display, providing advice on obtaining advocates. Residents are provided with tasty, wholesome food, on a four weekly menu cycle. Lunch on the day of the inspection was fish, onion sauce, chips and vegetables, followed by sponge and custard. Greensleeves H60 H11 S14541 Greensleeves V222869 120505 Stage 4.doc Version 1.30 Page 11 If residents do not want the food provided, then basic alternatives such as eggs, or salads would be made available. Staff were seen assisting some residents to eat. Residents enjoyed their lunch. At the last inspection, it was recommended that the timing of meals be slightly re-arranged to ensure that meals were served at intervals of not more than five hours. This was discussed with Mrs Gisbey, who confirmed that snacks are provided to service users to ensure that they eat at no more than five hourly intervals. Greensleeves H60 H11 S14541 Greensleeves V222869 120505 Stage 4.doc Version 1.30 Page 12 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 standard(s) 18 All staff need to learn about adult abuse in order to protect residents. EVIDENCE: The environment is safe for residents. The home has policies and procedures in place to follow in case of abuse. At the last inspection, a recommendation was made for all staff to receive adult protection training and this remains outstanding. In order to fully protect residents from abuse, all staff need training on this subject to build upon their existing knowledge. Greensleeves H60 H11 S14541 Greensleeves V222869 120505 Stage 4.doc Version 1.30 Page 13 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 standard(s) 19, 20, 26 Residents live in a pleasant, clean, safe home where they can access comfortable indoor and outdoor spaces. EVIDENCE: The home was very clean and tidy throughout. Lounges and dining rooms in both units were spacious and comfortable. All parts of the home were clean. The landscaped gardens were very attractive and secluded. A covered pond, with goldfish, garden furniture, patio areas, flowerbeds, water features, plants, hanging baskets and trees were some of the features. No residents were in the garden during the inspection, but many were gaining great benefit from looking at the gardens through the lounge windows. Greensleeves H60 H11 S14541 Greensleeves V222869 120505 Stage 4.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 Residents’ needs were being met by the staff on duty. The home has a satisfactory recruitment policy. Not all staff have received training relevant to their jobs. EVIDENCE: There were enough staff on duty during the inspection to meet the needs of residents. Mrs Gisbey has a hands-on role in the day-to-day caring of residents. Staff recruitment records were read and found to be in order. Mrs Gisbey is reminded that risk assessments need to be formalised for pregnant staff. From the information read at the inspection, it is clear that not all staff have received post-induction training. Further reference to this will be made later on in the report. Mrs Gisbey has introduced a dress code for staff; white top and black skirt or trousers, with a tabard and sensible shoes. Staff spoken to thought this was a good idea and had no objections. Greensleeves H60 H11 S14541 Greensleeves V222869 120505 Stage 4.doc Version 1.30 Page 15 Staff were seen to be caring, helpful and enjoying spending time with residents. One member of staff was seen to be sitting chatting with a resident and holding her hand. One member of staff spoken to, had a very good understanding of what the residents needs were and also knew what days certain visitors were due. Staff told the inspector, “It’s a really nice place to work”, and, “ Staff are friendly, ladies (residents) are lovely”. Greensleeves H60 H11 S14541 Greensleeves V222869 120505 Stage 4.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 36, 38 Staff are supported by Mrs Gisbey who has a hands-on role in the caring aspects within the home. Not all staff have been trained on safe-working practice topics, which could put the health, safety and welfare of residents at risk. EVIDENCE: The home has a quality assurance system in place, whereby questionnaires are distributed to residents and their families/supporters every year. Staff are supervised informally by Mrs Gisbey, who works on the floor with them most days. It is recommended that care staff receive formal supervision at least six times per year and annual appraisals. Some staff have attended training e.g. on first aid, food hygiene and COSHH. Greensleeves H60 H11 S14541 Greensleeves V222869 120505 Stage 4.doc Version 1.30 Page 17 Some staff however are employed without having attended any training other than the basic induction. Mrs Gisbey needs to ensure that all staff have completed mandatory training on safe working practice topics, e.g. moving and handling, first aid and infection control. This is an area that will be followed up at the next inspection. Greensleeves H60 H11 S14541 Greensleeves V222869 120505 Stage 4.doc Version 1.30 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x x 3 x x 3 x 1 Greensleeves H60 H11 S14541 Greensleeves V222869 120505 Stage 4.doc Version 1.30 Page 19 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 38 Regulation 18 Requirement All staff need to receive training appropriate to the work they are to perform, e.g. training on safe working practices. Timescale for action 24/9/05 2. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 18 36 29 2 Good Practice Recommendations All staff to attend adult protection training. Care staff receive formal supervision at least six times per year and have annual appraisals. Risk assessments need to be formalised for any staff that are, or in the future may become pregnant. The registered person shall review and revise the contracts to ensure that current legislation, e.g. The Care Homes Regulations 2001 is included. (Previous timescale of 28/12/04 not met). Greensleeves H60 H11 S14541 Greensleeves V222869 120505 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection 2nd Floor, Ridgeworth House Liverpool Gardens Worthing, West Sussex BN11 1RY 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 H60 H11 S14541 Greensleeves V222869 120505 Stage 4.doc Version 1.30 Page 21 - 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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