Inspection on 05/09/05 for Greenway House

This inspection was carried out on 5th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Greenway House 09/06/06

Greenway House 19/04/05

Greenway House 05/10/04

Greenway House 23/04/04

Greenway House 11/01/04

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

CARE HOMES FOR OLDER PEOPLE Greenway House 103 Springhill Lane Lower Penn Wolverhampton Staffordshire WV4 4TW Lead Inspector Mrs Wendy Grainger Unannounced Inspection 5th October 2005 09:00 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 Greenway House DS0000004948.V254679.R01.S.doc Version 5.0 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. Greenway House DS0000004948.V254679.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Greenway House Address 103 Springhill Lane Lower Penn Wolverhampton Staffordshire WV4 4TW 01902 330444 01902 335849 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 Deborah Roberts Mrs Jacqueline Edwards, Mrs Christine Munslow Margaret Davies Care Home 12 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (12), of places Physical disability over 65 years of age (7) Greenway House DS0000004948.V254679.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th April 2005 Brief Description of the Service: Greenway House is a twelve-bedded residential care home for elderly people. The home is located in Lower Penn; near to the city of Wolverhampton. Originally a private family home tastefully converted to a residential care home. Accommodation is to a very high standard. Residents’ bedrooms are located on the ground and first floor; the first floor can be accessed via the shaft lift or staircase. Each of the bedrooms had an en-suite facility. Bedrooms were tastefully decorated and personalised, views from the windows were over the extensive gardens and countryside. The larger lounge with an existing conservatory ensured that residents had egress and access into the garden. The home is tastefully decorated and maintained to a very high standard. Greenway House DS0000004948.V254679.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was completed on the 5 October 2005 by one inspector. Residents, staff and management provided information, documents, records and reports to assist in the completion of the report. Residents had been served breakfast in their rooms at the commencement of the inspection. Two of the residents continued with their daily routine with showers. Both confirmed that while one person preferred to be self caring she was aware that staff would help if necessary. The gentleman told the inspector that his carer was on holiday; she knew all his needs and respected them. Other staff were meeting his needs during her annual leave. Residents were happy and very satisfied with the home and the care they received, no adverse comment about the care or facilities was received from the residents spoken with. Located in a quiet lane in Lower Penn, Greenway House was opened in 1998 to offer accommodation to twelve older persons. At the time of this inspection there was one vacancy. Resident accommodation was located on the ground and first floor, which can be accessed via the shaft lift as was observed during the inspection or the main staircase. Bedrooms were comfortable and personalised to suit individuals taste. A number of the bedrooms had been re-carpeted and more were to follow. The communal areas were well furnished with quality fittings; the communal areas were warm and comfortable. Arrangements were in place for the residents to receive continued care from other professional care agencies. No person would be admitted to the home unless a full assessment of his or her needs had been assessed. The Statement of Purpose will be adjusted when the new care managers were appointed. Documents provided for each resident would ensure that they were aware of the process to follow in the event that they had a complaint. Greenway House DS0000004948.V254679.R01.S.doc Version 5.0 Page 6 Staff demonstrated their awareness of individuals needs during the inspection, they were experienced and competent to care for the resident group. Each person had a care plan of their personal care and health needs, including any calculated risk they may choose to take. It was suggested that parts of the care plans could be streamlined, and that only the most recent and pertinent documents relating to care should be evident. Residents were provided with a choice of a well balanced diet freshly prepared on a daily basis. Residents spoke well of the food and the consultation by the cook. What the service does well: What has improved since the last inspection? What they could do better: There was a need to be more proactive to training requirements, to source the possibility of distance leaning sets. While this home is a smaller establishment there was a need to consider identifying the communal toilets and bathrooms. Based on one persons care plan who was fairly new and needed on occasions directions to the facilities. Greenway House DS0000004948.V254679.R01.S.doc Version 5.0 Page 7 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. Greenway House DS0000004948.V254679.R01.S.doc Version 5.0 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 Greenway House DS0000004948.V254679.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,5, Standard 6 is not relevant to this home. The Statement of Purpose would provide any person with the relevant information to make a choice regarding a placement. This document and the Service Users Guide were readily available. EVIDENCE: At the time of this inspection Greenway House was without a registered care manager. Two of the providers were to take on this role. Arrangements were to be made to complete the application. Following this the Statement of Purpose will be amended. No person would be admitted to the home unless their needs had been assessed, this was evidenced in the care plans. It is the practice of the home to invite prospective residents to the home prior to admission. Greenway House DS0000004948.V254679.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The arrangements in place for the continued care from professional agencies were robust. Staff training and the system used by the staff ensured that residents were protected from any form of abuse when administering medication. Residents were treated with respect, their dignity was recognised by the staff who were committed to the care of the older person. EVIDENCE: Each person had a detailed care plan of his or her personal care and physical needs. Three care plans were seen during the inspection and followed up more fully by discussions with one resident. Greenway House DS0000004948.V254679.R01.S.doc Version 5.0 Page 11 Discussed with the providers was the need to consider streamlining the actual care plan; and to have only the relevant plan in the module. There were plans to revamp the care plans and this will be considered. Risk assessments were part of the previous reports recommendations, they had moved forward and following advice provided they would be further reviewed. Arrangements were in place for the continued care of any of the individuals health needs from professional agencies. At the time of this inspection District Nurses were visiting on a regular basis. The system for medication was satisfactory the inspector identified a small number of gaps in the records. One resident chooses to self administer her medication; a risk assessment was in place. There was need to update the training of staff in the Safe Handling of Medicines. The staff from entering the home when management were not available were warm in their welcome of the inspector. They responded to the inspection in a positive manner, they were aware of the location of documents required. During the inspection they were observed to share knowledge of individuals needs, the staff went about their duties in a quiet manner. Sensitive to individuals’ dignity while respecting their choice of life style; this was confirmed by a number of the residents. Greenway House DS0000004948.V254679.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15 Based on the needs of the residents a social programme was provided weekly. The atmosphere and ambiance of the home promoted choice and preferred lifestyle. The menus reflected personal choice and variety providing a balanced diet. EVIDENCE: The staff took the responsibility for the in house activity programme on offer three times each week based on the interests of the residents. Spiritual needs were met on a monthly basis within the home. It was obvious that residents had the option to maintain their chosen life style and daily routine. During the inspection relatives took out one resident. The menus were balanced and offered choice; alternatives were always available. Records evidenced that a personal choice was prepared for tea. The records for fridge, freezer and food were current. Greenway House DS0000004948.V254679.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The homes complaints procedure was clearly displayed and contained the appropriate information. Via the training process staff were aware of the need to protect the residents from abuse of any type. EVIDENCE: The homes complaint procedure was displayed in the hall, each resident was provided with a copy of the procedure personally. The provider has recently undertaken a project for revamping the staff induction process. New staff would be inducted this procedure was followed up by the National Occupational Standards Awards in Care training. Greenway House DS0000004948.V254679.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24,25,26. Greenway House offered a comfortable, well maintained environment within a homely setting. Externally the home offered a choice of seating areas. EVIDENCE: The home is located on a quiet lane near to the city of Wolverhampton, standing in its own well-tended grounds. Greenway has been transformed from a family home to provide accommodation for twelve older persons. Each of the single bedrooms had an en-suite facility; accommodation is comfortable with in the personal bedrooms and communal areas. Sufficient bathrooms and communal toilets were located within easy reach of the lounge. While this very homely home provided this facility there was a need for the providers to identify the bathrooms and toilets. Greenway is a pleasant attractive comfortable home, which was maintained to a high standard. The people responsible should be congratulated. Greenway House DS0000004948.V254679.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. The home had in place proper procedures for the recruitment of staff. The levels of staff were deemed appropriate to meet the needs of the residents. Staff training and experienced was demonstrated by the way in which the care of the residents was addressed. EVIDENCE: At the time of this inspection Greenway House was without a registered care manager. Two of the three providers had made an application to become care managers in a shared role. It is the practice of the home to have a senior care on each of the shifts. The morning shift contained one senior and two care staff. This reduced by one carer for the afternoon shift. Two waking staff completed the staffing levels. At the time of this inspection there were vacancies for the day shifts (28hrs) and four night shifts. Recruitment was via the local outlets, the providers complied with the required checks on staff prior to their employment. Staff training was planned and on going for all the staff, this was evidenced from the records; an alternative format for the training matrix was suggested. Two of the staff were currently undertaking NVQ in Care levels III & IV. Greenway House DS0000004948.V254679.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 36,37,38 The providers ensured that as far practicable the residents were safe guarded via the training and support of the management. The home had good systems in place for maintaining the records and reports. EVIDENCE: Mandatory training was current and ongoing there was need for the providers to source a course for infection control as reported in the report of April 2005. This had not been addressed in the interim time span. This was discussed with two of the providers. Green way House was a viable business. The business plan for the year was evidenced. Greenway House DS0000004948.V254679.R01.S.doc Version 5.0 Page 17 Formal supervision of the staff had been on hold since the previous care manager had left (July) the process will now be addressed by the providers. Records were in place relating to the fire records, the providers after discussion were to revamp the form for the staff drills. Greenway House DS0000004948.V254679.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 4 4 4 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 X 3 3 X X 3 3 3 Greenway House DS0000004948.V254679.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? N/A 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard 7 9 21 38 Good Practice Recommendations To consider streamlining the care plans for the staff to operate on the pertinent information regarding care. To monitor the records for the administration of medicines and to ensure that training is appropriate To consider some form of identification to enable new residents to locate the communal toilets and bathrooms To follow the advice given in respect of the staff receiving mandatory training for infection control as identified in the report of April 2005 Greenway House DS0000004948.V254679.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Greenway House DS0000004948.V254679.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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