Inspection on 09/06/06 for Greenway House

This inspection was carried out on 9th June 2006.

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 05/09/05

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 Kathryn Marks Key Unannounced Inspection 9 June 2006 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 Greenway House DS0000004948.V297252.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. Greenway House DS0000004948.V297252.R01.S.doc Version 5.2 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 Mrs Deborah Roberts Mrs Christine Munslow 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.V297252.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection October 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 being 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 by its owners. Greenway House DS0000004948.V297252.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Key inspection was carried out on the 9th June 2006. The Inspector was provided with information by resident’s staff and management that included documents, and records to assist in the completion of the report. Residents as usual had been served breakfast in their bedrooms if they wished and were deciding on their daily routines. Residents confirmed to the inspector that they 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 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 these areas were comfortable and homely. 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 carried out. The Statement of Purpose needs to be updated to include the new joint Care Manager role. All residents spoken with were aware of the complaints procedure and said they would know who to talk to if they were unhappy about something. Staff demonstrated their awareness of individuals needs during the inspection, they were experienced and competent to care for the resident group. Each person had an individual care plan identifying their health and personal care needs, including any assessed risk they may choose to take. Care Plans have recently been reviewed and updated by the deputy. Residents were provided with a choice of a well balanced diet freshly prepared on a daily basis. Greenway House DS0000004948.V297252.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Records of fire training and drills needs to be structured and contained in one place so staff know where to find them. This will be reviewed at the next inspection visit. Last Environmental Health Inspector report not on site so Inspector was unable to view. All records relating to the home must be kept on site for Inspection purposes. This report will be reviewed at the next inspection visit. Greenway House DS0000004948.V297252.R01.S.doc Version 5.2 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.V297252.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Greenway House DS0000004948.V297252.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3. Standard 6 is not applicable to the home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s Statement of Purpose and Service users guide provides prospective residents with up-to-date details of the services the home has to offer, enabling an informed decision about admission to Greenway House to be made. EVIDENCE: The homes Statement of Purpose and Service Users Guide is given to residents and relatives clearly describing the services and facilities the home is able to offer. The Care Managers/Proprietors are in the process of updating the statement of purpose to identify them as Care Management. All residents have contracts of terms and conditions of residence at the home a copy of which is on resident’s files. A full assessment of individual needs is carried out prior to admission to Greenway House to ensure that the needs of residents can be met. Greenway House DS0000004948.V297252.R01.S.doc Version 5.2 Page 10 The prospective resident or their relative would visit the home where possible and staff would visit the individual in their own home or current surroundings. The outcome of the assessment is confirmed to individuals in writing. Greenway House DS0000004948.V297252.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. As at previous inspection arrangements are in place for the continued care from professional agencies as necessary to meet the needs of residents. 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, with privacy and dignity being promoted. EVIDENCE: As at previous inspection all residents had an individual plan of care that has been reviewed and updated. Residents/relatives are encouraged to sign care plans. Two residents were case tracked care plans were reviewed, residents spoken to and bedrooms visited. Risk assessments are carried out and included in care records. Health care needs are met by accessing local health care practices all contacts regarding health and personal care are recorded in care records. Greenway House DS0000004948.V297252.R01.S.doc Version 5.2 Page 12 Visiting district nurse confirmed to inspector that communication with the home is good. Lockable facilities are provided for residents for the safe storage of valuables and medication should they self-administer. One resident is currently choosing to self-administer. Policies are in place to inform staff of systems and procedures in the home. Residents spoken to said they were treated in a dignified and respectful way and this was the observation of inspector in the home today. The Management of Medication and Dementia Care Training have been carried out at the home. Greenway House DS0000004948.V297252.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The systems for resident’s consultation in the home are good with a variety of evidence that indicates that resident’s views are sought and acted upon. There is a need to look at the diverse needs of small groups within the homes registration category. EVIDENCE: Through discussions with residents the inspector identified that individuals were content with the lifestyle they experienced at Greenway House. Comments from individuals include “you are very well looked after by staff” “ I always enjoy my food” “ The staff are very kind” The staff work on activities with residents and decide daily with residents what the activity will be. The home within its registration category is registered for 4 residents with dementia and 7 with a physical disability. The Care Manager said that there is no specific activities or social events for residents with dementia and that they generally join in with the main activities. The home must review and plan for the diverse needs of this group of residents and evidence appropriate activities. Greenway House DS0000004948.V297252.R01.S.doc Version 5.2 Page 14 Individuals with a physical disability are able to access all areas of the home and join in events taking place. Observations of staff interacting with residents were good with warm exchanges taking place. A number of visitors were coming in and out of the home some residents going out with visitors. The menu for the last month was seen and offered a varied traditional diet. The inspector had lunch today during this unannounced inspection. The meal was nicely presented and portions were generous fish and chips followed by choice of dessert. Greenway House DS0000004948.V297252.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system with some evidence that service users feel their views are listened to. Regular staff awareness training takes place to protect residents from abuse. EVIDENCE: Greenway House has a complaints procedure in place this is displayed in the hallway and contained in the homes Statement of Purpose and Service Users Guide. Individual residents are provided with a copy of the procedure. At the time of this key inspection there had been one complaint received about the home since the last inspection. This was investigated and not upheld. A subsequent concern has been raised relating to the previous complaint and has been put back to the provider to investigate. The home has in place a book to record any complaints and how they are dealt with. Discussions with some residents identified that they were aware of the complaints procedure and if unhappy about something they would talk to the care manager. Residents are protected from abuse by staff training on abuse/awareness, observations and discussions during staff meetings and supervision. Policies and procedures are in place at the home. The home does not deal with resident’s finances they are dealt with by the resident, their relatives/solicitors. Greenway House DS0000004948.V297252.R01.S.doc Version 5.2 Page 16 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, 21, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Greenway House provides a comfortable well-maintained environment within a very homely setting. Externally there are attractive gardens with a choice of seating areas. EVIDENCE: Greenway House is located on a quiet lane near to the city of Wolverhampton, standing in its own well-tended attractive grounds. The House 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. Greenway House is a pleasant attractive comfortable home, which was maintained to a high standard. Greenway House DS0000004948.V297252.R01.S.doc Version 5.2 Page 17 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate procedures are in place for the recruitment and selection of staff. EVIDENCE: As at previous inspections staff on duty at Greenway House was observed to be competent and satisfactory in number to meet the needs of individuals in their care. Staff morale was observed to be high with the staff team working well together assisting individuals where needed to make choices to improve their quality of life. Observations today were that staff on duty were as the rota and were sufficient in number to meet the needs of individuals in their care. Robust recruitment procedures are in place to employ staff Criminal Records Bureau checks are carried out along with POVA checks prior to permanent employment being offered. The home has a staff-training programme in place along with a training matrix. The Care Managers are currently doing NVQ Level 4 and the Registered Managers Award. Greenway House DS0000004948.V297252.R01.S.doc Version 5.2 Page 18 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): 31,33,35,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Care Manager/Proprietor provides clear leadership throughout the home with staff on duty demonstrating an awareness of their roles and responsibilities. EVIDENCE: Discussions with the Care Manager/Proprietor identified that she is experienced and competent to manage the home and care for older people. The Care Managers/Proprietors who have a job share are currently working towards obtaining their Registered Managers Award. Resident’s financial interests are safeguarded by the involvement of individuals themselves their relatives/solicitors. The staffs at the home are not involved. The Registered Proprietors/ Care Managers ensures so far as is reasonably practicable the health safety and welfare of service users and staff. Greenway House DS0000004948.V297252.R01.S.doc Version 5.2 Page 19 Health and Safety awareness training is covered and health and safety checks are carried out. Safe working practices are in place and staff had received training in moving and handling, fire safety, first aid, and food hygiene. Infection control training is being organised this has been arranged twice and cancelled by trainer twice at short notice. Hazardous substances are stored safely. Greenway House DS0000004948.V297252.R01.S.doc Version 5.2 Page 20 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 3 3 X X 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X X X 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 X 3 X 3 X X 3 Greenway House DS0000004948.V297252.R01.S.doc Version 5.2 Page 21 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 OP12 Regulation 16 (2) n Requirement Consult service users about programme of activities including those service users with dementia and provide evidence that activities for this group of service users is being provided Timescale for action 28/07/06 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 Refer to Standard OP1 Good Practice Recommendations To include the names of joint proprietors as Care Managers in the statement of purpose (This is in hand) Greenway House DS0000004948.V297252.R01.S.doc Version 5.2 Page 22 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.V297252.R01.S.doc Version 5.2 Page 23 - 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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