Inspection on 28/09/05 for Greensleeves

This inspection was carried out on 28th September 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 17/03/10

Greensleeves 28/01/10

Greensleeves 07/07/09

Greensleeves 08/07/08

Greensleeves 02/05/06

Greensleeves 24/06/05

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 Mrs L Riddle Announced Wednesday, 28 September 2005 V243991 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 V243991 280905 Stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Greensleeves Address 19 Perrfield 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 (CRH) 41 41 Category(ies) of Dementia - over 65 years of age (DE(E)) registration, with number places - Female of places Greensleeves H60 H11 S14541 Greensleeves V243991 280905 Stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th June 2005 Brief Description of the Service: Greensleeves is a care home providing accommodation and personal care for up to fourty one older (over the age of 65 years) persons. The home accommodates only female residents. The owner and manager is Mrs Jean Gisbey. The home is situated 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. There are two units, largely based upon residents needs. Both units have their own lounges,dining areas and gardens. Bedrooms are on the two floors, with a lift serving most rooms on the first floor. The gardens are safe and accessible for residents to use and enjoy. There is off-road parking for staff and visitors. Greensleeves H60 H11 S14541 Greensleeves V243991 280905 Stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This scheduled announced inspection was carried out over seven hours by one inspector. As part of the preparation for the inspection the two previous report were read along with other documents and correspondence held on file. Information provided by the registered provider in the pre-inspection questionnaire also contributed to the inspection process. Comment cards were sent out to residents/relatives and seven were returned. These all contained positive comments. During the inspection nine residents were spoken with in communal areas. Due to their mental frailty, some were more able than others to communicate their thoughts and opinions about the home and the care they receive. The interaction between staff and residents was observed for lengthy periods of time and staff were spoken with. A discussion took place with the registered manager and some information was provided by the business manager. Various records and documents were examined and a tour of the premises was undertaken. What the service does well: What has improved since the last inspection? All staff have undertaken training in the Protection of Vulnerable Adults. Letters amending the current resident’s contracts have been sent to their representatives and contracts for future residents will include reference to current legislation. Staff appraisals have been undertaken. Greensleeves H60 H11 S14541 Greensleeves V243991 280905 Stage4.doc Version 1.40 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 H60 H11 S14541 Greensleeves V243991 280905 Stage4.doc Version 1.40 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 V243991 280905 Stage4.doc Version 1.40 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 Each resident/resident’s representative has a written statement of the terms and conditions agreed with the home so that they know clearly what can be expected of the provider and the service. EVIDENCE: Each resident’s file was seen to contain a copy of the signed contract of terms and conditions of residence. Reference to legislation in the contracts is being updated as was seen in the copy of a letter sent out to the representatives of all current residents. Greensleeves H60 H11 S14541 Greensleeves V243991 280905 Stage4.doc Version 1.40 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) 7, 8, 9, 10 Arrangements to ensure that the health care needs of residents are met are in place. The assessment/care-planning format needs to be clearer to reflect the current situation relating to each resident. The system of medicine administration could put residents at risk. EVIDENCE: Individual plans of care are available but these are contained within large Kardex systems which hold information for a number of residents as opposed to individual files. Some of the information held is out of date and it is difficult in some cases to ascertain the current needs of residents as added information to the care plans has not been dated or signed. The information in the care plans is quite basic. Weekly and monthly entries on care sheets do provide ongoing information about each resident but the actual care plans need to be updated accordingly and, in some cases, re-written to reflect the changing needs. There are no separate records of GP and other healthcare visits to individual residents which means having to go back through daily records or diaries in order to find out when each was last visited or treated. Individual risk assessments are few, not clearly documented and do not provide in-depth information about the recognised risks and what action is being taken to minimise them. Greensleeves H60 H11 S14541 Greensleeves V243991 280905 Stage4.doc Version 1.40 Page 10 Residents are not really able to take an active part in planning or reviewing their care due to their mental frailty. From discussion with staff and from observations made, it is evident that wherever possible residents are encouraged to make choices such as what they want to wear, what they want staff to do for them. There are clear instructions in each resident’s room as to what assistance each person needs and how it should be given. Staff were observed to approach residents in a quiet manner and to assist them discreetly with personal tasks. There was no sense of any resident being rushed and requests for or indications of residents wanting or needing help were responded to quickly and appropriately. Staff spoken with were knowledgeable about individual resident’s needs and the way they should be cared for and approached. Diversionary tactics were seen to be used when a resident was being particularly noisy. All medicines are in the control of the home. Not all staff who handle medications have had training in the safe handling of medicines. Medicines received from the chemist are re-dispensed from their original packs/containers into daily containers for each resident. These are prepared for a week at a time. This system is not considered to be best practice as there is a large margin for errors to occur. It is also contrary to guidelines from the Royal Pharmaceutical Society. Greensleeves H60 H11 S14541 Greensleeves V243991 280905 Stage4.doc Version 1.40 Page 11 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) 12 Social activities are well managed and provide daily variation and interest for residents living in the home. EVIDENCE: Staff take responsibility for arranging daily activities such as exercises to music, singing, colouring, ball and beanbag games and bingo. Outside entertainers come into the home several times a year including a storyteller, singer/musicians and others. A relative spoken with said that the home organises a number of functions each year when relatives are invited to attend. She said that these are much appreciated and enjoyed by all. During the inspection some residents were observed participating in exercises to music. They joined in very spontaneously and clearly enjoyed the activity. Residents were also seen making Christmas cards with staff. In the afternoon staff were providing hand and foot massages for those who wanted them and again this was clearly enjoyed. Staff said that they try to do some activities with residents every day. It was noticed in one lounge area that the TV was on all day although no residents appeared to be watching it. In another lounge area there was pleasant background music which was more appropriate and clearly more appreciated. The residents said how much they like to listen to the music. A resident commented “we sing and dance, I like that”. One or two residents had puzzle books and said they liked to do the crosswords. One resident was seen to go in and out to the garden for walks. Greensleeves H60 H11 S14541 Greensleeves V243991 280905 Stage4.doc Version 1.40 Page 12 Staff said that they take residents for walks and sometimes to Asda for a cup of tea and to shop when they have time. It was noted that there is a lack of orientation aids in the communal areas. Little or nothing to remind residents what day of the week it is, what year, what the next meal will be e.g. Lunch, Tea. What the weather is like outside. Such information would assist residents to have more awareness of what is happening. Greensleeves H60 H11 S14541 Greensleeves V243991 280905 Stage4.doc Version 1.40 Page 13 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) 16, 18 Complaints are handled objectively and residents/relatives can be confident that their concerns will be listened to. Residents are protected from all forms of abuse. EVIDENCE: The home has a detailed complaints procedure which is made known to relatives and visitors. A visiting relative confirmed that she knew about the procedure. Relatives who completed and returned comment cards to the Commission confirmed their awareness of the complaints procedure. The visitor said that she always sees Mrs Gisbey or the business manager if she has any worries or concerns and any problems are quickly dealt with. Records examined showed that all complaints are fully recorded and investigated appropriately. Since the last inspection all staff have undertaken training in the Protection of Vulnerable Adults and training records verified this. Staff asked, were aware of what action to take if they witness poor practice and what their responsibilities are in relation to this. Greensleeves H60 H11 S14541 Greensleeves V243991 280905 Stage4.doc Version 1.40 Page 14 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) These standards were not assessed during this inspection. EVIDENCE: Greensleeves H60 H11 S14541 Greensleeves V243991 280905 Stage4.doc Version 1.40 Page 15 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) 28, 30 Some improvement has been made in the amount of training offered to staff but more is needed to ensure all staff are competent to carry out safely the tasks they have to perform. EVIDENCE: Seven staff have achieved National Vocational Qualifications (NVQ) at level 2 and others are currently undertaking this. This means that the home has virtually achieved the 50 in accordance with National Minimum Standards. Currently there is no formal recognised induction or foundation training programme for new staff. Some staff have had training in topics relating to health and safety but not all and some are due to update training in topics such as first aid, food hygiene and manual handling. There needs to be a clear planned training programme for each year which covers all aspects of training from the induction of new staff to NVQ training for those with more experience. It is planned that all staff will have an individual portfolio which should provide a clearer record of what each has done and what is needed. One portfolio has been compiled and was seen. Each staff file did contain a record of training undertaken but a number of these showed very little. Greensleeves H60 H11 S14541 Greensleeves V243991 280905 Stage4.doc Version 1.40 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) 35, 36, 38 There is leadership, guidance and direction to staff to ensure residents receive consistent quality care. EVIDENCE: The home does not handle any monies or personal allowances belonging to residents. Following recommendation in the last report, the manager set up a system for providing formal supervision to care staff which was seen. Unfortunately she had not fully understood the type of supervision intended by this National Minimum Standard. Now that she is clear about the method and purpose, she has agreed to commence a programme without delay. Staff appraisals had been undertaken. Mrs Gisbey works alongside staff on a daily basis so is able to oversee and provide guidance and support to her staff. Greensleeves H60 H11 S14541 Greensleeves V243991 280905 Stage4.doc Version 1.40 Page 17 Staff made such comments as “I look forward to coming to work and feel part of a team” and “it’s a really nice place to work, very friendly and we are well supported and appreciated” “the manager is very helpful”. Staff felt that there is good communication throughout the home and everyone knows what is expected of her. Some training had been arranged for later this year to cover fire safety and manual handling but there is still a need to ensure that all staff have training in infection control and health and safety. This matter was raised in the previous report and a requirement made which has yet to be fully met. Maintaining good training records for each staff member should ensure that they receive training updates when needed. Records showed that fire alarm testing is carried out regularly and staff receive regular updates in fire safety training. All fire doors were seen to be kept closed and fire exit routes clear. All radiators are covered for safety and hot water temperatures regulated. There was documentary evidence to show that contractual arrangements are in place for the servicing and repairs of equipment and installations in the premises such as the passenger lift, the electrical system and equipment, hoists and others. A risk assessment of the building and gardens had been undertaken as had a fire risk assessment of the premises. Records showed that accidents are recorded and reported as required. The home was very clean and fresh throughout. Greensleeves H60 H11 S14541 Greensleeves V243991 280905 Stage4.doc Version 1.40 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 3 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 x COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 x 28 3 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x 3 2 x 3 Greensleeves H60 H11 S14541 Greensleeves V243991 280905 Stage4.doc Version 1.40 Page 19 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 38 Regulation 18(1)( c)(i) Requirement All staff must receive training appropriate to the work they are to perform. (previous timescale 24/09/05 not met) Timescale for action 31st December 2005 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. 5. 6. Refer to Standard 7 7 9 30 36 Good Practice Recommendations Care plans should set out clearly the action needed by staff to meet the needs of residents and updates in these should always be dated and signed. Risk assessments, particularly those relating to use of cot sides and residents at risk of falls should be more in-depth and should be reviewed regularly. The system of re-dispensing medications should be reviewed. All staff who handle medicines should undertake training. A recognised Induction and Foundation training programme should be put in place. Care staff should receive formal supervision at least six times per year. Greensleeves H60 H11 S14541 Greensleeves V243991 280905 Stage4.doc Version 1.40 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. 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