Inspection on 07/07/09 for Greensleeves

This inspection was carried out on 7th July 2009.

CQC found this care home to be providing an Adequate service.

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 08/07/08

Greensleeves 02/05/06

Greensleeves 28/09/05

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 15/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Greensleeves 19 Perryfield Road Southgate Crawley West Sussex RH11 8AA Lead Inspector Ed McLeod Key Unannounced Inspection 7th July 2009 09:40 DS0000014541.V375581.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Greensleeves DS0000014541.V375581.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Greensleeves DS0000014541.V375581.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greensleeves Address 19 Perryfield Road Southgate Crawley West Sussex RH11 8AA 01293 511394 01293 513680 greensleeves19@btconnect.com 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) Mrs Jean Thompson Kennedy Gisbey Mrs Linda Jane Bartley Care Home 41 Category(ies) of Dementia (0) registration, with number of places Greensleeves DS0000014541.V375581.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Dementia (DE) The maximum number of service users that can be accommodated is 41. 8th July 2008 Date of last inspection Brief Description of the Service: Greensleeves is a care home providing accommodation and personal care for up to forty one older people who suffer from dementia. The owner is Mrs Jean Gisbey, and the registered manager is Mrs Linda Bartley. 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, and each unit has a sitting room and dining area. Bedrooms are on the ground and first 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. Fees range from £562 per week to £585 per week. Greensleeves DS0000014541.V375581.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate outcomes. The visit was arranged to assess the service’s compliance with previous requirements made and the Care Homes for Older People key national minimum standards. In preparation for this visit we looked at the information we have received or asked for since our previous visit and this included: The annual quality assurance assessment (the AQAA) which was sent us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. The AQAA was completed by the manager Mrs Bartley and we received it by the date we asked for it. The AQAA was not fully informative about the performance of the service – for example it did not properly evidence compliance with the outstanding requirements. What the service has told us about things that have happened in the service The previous key inspection and the annual service review reports The three CQC survey forms we received from people living in the home, and the four CQC survey forms we received from staff working in the home. During this visit we spoke with five people living in the home, with four members of staff and the manager. We sampled the pre-admission assessment for one person who has come to live in the home, and care plans for six people living in the home. Other records we sampled included activities records, medication records, and records relating to complaints and health and safety. We sampled recruitment and training certificates for three members of staff, and records for training undertaken by staff members this year. The visit took place on 7th July 2009 between 9.40 a.m. and 3.50 p.m. The inspector was accompanied by an expert by experience, who spoke with people living in the home and made observations of the interaction between people living in the home and staff. An expert by experience is an independent Greensleeves DS0000014541.V375581.R01.S.doc Version 5.2 Page 6 person who has experience of or knowledge of the conditions or disabilities affecting the people receiving the service that is being visited. What the service does well: People are being cared for well, and staff are kind and supportive. One relative wrote that Greensleeves was “a very well run care home. All the residents seem well cared for and the staff are very good and attentive”. The environment is being well maintained. The home is clean, hygienic, homely and free of hazards. The gardens are attractively laid out and there are places where people can sit and enjoy being in the garden. The staff team receive regular training in health and safety topics and in topics which assist them in providing the care people need. What has improved since the last inspection? What they could do better: The recording of medication stocks and administration needs to be more robust to better ensure the safety of medicine administration. Care staff do not received formal supervision at least 6 times a year which should cover all aspects of practice, philosophy of the care home and career Greensleeves DS0000014541.V375581.R01.S.doc Version 5.2 Page 7 development This formal supervision should assist staff in meeting the needs of the people receiving care and support. People living in the home and their relatives are expressing a wish for more regular activities and outings. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Greensleeves DS0000014541.V375581.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Greensleeves DS0000014541.V375581.R01.S.doc Version 5.2 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are confident that the care home can support them. This is because a detailed and accurate assessment of their needs that they, or people close to them, have been involved in has been carried out. This tells the home all about them and the support they need. EVIDENCE: At our previous visit we found that care in the home would be improved by more detailed admission assessments, including risk assessments, being undertaken. A requirement was made concerning this, advising that there was a need to ensure that care provided was taking into account the wishes, routines and interests of the person receiving the care. Greensleeves DS0000014541.V375581.R01.S.doc Version 5.2 Page 10 At this visit we looked at the pre-admission assessment for a person recently admitted to the home. We found that the assessment was taking into account the person’s needs, wishes and preferences, and that the care plan was setting out how those needs would be met. We found the previous requirement to have been met. There are no arrangements for the home to provide intermediate care. Greensleeves DS0000014541.V375581.R01.S.doc Version 5.2 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans are ensuring that peoples health, personal and social care needs will be met. The home has a plan of care that the person, or someone close to them, has been involved in making. The care home is not always ensuring that the records of medication stocks and medication administration are ensuring people’s safety. People receive support in a way that maintains their dignity and encourages their independence. EVIDENCE: Greensleeves DS0000014541.V375581.R01.S.doc Version 5.2 Page 12 At our previous visit we made a requirement that care plans provide more detailed advice to staff on the person’s wishes and how their care is to be provided. The manager Mrs Bartley told us during this visit that staff have been undertaking training in care planning, and that the home has begun updating care plans to more fully record the person’s wishes and preferences. We sampled three care plans which had been recently updated, and found that they were setting out details of people’s wishes and preferences. We found that these care plans were advising staff of the action to be taken to meet people’s health, personal and social care needs. The previous requirement was found to have been met. Care records we sampled indicated that people were accessing the health care services they require. The three people living in the home who responded to our CQC survey told us that they are receiving the medical care they need. One member of staff wrote to us in their CQC survey form that the service was “good at communicating with and liaising with doctors, district nurses, family. We take all ideas and suggestions on board”. We received three CQC surveys from people living in the home, all of which had been completed with the assistance of relatives. These told us that people usually received the care and support they needed, that people are treated with respect and kindness and one person wrote “my mother is very well cared for”. During this visit we looked at recent medication records for one person and discussed medication arrangements with the manager Mrs Bartley and with two members of care staff. We found that there are clear arrangements for medication administration and for the training of staff in medication administration in the home. When we looked at recent medication records for one person we found that there were some gaps in the medication administration recording. We also found that no written advice was being provided for staff on when “as needed” medication should be administered, and stocks of a medication in the home used by district nurses were not being fully monitored. We also found there to be gaps in medication administration records being completed by district nurses which Mrs Bartley told us she had not been aware of. Greensleeves DS0000014541.V375581.R01.S.doc Version 5.2 Page 13 A requirement has been made concerning medication administration arrangements. We observed that people are being treated with respect and their right to privacy upheld. We observed that staff chatted with people and called them by their first names as they went about their work and there was a good atmosphere. One person asked for some toast when the tea trolley came round and this was made and brought to her. We talked to two care staff who gave examples of how care is provided flexibly, such as having a later breakfast or later bed time if people wish. Greensleeves DS0000014541.V375581.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities, although there was some evidence that activities and outings are not provided regularly. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks at a time and place to suit them. Greensleeves DS0000014541.V375581.R01.S.doc Version 5.2 Page 15 EVIDENCE: The home’s annual CQC quality self-assessment (the AQAA) tells us that the Church of England visit once per month and service users are being supported to attend church, go shopping, undertake education and attend a day centre. We are also told in the AQAA that activities in the home include singers, mobile theatre, bingo, card making, computer games, walks, karaoke, manicures, and audio tapes for the partially blind. One relative wrote in a CQC survey form that “Greensleeves are good at organising Christmas parties, garden parties and fund raising events”. People living in the home we spoke to told us that there had been a garden party the previous Sunday, and it had been a great success and lovely sunny day. One person said she had painted pictures to be exhibited there and some had been sold. One person we spoke to told us that one day their relative had made cards with some people living in the home. We found that people’s interests and the activities they take part in are being recorded. We found, for example, that for two people who told the home they liked singing and dancing, their activity records indicated that they had taken part in singing and dancing on different occasions. The activity records we sampled did not evidence that this was happening regularly. For example, it was recorded that one of the people referred to had been singing on the 2nd and 15th April 2009, but there was no record that she had had the chance to join in singing since then. The care records we sampled did not provide evidence that each person has an individual plan of activities. Providing an individual plan of activities for each person shows that a service are responsive to the person’s individual needs and interests. One relative who sent us comments in a CQC survey form told us “I don’t think the residents are stimulated enough”. A member of staff wrote in their CQC survey form that there was a need to “employ more staff ie to interact with clients more, also to take them out of the home for shopping, walking”. People living in the home we talked to expressed a wish to go outside the home, but accepted that this was difficult as they would need to be Greensleeves DS0000014541.V375581.R01.S.doc Version 5.2 Page 16 accompanied by a care worker. Some people we spoke to said that they never went out. We discussed these views with the manager Mrs Bartley who told us that it was hoped that a mini bus for outings could be purchased. Mrs Bartley agreed that by providing more staff more activities or outings could be arranged, and said that Mrs Gisbey the home owner has agreed to an additional three members of staff being appointed. A requirement was made concerning social contact and activities. A member of care staff we spoke to told us that the staff team contact family members to let them know if there are issues. The care recordings we sampled also show that staff are supporting people to remain in contact with their families and friends. We talked to two care staff who gave examples of how care is provided flexibly, such as having a later breakfast or later bed time if people wish. We talked to the cook who advised us of the arrangements in place to ensure that people receive the specialist diets, such as diabetic diets, if they need these. The cook told us that her menus tend to keep to traditional and simple British food which is home cooked. On the day of our visit the main course during lunch was mince, vegetables and potatoes and people were observed to be eating well and receiving assistance if they needed this. The atmosphere at lunch was calm and relaxed. The second choice at lunch was chicken in a sauce and we observed one person having this instead. We received a service user survey filled out by a relative who told us that staff will arrange something different for the person to eat if they don’t want the main choices. Greensleeves DS0000014541.V375581.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. If people have concerns about their care they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. EVIDENCE: There is a complaints procedure in place and the relatives who completed CQC surveys on behalf of three people living in the home told us they knew who talk to if they had concerns, and that they knew how to make a complaint. We looked at the complaints book and found that no complaints had been recorded since our previous visit. The AQAA advises us that there have been safeguarding issues in the home since our previous visit. Greensleeves DS0000014541.V375581.R01.S.doc Version 5.2 Page 18 Staff training records we sampled indicate that staff have been undertaking distance learning training in safeguarding, appointed person first aid training, and in the Mental Capacity Act. During our visit Mrs Bartley advised us she was arranging for herself and the key workers to attend training in local safeguarding procedures. There was evidence that the service has taken action to protect people living in the home in response to safeguarding concerns, for example by taking appropriate staff disciplinary action and making appropriate referrals. Greensleeves DS0000014541.V375581.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. EVIDENCE: Greensleeves DS0000014541.V375581.R01.S.doc Version 5.2 Page 20 We visited the main communal areas of the home, the kitchen and food store, and four bedrooms. Improvements to the premises have included updating the alarm system for leaving the building and some redecoration and refurbishment of bedrooms. Lounge chair cushions have been replaced, and soap dispensers are now provided in all shared rooms and communal bathrooms. We found the home to be clean, homely and in good decorative order. The garden is well-maintained and has walkways, furniture, seating and umbrellas and the people we spoke to told us that they liked sitting out there and enjoyed the flowers. We visited four bedrooms which were found to be clean, tidy and free from hazards. People had personalised their bedrooms. A member of staff we spoke to said that people personalise their bedrooms by families bringing in pictures and possessions like teddy bears and televisions. One person who showed us her bedroom said she liked her room a lot. As well as possessions such as books, DVDs and photographs it had been agreed that she could have her cat with her. Having the cat with her was important to her she said. The AQAA tells us that all staff have updated their training in the control of infection. Staff we spoke to told us about the arrangements for incontinence laundry. All areas of the home visited were found to be clean and fresh. The three CQC service user surveys we received told us that the home is usually fresh and clean. Greensleeves DS0000014541.V375581.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are not always enough competent staff on duty at all times. People have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. EVIDENCE: The three CQC service user survey responses we received told us that there were usually staff available when needed. On the day of our visit one of the communal lounges and dining rooms was not in use. The manager Mrs Bartley explained to us that a member of care staff had not turned up for work, and so all people living in the home had been asked to use the main sitting room and dining room to minimise risk. This resulted in the Greensleeves DS0000014541.V375581.R01.S.doc Version 5.2 Page 22 one area being rather crowded, especially at lunchtime, and some people being in less familiar surroundings. During our visit people appeared to be well cared-for and having their personal care needs met. We did note however that staff had limited time to spend with people, and although some people said they would like to have gone out (to the local shops for example) there were not sufficient staff available to take them out. Mrs Bartley advised us that Mrs Gisbey, the home’s owner, has asked her to advertise for an additional three members of staff to meet the needs of the people accommodated. As this indicates that the service has been reviewing staffing levels in the home, no requirement was made at this visit. We sampled the recruitment and training records for three staff working in the home and found that required checks and references were obtained before staff commence work in the home. The AQAA tells us that two care staff have completed the recommended Skills for Care induction training. During our visit we sampled the home’s new employee induction checklist, common induction standards workbook and employee handbook. Our discussions with Mrs Bartley and care staff however indicated there are not arrangements in place for staff to receive formal supervision which should assist staff in learning about all aspects of practice, the home’s philosophy of care, and discussing their learning and development needs. A requirement concerning this has been made in the next section of this report. We looked at the record of trainings undertaken by staff in the past three months and the list of trainings planned over the next three months. This indicated that staff are receiving training in recommended topics. One member of staff told us in their survey form that there was “a good in house training programme in place”. The two care staff we spoke to during our visit gave examples of how helpful the training they had received had been in supporting them to provide safer care. The AQAA tells us that it is planned that all new staff undertake dementia care and National Vocational Qualification (NVQ) in care training. The care staff we talked to had either undertaken NVQ training or been offered the opportunity to do the training. Greensleeves DS0000014541.V375581.R01.S.doc Version 5.2 Page 23 Greensleeves DS0000014541.V375581.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The duties of management in the home are not always being fully undertaken. The environment is safe for people and staff because appropriate health and safety practices are carried out. EVIDENCE: The manager Mrs Bartley has continued to update her training. She has introduced improvements to the service provided, for example more informative care plans. Greensleeves DS0000014541.V375581.R01.S.doc Version 5.2 Page 25 Mrs Bartley told us that the local authority’s social services department and another provider had given support and advice on the updating of care plans which had contributed to her understanding of the issues and changes made to care planning in the home. Management shortfalls have been noted in this report, in relation to the quality of the information provided in the AQAA, that staff supervision arrangements are not in place, and the lack of robust monitoring arrangements for medication recording and administration. Some of those issues had been highlighted previous to the visit at a meeting on the 14th May 2009 convened by West Sussex County Council and attended by the Commission, Mrs Bartley and Mrs Gisbey. Our visit indicates that issues relating to staff support and medication arrangements had subsequently not been addressed. Discussion with Mrs Bartley indicated that she was unclear about the components of one to one staff supervision set out in the National Minimum Standards for Care Homes for Older People, and it may be that in relation to this and some of the other shortfalls found that training, mentoring or support for the manager would be beneficial for the service. Comments the home received from relatives in the survey they carried out in February 2009 included “A very well run care home. All the residents seem well cared for and the staff are very good and attentive”. The home has been able to involve residents and their relatives in fundraising events and the money raised has bought activities materials and DVD players, and the home’s social events have been popular. A member of staff told us in their survey response that there was a “very relaxed and friendly atmosphere”. Mrs Bartley told us that the home seeks the views of the people living in the home and their relatives about the service provided through reviews and coffee mornings. A survey of their views was also carried out in February 2009, and we looked at ten of the survey forms completed. Mrs Bartley gave examples of things that have been done in response to views expressed – for example, the proposal to purchase a mini bus. The manager was not able to provide evidence that formal staff supervision was taking place. We talked to the manager about sit-down staff supervision and found that while staff are receiving annual appraisals, formal supervision is not being carried out. Greensleeves DS0000014541.V375581.R01.S.doc Version 5.2 Page 26 A member of staff we spoke to confirmed that sit-down supervision is not being provided. A requirement has been made concerning staff supervision. The service has advised us in their AQAA of the most recent equipment maintenance services or tests carried out. Training records we sampled indicated that staff are receiving training in health and safety topics such as fire safety, appointed person first aid, moving and handling, hazardous substances and use of hoists. Greensleeves DS0000014541.V375581.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x n/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x 3 x 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 3 3 x x 1 x 3 Greensleeves DS0000014541.V375581.R01.S.doc Version 5.2 Page 28 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 OP9 Regulation 13 Requirement The registered person must ensure that arrangements for the recording, handling, safekeeping and safe administration and disposal of medicines received in the home are safe. The recording of medication stocks and administration were not found to be ensuring the safety of medicine administration. 2. OP12 16 The registered person must 19/10/09 consult service users about the programme of activities arranged by the care home and provide facilities for recreation having regard to the needs of service users. People living in the home and their relatives are telling us there is a need for more regular activities and outings. 3. OP36 18 The registered person shall ensure that persons working in the care home are appropriately DS0000014541.V375581.R01.S.doc Timescale for action 19/10/09 19/10/09 Greensleeves Version 5.2 Page 29 supervised and that for the duration of a new worker’s induction training a member of staff who is appropriately qualified and experienced is appointed to supervise the new worker. There are not arrangements in place for staff to formally and regularly sit down with a senior member of staff or manager to talk about all aspects of practice, the philosophy of care in the home, and their career development needs. This formal supervision should aim to assist staff in meeting the needs of the people receiving care and support. 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 DS0000014541.V375581.R01.S.doc Version 5.2 Page 30 Care Quality Commission South East Region PO Box 1250 Newcastle upon Tyne NE99 5AL National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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