Inspection on 08/07/08 for Greensleeves

This inspection was carried out on 8th July 2008.

CSCI found this care home to be providing an Good 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 07/07/09

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 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Greensleeves 19 Perryfield Road Southgate Crawley West Sussex RH11 8AA Lead Inspector Ed McLeod Unannounced Inspection 8th July 2008 09:30 X10015.doc Version 1.40 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 DS0000014541.V367468.R01.S.doc Version 5.2 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 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 DS0000014541.V367468.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.V367468.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: Female Whose primary care needs on admission to the home are within the following categories: Dementia (DE) The maximum number of service users that can be accomodated is 41. 2. Date of last inspection 2nd May 2006 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, largely based upon residents needs. Both units have their own sitting rooms, 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. Fees range from £430 per week to £535 per week. Greensleeves DS0000014541.V367468.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 2 star. This means the people who use this service experience good quality outcomes. The visit was arranged to follow up requirements made at the previous inspection and to review the performance of the service against the key national minimum standards for care homes for older people. In preparation for the visit, we received a CSCI annual quality assurance selfaudit from the provider, and asked some of the people who receive a service and some of the staff who work for the service for their views. This was done by sending CSCI survey forms to the service. Other information received on the service since the previous inspection, including notifications, reports from other agencies and the previous inspection report supported our planning for this visit. The visit was carried out by one inspector who was on the premises for five hours. During the visit we spoke to four members of staff and the manager Mrs Bartley. We sampled four sets of assessment and care records, and four sets of staff recruitment and training records. Other records sampled included the record of complaints. What the service does well: People in the home are being well cared for, and enjoy an active lifestyle. There is a calm atmosphere, and people interact in a relaxed way with staff. Staff are quick to respond if people are suffering distress. Personal care is provided in conditions of privacy, and in a calm and respectful way. People who need assistance with eating receive this in an unobtrusive and supportive way. Greensleeves DS0000014541.V367468.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Greensleeves DS0000014541.V367468.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Greensleeves DS0000014541.V367468.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. More complete assessments of people’s needs which tell the home all about them and the support they need should be provided so that people can have confidence that their needs can be met. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. EVIDENCE: A requirement was made at the previous inspection that pre admission assessments should provide more information on the person’s established Greensleeves DS0000014541.V367468.R01.S.doc Version 5.2 Page 9 routines, interests, and personal history to help in the writing of care plans with residents. At this visit we looked at three pre-admission assessments and found in them a lack of information on how the person wishes their care to be provided, their interests and social needs, and if the home can meet their needs. We discussed this with registered manager Mrs Bartley, who said that the need to update the pre-admission assessment form had already been identified, and this would now be undertaken. This requirement was found not to have been met. A requirement was made at the previous inspection that the statement of purpose and service user guide should be updated to ensure residents and prospective residents have current information on the home. At this visit we found that the service user guide has now been updated, and the person or their relative sign a form to say that they have received a copy of this. This requirement was found to have been met. Intermediate (formal rehabilitative) care is not provided in the home and so this standard was not assessed. Greensleeves DS0000014541.V367468.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s health, personal and social care needs are met, but need to be supported by more specific care plans which take into account how they wish their needs to be met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, people manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. EVIDENCE: Greensleeves DS0000014541.V367468.R01.S.doc Version 5.2 Page 11 A requirement was made at the previous inspection that care plans should include some provision for the resident’s individual interests and established routines. At this visit, we looked at four sets of care plans. The care plan is found in each person’s bedroom, and is therefore accessible to them and/or their relative. The care plan folder includes a medical history provided by the GP each year, and a brief monthly review of the care plan. For one person we found that the care plan did not include guidelines on meeting the person’s social needs, treatment of their diabetes and chiropody needs, when they usually would wish to get up and go to bed, and their night routine. The care plan did not include information on how the person wishes their care to be provided. For one person we found the care plan indicated that the person had hygiene needs but did not say what these were or how they would be met, and there was nothing recorded on how the person’s social needs were being met. Some of the needs identified in a local authority assessment 12 months’ previously were not addressed in the care plan. This requirement was found not to have been met, and has been reworded. A requirement was made at the previous inspection that where relevant guidelines for staff on dealing with aggressive incidents should be provided on the care plan. We discussed with the manager the care of one person who had been involved in aggressive incidents. We noted that an extra member of staff was on duty on the day of our visit to provide one to one support for the person, and that the plan was for the person to move to a service that could better meet her needs. We found that while incidents of aggression were being recorded by the home, the care plan did not refer to managing the person’s aggression and did not provide guidelines on how staff should best be dealing with the person’s aggression. This requirement was found not to have been met, and has now been included in a single requirement concerning care planning. Greensleeves DS0000014541.V367468.R01.S.doc Version 5.2 Page 12 While these shortfalls in planning and recording of the care to be provided were identified, we did note that people in the home are being well cared for. For example, people were observed to be calm, settled, and interacting in a relaxed way with staff. People were observed to be clean and well dressed. It was our observation that staff appreciated their needs and were quick to respond if they were suffering distress. People were always being addressed by their first name, and there was a lot of friendly interaction between people and staff. Care records we looked at indicated that people were accessing the health care support which they are in need of. Medication systems in the home have been updated with a change from secondary dispensing (the dosette box system) to medicines being administered from blister packs, which the manager believes provides a more safe method of giving medicines. Relevant staff have received training in this new system, and staff training certificates we looked at indicated that staff are being provided with training in the safe administration of medicines. It was our observation that staff are ensuring that the privacy and dignity of the person being cared for is being respected at all times. Personal care is provided in conditions of privacy, and in a calm and respectful way. Greensleeves DS0000014541.V367468.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available 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 and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. 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. EVIDENCE: Greensleeves DS0000014541.V367468.R01.S.doc Version 5.2 Page 14 During our visit there were a number of social activities taking place, usually spontaneously initiated by staff such as singing, dancing, and bingo. One person was provided with colouring pencils and a book, and was enjoying doing some colouring. On the afternoon of the visit a musical entertainer put on a show and people were clapping and singing along with him. The local newspaper had recently published an article on how some of the residents in the home enjoyed playing Wii computer games, and the home was arranging to purchase more Wii equipment for residents to make use of. Staff we talked to said that some people liked to come out for a short walk to local shops and have a coffee or ice cream. Staff said that exercise games were also popular, and that a recent garden party had been a great success and raised money for the residents’ social fund. Staff said that a number of relatives had attended and contributed to the garden party. Three people living in the home we talked to said they enjoyed the food in the home. None of them knew what was on the menu for lunch, and when advised that it would be steak and kidney they all said they liked steak and kidney. We talked with the cook, and discussed the arrangements for people who have specialist diets, such as a diabetic diet. We found a choice of main meals was offered only if requested by the person, or if it was known that they didn’t like the meal that was planned. Staff told us that they would then ask the person what they would like – popular alternatives were said to be ham, omelette and fish. We observed a lunch sitting, and found the lunch to be relaxed and unhurried. People were offered more food if they wished, and people were eating well and enjoying their food. People who needed assistance with eating were receiving this in an unobtrusive and supportive way. Greensleeves DS0000014541.V367468.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. If people have concerns about their care, they or other 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: We looked at the record of complaints, and found that complaints were being recorded and acted on appropriately. At the previous inspection a requirement was made that the policy and procedures on adult protection need to clarify that the local authority should be advised of adult protection or suspected adult protection incidents, and that it is the local authority and/ or if appropriate the police, not CSCI, which have responsibility for the investigation of adult protection incidents. Greensleeves DS0000014541.V367468.R01.S.doc Version 5.2 Page 16 At this visit we found that the safeguarding procedures have been updated, and that the manager has attended a briefing on changes to local safeguarding of vulnerable adults procedures. The home has a copy of the updated local safeguarding procedures. Discussions with the managers and staff indicated that they have an understanding of the process of safeguarding referrals in the local area. This requirement was found to have been met. At the previous inspection a requirement was made that staff training in local adult protection procedures should be provided, to ensure staff are aware of the steps that must be taken when an incident of abuse has taken place or has been suspected. At this visit we looked at staff training certificates, and found that regular training for staff in safeguarding adults is being provided. This was confirmed by staff we talked to. The manager advised us she has attended a briefing on an update to local safeguarding procedures, and a copy of the updated multi-agency safeguarding procedures is held in the home. This requirement was found to have been met. Greensleeves DS0000014541.V367468.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People stay in a 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 rooms feels like their own, it is comfortable and they feel safe when they use it. EVIDENCE: Greensleeves DS0000014541.V367468.R01.S.doc Version 5.2 Page 18 We found that arrangements were in place for the maintenance of the building and grounds, and that the building and grounds are being maintained to a good standard. We found that improvements to the premises since the last inspection have included new medication trolleys, the installation of a wet room shower, the purchase of two beds and a new hoist, and net curtains. The home is divided into two units with separate sitting and dining areas. All people have access to the garden which has paths and sitting areas and is attractively laid out. We visited seven bedrooms, all of which had been personalised by or for the person. Bedrooms were clean, comfortable and homely. We found the decoration and furnishing of the home to be to a good standard, and that sufficient bathrooms and toilets are provided. All areas of the home visited were clean and fresh. Greensleeves DS0000014541.V367468.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have safe and appropriate support as there are enough competent staff on duty at all times. They 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: On the day of our visit we observed there to be sufficient staff on duty to ensure that care needs were being met, including social support needs, and that at busy times such as lunch time there were enough staff present to offer support to people who needed support with their meal. We discussed staff qualification training with the manager Mrs Bartley. She advised us that there are twenty-eight care and domiciliary staff in the home, and at present seven staff have achieved the National Vocational Qualification Greensleeves DS0000014541.V367468.R01.S.doc Version 5.2 Page 20 (NVQ) in care at least at level 2, and one person is presently undertaking NVQ at level 2. Seven staff are being enrolled on NVQ at level 2 or 3 for the coming academic year. We looked at recruitment records for four members of staff, and found that the appropriate checks and references had been carried out before the member of staff began work in the home. An induction training for new staff is in place, and we sampled records relating to one person’s induction training. We looked at training certificates for a number of topics, and found that most staff had undertaken safeguarding, manual handling and fire training. Mrs Bartley advised us that staff training in infection control, food hygiene, and the use of the new hoist were being planned. Staff we spoke to thought there was sufficient training being provided for them to do their job. The previous requirement relating to staff training was found to have been met. Greensleeves DS0000014541.V367468.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. EVIDENCE: Greensleeves DS0000014541.V367468.R01.S.doc Version 5.2 Page 22 Since the previous inspection, Mrs Linda Bartley has been registered as manager of the service. Mrs Bartley continues to update her training and to introduce improvements into the service. We observed that the home has a very friendly atmosphere, and staff are quick to ensure that when people feel excluded or upset reassurance and support is provided. At the previous inspection a requirement was made that an annual quality audit which includes the views of residents, relatives and relevant others on the service must be undertaken and the outcomes published. We found that a quality audit had been carried out subsequent to the previous inspection. On the day of our visit, questionnaire forms were being readied to send out as part of the home’s 2008 quality audit. This requirement was assessed as met. At the previous inspection a recommendation was made that one to one staff supervision should be provided a minimum six times per year, cover all recommended topics, and should be recorded. At this visit we found that arrangements were in place for staff supervision, but Mrs Bartley acknowledged that this wasn’t always being recorded and there was a need to ensure this was done. We looked at staff training certificates for health and safety topics, and found that recent training has included first aid and manual handling. We noted that few staff were presently up to date with their training in infection control and in food safety, and Mrs Bartley advised that more training in these topics was being planned. Greensleeves DS0000014541.V367468.R01.S.doc Version 5.2 Page 23 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 3 x 2 3 x N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x x 3 x 3 Greensleeves DS0000014541.V367468.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 (1) (c) Requirement Timescale for action 19/12/08 2 OP7 15 The registered person shall not provide accommodation to a service user at the care home unless there has been appropriate consultation regarding the assessment with the service user or a representative of the service user. This is to ensure that the care provided takes into account the wishes, routines and interests of the person receiving the care. The registered person shall, after 19/12/08 consultation with the service user or their representative prepare a written plan as to how the service user’s needs in respect of his/her health and welfare are to be met, to include arrangements in place to ensure the safety of the person and others and how their individual interests and social needs will be met. Greensleeves DS0000014541.V367468.R01.S.doc Version 5.2 Page 25 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.V367468.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000014541.V367468.R01.S.doc Version 5.2 Page 27 - 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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