Inspection on 29/09/07 for Greensleeves Residential Care Home

This inspection was carried out on 29th September 2007.

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 Residential Care... 16/09/08

Greensleeves Residential Care... 18/04/06

Greensleeves Residential Care... 06/12/05

Greensleeves Residential Care... 02/09/05

Greensleeves Residential Care... 22/03/05

Greensleeves Residential Care... 27/09/04

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

CARE HOMES FOR OLDER PEOPLE Greensleeves Residential Care Home 8 Westwood Road Portswood Southampton Hampshire SO17 1DN Lead Inspector Christine Walsh Unannounced Inspection 29th September 2007 10:00 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 Residential Care Home DS0000059080.V344853.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 Residential Care Home DS0000059080.V344853.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greensleeves Residential Care Home Address 8 Westwood Road Portswood Southampton Hampshire SO17 1DN 023 8031 5777 023 8049 0033 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) Greensleeves Residential Care Home Limited Mrs Maria Sebastianpillai Care Home 21 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Greensleeves Residential Care Home DS0000059080.V344853.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: Old age, not falling within any other category (OP) 2. Dementia (DE). The maximum number of service users to be accommodated is 21. Date of last inspection 18th April 2006 Brief Description of the Service: Greensleeves is a care home situated in Southampton and close to local facilities. The home is registered for twenty-one service users within the category of older persons and dementia care. The home provides accommodation in a range of single and double bedrooms, which mainly have en suite facilities. There are two shared bedrooms. The home has two communal lounge areas, and a dining area which are on the ground floor of the home and easily accessible to service users. All meals are provided, and due to the needs of service users access to the kitchen may be restricted. To the rear of the property is an enclosed garden that is accessible to service users wishing to use it. Fees range from £335 - £420 per week. Greensleeves Residential Care Home DS0000059080.V344853.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit formed part of the key inspection process and was carried over one day by Mrs C Walsh, regulatory inspector. The manager completed an Annual Quality Assurance Assessment (AQAA) document, which was returned to the Commission for Social Care Inspection prior to the visit to the home. In addition “Have Your Say” resident and relatives comment cards were sent of which a small number have been received. The information obtained to inform this report was based on viewing the records of the people who use and work at the service, where possible speaking with the residents and staff and observing care and support practices. A tour of the home took place and documents pertaining to health and safety were viewed. What the service does well: Greensleeves does well to provide a comfortable clean environment where the people who use the service are encouraged to engage in stimulating activities, have a say about how they wish the home to be run and meet with their friends and relatives when they wish. A resident said: “ I’m quite happy with everything”. A Relative said: My mother has never had a bad word to say about the staff and is in better health now than when she was living on her own”. The home has established good relationships with health care professionals such as GP’s and district nurses and supports the people who use the service with their medications using appropriate medication administration practices. A relative said: “If there is a problem staff call me immediately and at the first sign of illness they call the doctor”. Greensleeves Residential Care Home DS0000059080.V344853.R01.S.doc Version 5.2 Page 6 The appointment of a qualified cook has improved the quality of food the home has improved their staffing levels, their training and skills and encourages their staff to undertake a national vocational qualification. A resident said: “ The standard of staff is excellent, conditions are very good and the food is also excellent”. A relative said: “Greensleeves is a wonderful home, the meals are excellent and 24 hour care is given, and everything is kept very clean”. A relative said: The care home always makes us welcome and we often have long chats with the owner. We cannot find fault with anything, we feel mum is being well looked after, she is putting on weight and looks very well. If she needs anything we are told straight away”. What has improved since the last inspection? What they could do better: The home has made improvements from its previous visit however five requirements ave been made following this visit. Despite improvements to the pre assessment process the home must ensure that it is not admitting people who they are not registered for. Greensleeves Residential Care Home DS0000059080.V344853.R01.S.doc Version 5.2 Page 7 Care plans show an improvement to their structure and in some areas their detail, however the home must ensure that care plans provide guidance for staff on how the residents wish to have their care carried out. Care plans must also reflect the current needs of the resident. A care manager said: “Care plans need to be clearer and easier to read. Some do not appear to be reviewed very often”. Although the staff interact with the people who use the service in a dignified and respectful way, some care plans and information compromises this. The home must ensure language and comments made in care plans and other forms of information about the people who use the service are not disrespectful or derogatory. The home must also ensure screens are used in double rooms to protect dignity and privacy. The home must also ensure that they are not impinging or restricting the rights of individuals, unless it can be evidenced that this has been done in the best interest of the person and agreed using a multidisciplinary approach, this includes the use of covert medications. The home has a complaints procedure, however some people who use the service are not aware of the procedure and for others it will not meet their cognitive and sensory needs, therefore the home must ensure all are made aware of the procedure and provided with the information in a way that will assist them to comprehend the information. The home provides a clean and conformable environment but this must extend to ensuring bed linen is clean and regularly changed and new pillows are replaced as required. The home has improved its staffing levels, their skills and ensures they receive training in abuse awareness and whistle-blowing, however to further protect the people who use the service the home must ensure it undertakes robust recruitment procedures by ensuring staff complete an application, provide reliable references and can demonstrate that they have a clear criminal record and have not been placed on the protection of vulnerable adults checklist (POVA). In general the home is hygienically clean, however the home should consider providing disposable hand towels and gels for staff to further prevent the risk of cross infection. The home supports people with mental health needs and although staff training has improved the home should consider providing staff with the knowledge and skills to support people who suffer with mental illness such as depression, schizophrenia and psychosis. Greensleeves Residential Care Home DS0000059080.V344853.R01.S.doc Version 5.2 Page 8 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 Residential Care Home DS0000059080.V344853.R01.S.doc Version 5.2 Page 9 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 Residential Care Home DS0000059080.V344853.R01.S.doc Version 5.2 Page 10 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): 1 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Greensleeves provides people who may wish to use the service with information about the home, which enables them to make a decision if to except a placement. Improvements have been made in assessing the needs of people who may wish to use the service, however the home must ensure they are not admitting outside of their certificate of registration. The home does not provide a service to people requiring intermediate care. Greensleeves Residential Care Home DS0000059080.V344853.R01.S.doc Version 5.2 Page 11 EVIDENCE: The AQAA informed us that the home has rewritten its Statement of Purpose and Service User Guide to reflect the philosophy of the home and to set objectives, it also informed us that the home assesses the needs of prospective residents prior to moving into the home to ensure they can meet their assessed needs. This was tested by viewing the homes revised Statement of Purpose, viewing assessment documents of three people newly admitted to the home, speaking with the manager and meeting with a newly admitted resident. The Statement of Purpose is easy to read, in plain English and describes the home, its facilities and the level of support the residents can expect from staff. Following the last visit to the home the service was advised to improve its assessment documentation to include obtaining information on the residents mental health needs and a history of the persons life to assist staff to have a better understanding of the persons previous life events, character and behaviours. The home can demonstrate that this process has improved. It obtains detail of personal information such as Date of birth, Next of Kin and GP details. It documents the prospective residents physical and mental health care needs, and their ability to carry out day-to-day life skills such as washing, dressing, eating and drinking. Life histories are obtained and provide good information on the prospective persons family, occupation and important events in their life. The manager stated she and a senior member of staff undertake an assessment of the prospective residents needs prior to them visiting the home and will obtain information from others such as care managers, GP’s and family members. The prospective resident is invited to visit the home is they are able. A resident said: “I was given information about the home before moving in and I liked the home very much” A relative said: “We met with the manager and answered questions about our relative before she moved in” Greensleeves Residential Care Home DS0000059080.V344853.R01.S.doc Version 5.2 Page 12 However the home must ensure that it is admitting people who are diagnosed as old age and dementia and over the age of sixty-five. It was established during the course of the visit that the home might have admitted someone out of category. The home was advised that they must review the information provided to them and a decision will be made if the home is in breach of its registration. At the time of writing this report the manager has written to the Commission for Social Care Inspection to confirm they are looking into the clinical diagnosis of the person admitted. Greensleeves Residential Care Home DS0000059080.V344853.R01.S.doc Version 5.2 Page 13 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): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Greensleeves has moved some way to improving the standard of information in care plans and describing how people who use the service have their health, wellbeing, and medication needs met. However further improvements are required in this area, the home must provide evidence that the residents’ holistic needs are being met and to ensure inappropriate language written in personal plans does not compromise the resident’s dignity and rights. EVIDENCE: The AQAA informed us that the home has comprehensive and structured care plans, which are agreed and signed by the resident or representative. The home ensures the health care needs including the administration of medication are met by various health care professionals, staff receive training and the dignity and privacy of the residents is upheld. Greensleeves Residential Care Home DS0000059080.V344853.R01.S.doc Version 5.2 Page 14 This was tested by viewing four residents personal plans, medication records and the accident book, speaking with residents and relatives, and observing practices in the home between residents and staff. Following the last visit to the home it was recommended that care plans needed to be developed further to cover social aspects of the residents quality of life and that the plans need to be more specific in guiding staff on how to support the residents. Changes to the structure of care plans was found, however the care plans fail to provide staff with information on how to support residents in areas identified in the residents pre admission assessment. An example of this being the home is aware through the assessment process that a residents is prone to bouts of depression, takes to their bed days on end and refuses to eat, however there was no plan in place to give staff guidance of how to support the resident and what action they must take to prevent the resident from becoming irreversibly unwell. A care manager said: “ Care plans need to be clearer and easier to read. Some do not appear to have been reviewed very often.” The majority of residents and relatives spoken with said they were very happy with the care they receive. All residents were smartly dressed and groomed with clean dentures, glasses and fingernails. A resident confirmed that she is aware she has a personal file and regularly meets with a member of staff to review her notes. A resident said: “The staff are wonderful they always treat me with kindness and help me with the things I need, I can’t fault them”. A relative said: “This is a very good home, I couldn’t want for a better place for my relative, she is very well cared for, it’s just a shame there are not other places like this”. The AQAA informs us that the home records visits from all health care professionals and attendance to hospital. Good detail was found in a residents personal plan detailing a GP’s visit, how the visit went the outcome and treatment. A comment card received from a GP indicated that he was happy with the home, the staff and the way in which the residents are cared for. Comment cards received from ten residents indicated that they always have their health care needs met. Greensleeves Residential Care Home DS0000059080.V344853.R01.S.doc Version 5.2 Page 15 A resident said: “The staff call the GP when I am unwell, I see the opticians and have my feet done by the chiropodist”. A relative said: “Mum looks so much better since she has moved into Greensleeves” The home has medication policies and procedures in place. All medications are stored securely including controlled drugs. The home has appropriate systems in place for the storage, administration, recording, disposal and receipt of medications. A senior member of staff is responsible for maintaining safe practices and procedures in the administration of medication. All staff have received training and a care plan is in place for each residents who requires as required medications. The home is currently using covert procedures in the administration of medication (medication disguised in food or drink) The manager confirmed that all parities involved in the residents care had been involved, however there was no evidence to support this. The care plan detailing the actions required by staff is conflicting and doesn’t provide staff with clear information on how he should be supported. The home must consider the rights of the residents in respect of their care and refer to the Mental Health Capacity Act 2005 to ensure they are not in breach of people’s human rights, such as the use of covert medication. The location where medications are administered is dark and could do with extra lighting, the manager said she would deal with it straight away. Through observation it was established that the staff show kindness and respect towards the residents and compliments were received from residents and relatives of how kind and thoughtful the staff and the manager are. Although some care plans and other information held in resident’s notes raise demonstrates that the home does not fully respect the residents, such as informing staff to ignore a resident when he is moaning, “as he will forget soon enough”. Notes detailing a residents personal care held in the staff hand over book also compromises residents dignity and privacy. The home must also ensure screens are provided in shared rooms to preserve resident’s dignity and privacy. Greensleeves Residential Care Home DS0000059080.V344853.R01.S.doc Version 5.2 Page 16 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): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home does well to ensure it provides people who use the service with opportunities for individual and group activities. The people who use the service are supported to maintain links with family and friends, however the home must address the internal isolation of some people who use the service. The home could do better to consider the rights and choices of people who use the service. The people who use the service receive well-balanced and nutritional meals, however the home must ensure people who have additional nutritional needs have these appropriately met. EVIDENCE: The AQAA informed us that the home has done well to listen to the views and wishes of the residents in terms of activites, providing an open and friendly Greensleeves Residential Care Home DS0000059080.V344853.R01.S.doc Version 5.2 Page 17 home for relatives and friends to visit and providing hot meals when and where they wish. This was tested by observing activity in the home, seeking the views of residents, observing staffs interactions, and viewing residents personal plans, menus and comment cards. Greensleeves offers a homely environment where residents are encouraged to participate in-group and individual activities. At the time of the visit residents were observed engaging in knitting and crochet with the support of a staff member and watching the television. Crochet arm covers made by a resident were found on the arms of chairs, the resident was very proud of her achievement. A resident spoke of the group games they play in the afternoon and how enjoyable this is, the inspector was later informed that the same resident was resistant to join in up to a number of months ago but now offers ideas for activities. The home has appointed the responsibility of activity coordinator to a senior member of staff who confirmed that she really enjoys spending time with the residents and organising activities for them. Individual activities such as gardening and shopping for plants and going down the pub for a drink are also supported by the home. Resident’s hobbies and interests are recorded in their personal plans. The home is friendly and welcoming and the two relatives with whom were spoken with were very complimentary of the hospitality of the staff and manager. A relative said: “The manager is very approachable and is always available to answer any of my queries” Another said: “I visit several times a week and I am always greeted well”. Other comments recieved confirmed that regular contact is made to or by the home keeping them informed of their relative’s wellbeing. The manager stated that if residents wish to contact their relatives they can use the cordless phone. Greensleeves Residential Care Home DS0000059080.V344853.R01.S.doc Version 5.2 Page 18 The staff with who were spoken with at the time of the visit demonstrated an understanding and the importance of ensuring that the residents are treated with dignity, supported to maintain their independence and have their decisions and choices respected. Care plans incorporate these values reminding staff of their role when supporting the residents to get up, get dressed, bathe, dine and go to bed. Minutes of residents meetings provide evidence that residents are consulted about activities, menus and the environment. The home provides well-balanced and nutritional meals of which the residents have an opportunity to choose and plan with the cook. The cook is new to the service but stated he is already getting to know the residents likes and dislikes, these are also recorded in the resident’s personal plans. Meals are taken in a congenial setting and assistance is given where required; however the home must seek advice on the nutritional needs of a resident identified at the time of the visit and draw up a plan of care that will provide guidance for staff when the residents refuses to eat. Greensleeves Residential Care Home DS0000059080.V344853.R01.S.doc Version 5.2 Page 19 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): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides information to people whom use the service on how to raise concerns and complaints, however it can be improved upon by making it accessible for residents whose cognitive and sensory abilities are limited. The home does well to ensure the people who use the service have their welfare protected by staff who have a good understanding of adult protection. EVIDENCE: The AQAA informed us that they promptly reply to complaints and the complaints policy is displayed in each bedroom. Training is provided on abuse awareness and staff are encouraged to whistle blow. This was tested by viewing the home complaints procedure and comment cards received from residents and relatives, speaking with staff and observing practices. The home issues each resident with a complaints procedure, which is displayed in their bedrooms. It is precise and informs residents how to make a complaint, although the complaints procedure was written in small print and did not provide the contact details of other agencies the residents or relatives can go to. Greensleeves Residential Care Home DS0000059080.V344853.R01.S.doc Version 5.2 Page 20 The home holds regular minuted residents meetings where residents are able to express their views and concerns. Residents with whom were met with said they were very happy and did not have any complaints. The same response was received from two sets of relatives who stated they had no concerns but would not be afraid to approach the manager if they had. The majority of comment cards received from residents and relatives said they knew how to complain, however a small number of residents indicated they didn’t. The home has appropriate policies and procedures in place in respect of adult protection and staff receive training in abuse awareness and whistle blowing. The staff spoken with at the time of the visit were aware of their roles and responsibilities in reporting acts of abuse. Although resident’s safety is compromised as the home does not follow robust recruitment procedures. Greensleeves Residential Care Home DS0000059080.V344853.R01.S.doc Version 5.2 Page 21 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): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service are provided with a comfortable, clean and homely environment and are protected from the risk of infection. However the risk of cross infection could be further minimised. EVIDENCE: The AQAA informed us that the home is continuously monitoring and improving the external and internal decoration of the home and in the last twelve months the home has replaced furniture and carpets. This was tested by touring the home, viewing some bathrooms and bedrooms, speaking with residents and relatives and observing hygiene procedures. Greensleeves Residential Care Home DS0000059080.V344853.R01.S.doc Version 5.2 Page 22 On entering Greensleeves it was warm and welcoming, resident were comfortably sat in various communal areas of the home. The home was bright, airy and free from offensive odours. The home is furnished with quality furniture and soft furnishings and in some areas of the home newly purchased. The home has an enclosed secure garden with a patio area and an area specifically put aside for a resident with an avid interest in gardening. A resident said: “I like sitting out in the garden in the summer under the brolly, its good to listen to the birds”. Other residents were very complementary of the environment and its cleanliness and said they liked their rooms. Residents bedrooms have been tastefully decorated and furnished; residents are able to bring in small items of their own furniture if they wish. Rooms are personalised and reflect the resident’s individuality and history, although the manager must ensure bed linen is changed frequently, as required and bedding and pillows are replaced as necessary. At the time of the visit an area of the home, including bedrooms was cold, as the heating had failed. The manager had made arrangements for it to be repaired the same day, insisting that the repairs are made on the same day. The home has adequate bathing facilities, however these are looking worn and in need of refurbishment, the manager confirmed that this is planned for in the very near future. The home has systems and procedures in place to minimise the risk of cross infection, staff are issued with appropriate protective clothing, training and the home has adequate laundry and waste facilities. However the risk of cross infection could be further minimised by the use of disposable towels and hand gel for staff. Greensleeves Residential Care Home DS0000059080.V344853.R01.S.doc Version 5.2 Page 23 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): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has appropriate staffing levels to meet the current needs of the people who use the service. The home has made improvements to the level of training staff receive, however the effectiveness of training should be monitored to ensure staff implement the knowledge they have received. The home does well to ensure staff are appropriate trained to meet the people who use the service needs. However the home must make further improvements to its recruitment procedures to ensure the people who use the service from potential risk of harm. EVIDENCE: The AQAA informed us that the home has appointed to new staff in the position of staff as a team leader who is experienced and qualified and appointed a qualified cook and staffing levels have been stepped up to meet the layout and needs of the residents. Greensleeves Residential Care Home DS0000059080.V344853.R01.S.doc Version 5.2 Page 24 This was tested by observing staff working practices throughout the course of the visit, viewing training and recruitment records and speaking with staff. The home has recently appointed new staff and still have a vacancy of which they are recruiting to. Numbers have increased which allows more time with residents engaging in social activities and covering different areas of the home at the same time. Staff were observed to go about their work in a relaxed and unhurried way and were readily available to answer residents queries and buzzers promptly. The manager stated that addition of a full time cook and team leader as improved the quality of time spent with residents. Comment cards received from residents and relatives confirmed that there is always a member of staff available. Staffs engagement and caring practices were observed periodically through the day and they were observed to be courteous and respectful to the residents and visitors, however a comment received from a care manager in respect of overseas staff speaking their own language in front of residents was described as a concern, this can be confusing and disorienting for some residents and therefore the manager must address this with her staff. The manager encourages her staff to undertake a national vocational qualification (NVQ) and has appointed a team leader who has NVQ 4 registered managers award (RMA) and a cook who has NVQ 3 in catering. 90 of the staff have an NVQ 2 or above. This demonstrates that the home is committed to having a qualified workforce. The manager interviews staff, seeks two references, relevant documents for overseas workers and issues them with contracts. Some staff have evidence of CRB and POVA checks, however newly appointed staff records seen at the time of the visit did not provide evidence that they had been recruited correctly, the home does not ask the applicant to complete an application form. Some references referred to “To whom it may concern” indicating that the manager has accepted pre written references and could not be established if they were from the applicant’s last employer. The manager has accepted a CRB previously undertaken in another service and has started people without the evidence of a POVA check taking place. The home provides the staff with mandatory training such as health and safety, safe manual handling, fire training twice a year from an external facilitator and specific training such as dementia awareness, understanding abuse, infection control and medication awareness, however the manager is advised to provide staff with training in mental health such as schizophrenia, Greensleeves Residential Care Home DS0000059080.V344853.R01.S.doc Version 5.2 Page 25 psychosis and depression to provide staff with a better understanding of the people who have these illnesses. Comments received in comment cards from residents and relatives was that they felt the staff were skilled and qualified to meet they’re needs. Greensleeves Residential Care Home DS0000059080.V344853.R01.S.doc Version 5.2 Page 26 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): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well run by a manager who is empathic and has an awareness of the needs of the people who use the service. The home does well to ensure the financial interests relating to the management of personal allowances of the people who use the service are safeguarded. The home has done well to improve its process of seeking the views of the people who use the service. The home must ensure all areas of the home, which are a potential risk to the health, and safety of people who use the service are addressed within the timescales stipulated by other agencies. Greensleeves Residential Care Home DS0000059080.V344853.R01.S.doc Version 5.2 Page 27 EVIDENCE: Information gathered prior to the visit and the AQAA informed us the manager is newly registered and is also joint owner of the home and there is a clear sense of leadership. This was tested by speaking with residents, relatives and staff, viewing records and observing interactions and management practices throughout the course of the visit. The manager demonstrated kindness, sensitivity and interacted well with residents, relatives and residents. Comments from residents supported this and a relative said: “Mrs Sebastian is approachable and listens to what we have to say” Another said: “She is always available to speak to if you need her” Staff said that improvements had been made since Mrs Sebastianphillai has been working in the home and it is a much nicer place to work. Mrs Sebastianpillai demonstrated that she is keen to take on board information and advice from other authorities and is keen to drive up standards in the home. However Mrs Sebastianpillai must make herself familiar with legislation and area raised with Mrs Sebastianphillai at her registration interview. The home undertakes quality audits of its service by holding regular residents and staff meetings, maintaining open dialogue with relatives and professionals. The home demonstrates that they undertake regular audits of the working practices such as medication, food, health and safety and staff supervisions and appraisals. The home looks after small amounts of resident’s monies. Accurate records for the individual monies are kept, with all money being received and expenditure by the residents recorded. A tour of the building and viewing service certificates demonstrated that the home is well maintained and as far as reasonably practical provides a safe place for the residents to live, however the manager must address the hot water tap readings that have been rising over five weeks from 43 – 50 centigrade. The manager agreed to deal with this straight away. Greensleeves Residential Care Home DS0000059080.V344853.R01.S.doc Version 5.2 Page 28 All visitors to the home are asked to sign in and out of the building and all doors are alarmed and will alert staff to a resident leaving the building unescorted Staff records provided evidence that they have received training in health and safety, first aid, food hygiene, moving and handling and fire safety. Fire safety records and service certificates demonstrated that the home is regularly monitored to eliminate risks to residents and staff, however the manager must ensure fire alarm points are tested weekly as per legislation and not fortnightly as the current practice indicates. Greensleeves Residential Care Home DS0000059080.V344853.R01.S.doc Version 5.2 Page 29 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 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X 2 X X X X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Greensleeves Residential Care Home DS0000059080.V344853.R01.S.doc Version 5.2 Page 30 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 OP7 Regulation 12(2) 15(1) Requirement The home must ensure that all staff responsible for the care of the people who use the service are aware of how they wish to have their care needs tended to and this is recorded. The home must ensure screens are provided in shared rooms to protect the people who use the service dignity and privacy. Timescale for action 30/11/07 2 OP10 12(4)(a) 11/11/07 3 OP14 12(3) The home must ensure the rights 11/11/07 of the people are not compromised. The home must demonstrate that it has consulted with other professionals in respect of the use of covert medication. The home must ensure it appropriately recruits staff using robust recruitment procedures to protect the people who use the service from potential risk of harm. The home must ensure staff 11/11/07 4 OP6 13(3) 12(3) 5 OP29 19(1) 11/11/07 Greensleeves Residential Care Home DS0000059080.V344853.R01.S.doc Version 5.2 Page 31 complete an application form. Ensure a POVA and CRB check is obtained before commencing in the home. The home must know the origin of references. 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 Residential Care Home DS0000059080.V344853.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Residential Care Home DS0000059080.V344853.R01.S.doc Version 5.2 Page 33 - 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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