Inspection on 01/03/06 for Greenways

This inspection was carried out on 1st March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Greenways 30/11/07

Greenways 17/10/06

Greenways 22/11/05

Greenways 22/11/04

Greenways 28/05/04

Greenways 05/03/04

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

CARE HOMES FOR OLDER PEOPLE Greenways Salisbury Road Darwen Lancashire BB3 1HZ Lead Inspector Mrs Janet Proctor Unannounced Inspection 1st March 2006 11:20 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 Greenways DS0000034755.V285510.R01.S.doc Version 5.1 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. Greenways DS0000034755.V285510.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Greenways Address Salisbury Road Darwen Lancashire BB3 1HZ 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) 01254 701954 01254 777574 greenways@blackburn.gov.uk www.blackburn.gov.uk Blackburn with Darwen Social Services Mrs Louise Anne Turner-Hope Care Home 28 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (27) of places Greenways DS0000034755.V285510.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service should employ a suitably qualified and experienced manager who is registered with the CSCI. Within the overall registration of 28 the number of service users permitted is: 27 in the category of OP 1 in the category of DE(E) When the named service user in the category of DE(E) leaves the care home, the registered person must apply for a variation to revert the registration to 28 service users in the category of OP. 3. Date of last inspection Brief Description of the Service: Greenways is a purpose built home situated in Darwen near to Sunnyhurst Woods. The home is registered for 28 residents - 23 reside in the main area of the home and five are accommodated in an Intermediate Care Unit situated on the 1st floor of the home. This Unit is managed separately from the main area of the home. The building is surrounded by lawns and patio areas. There is a small area for parking cars at the front of the home. Greenways is a twostorey building but due to the layout of the building the rear elevation is 3 storeys high. Bedrooms are situated on both the ground and first floors, as are bathing and W.C. facilities. On the ground floor there is a large dining room that is used for social events, and there are a number of small lounges. Smokers are catered for. A passenger lift connects the two floors. There is easy access for wheelchair users at the front door. The home is close to a bus route into Darwen Town Centre, and is approximately one mile from the main shopping centre. Greenways DS0000034755.V285510.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 1 day on the 1st March 2006. A short visit was done on 3rd March 2006 to obtain further information about recruitment. The previous inspection was done on 22nd November 2005 and information on the findings of this can be obtained from the home or from www. CSCI.org.uk . No additional visits have been made since the previous inspection. On the day of the inspection there were 24 residents at the home, 20 in the residential unit and 4 in the Intermediate care unit. Information was obtained from staff records, care records, and policies and procedures. Information was also got from talking to 7 service users, staff members and 3 visitors. Wherever possible the views of residents were obtained about their life at the home. Detailed notes were taken, which have been retained as evidence of the inspection findings. What the service does well: What has improved since the last inspection? Following a pre-admission assessment the prospective resident received a letter confirming that the home could meet their needs. This meant that they could be confident that they would get the care they needed. Records were kept of when a resident received a nutritional supplement that had been prescribed by their Doctor. Greenways DS0000034755.V285510.R01.S.doc Version 5.1 Page 6 A Criminal Records Bureau clearance had been received before a new member of staff started work. This meant that residents were safeguarded. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Greenways DS0000034755.V285510.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Greenways DS0000034755.V285510.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Information was available to enable prospective service users to make an informed choice about whether they wished to live at the home. Residents could be confident that the home could meet their needs. This was because they had their needs assessed before moving into the home and received a letter confirming whether the home could meet these needs. EVIDENCE: A copy of the Statement of Purpose and the Residents Guide were on display in the reception area. A copy of the complaints procedure needed to be included in these documents. Reference was made to the Council’s separate “Complaints, Compliments and Comments” leaflet but this was not physically attached to the Statement Of Purpose and Service User’s Guide. Although they had been reviewed, there was no indication relating to when this had taken place. This meant that people reading the Statement of Purpose and the Service User’s Guide could not be assured that this was current information. Residents’ files contained copies of assessments completed by health and social care professionals. It was evident that it was also usual practice for the Manager to visit and assess prospective residents before offering them a place Greenways DS0000034755.V285510.R01.S.doc Version 5.1 Page 9 at the home. A letter was then sent to the prospective resident telling them whether the home could meet their needs or not. A copy of this letter was not kept on file. Greenways DS0000034755.V285510.R01.S.doc Version 5.1 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 and 8 The lack of a clear care planning system may result in residents’ personal, health and social needs not being recorded and staff not being aware of what care is required. EVIDENCE: There were two care plan formats in use. One set available to staff in the staff room and the other set filed in the office. Having two sets of care plans for each resident created a time consuming and confusing system. The information in the care plans available to staff was not complete and the details were not always current, accurate and explicit. This meant that staff did not have the full information they required to be able to give consistent care. This was of particular importance as a number of Agency staff were being used at the home. The plans for three residents were examined. One resident did not have a plan available to staff, although one had been completed and was filed in the office. This meant that staff were working to the details on the Care Manager’s Overview Assessment, which may not be current to the needs identified whilst living at the home. There were no directions to staff about how to give the care she needed. Whilst the other plans outlined the residents’ personal, health and Greenways DS0000034755.V285510.R01.S.doc Version 5.1 Page 11 social care needs, all the assessments e.g. moving and handling and nutrition had not been completed. The weight of a resident who had been at the home for 2 months had not been recorded. This meant that there was no base-line weight to judge whether weight loss or gain had occurred during her stay at the home. There were no directions to staff on dealing with episodes of confusion or episodes of difficult behaviour. The care plan for one new admission showed that her care had been reviewed and the plan updated on nearly a daily basis. However, another resident’s plan did not have a record of review since early December 2005. There was space available to show that the care plans had been drawn up with their or their relative’s involvement. This had not been signed, although there was evidence on the plans filed in the office that this took place. Visitors spoken to said that they were invited to read the plan of care and felt fully informed of what was being done. The fact that the District Nurse visited was recorded. Equipment for the prevention of pressure sores was obtained as needed and recorded in the plan of care. GPs were contacted and asked to visit the residents if they were unwell. Continence products were stored in the individual residents’ bedrooms and the use of any products noted in the plan of care. Greenways DS0000034755.V285510.R01.S.doc Version 5.1 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 and 15 The lack of recreational activities meant that residents’ social interests and needs were not being met. EVIDENCE: At the previous inspection a recommendation was made for there to be a variety of social activities available to residents. From talking to residents, visitors and staff it was evident that there was a lack of regular activities undertaken. The activity records showed that no activities had been recorded as being done from 17th February 2006 to 27th February 2006. Residents said, “There’s nothing going on. It must be difficult to find something for us all to do but I’d like to do things. I’ve a lot of go in me” and “I like dominoes and bingo. I’d play it every day if I could”. A visitor said, “ There’s very few activities going on. They’ve started an exercise and balance class and that’s good”. Staff said that they had a difficulty in finding time to do activities because of the need to be giving care “We do them if we’ve time”. From discussion with staff it was evident that they were aware that activities needed to be increased and a member of staff had just been allocated 4 hours per week for this. At the previous inspection a recommendation was made about recording on the Medication Administration Recording sheet when prescribed food supplements were given. There were no residents on a food supplement at the time of the Greenways DS0000034755.V285510.R01.S.doc Version 5.1 Page 13 inspection but staff said they were now aware that this had to be recorded when given. Greenways DS0000034755.V285510.R01.S.doc Version 5.1 Page 14 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 Written compliments made by visitors and residents showed that residents were happy, safe and confident about the care given. There was a lack of a stated time in which a response to a complaint would be made. This had the potential to reduce confidence that a complaint would be acted upon. EVIDENCE: The home had a complaints procedure, which was accessible to the residents and any visitors to the home. The procedure stated that an acknowledgement of the complaint would be made within 7 days but it did not state the time period for complaints to be dealt with. This meant that the complainant would not be aware of when they could expect a response to their complaint. No complaints had been made to the home or direct to CSCI since the time of the previous inspection. Written compliments were kept on file. Residents and their relatives had made some very praising comments and these showed that there was a high regard for the staff, facilities and care given. Greenways DS0000034755.V285510.R01.S.doc Version 5.1 Page 15 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): 26 The facilities and procedures at the home ensured that it was clean and hygienic. EVIDENCE: There was a laundry room, which had space for the washing of clothes and a separate area for ironing and storage of clean clothes. There were 2 washers and 2 dryers. Facilities for sorting soiled clothes were seen. The washers did not have a sluice programme but did do a 95 degree wash. There was a separate sluice room on both the ground floor and the first floor. These were clean and tidy. Facilities for disposal of continence products were appropriate. Hand washing facilities were available for staff. All parts of the home were clean and fresh smelling. Residents spoken to said that they were happy with the standard of cleanliness of their rooms. Greenways DS0000034755.V285510.R01.S.doc Version 5.1 Page 16 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 and 29 The numbers, skill mix and competencies of staff on duty met residents’ needs The details held at the home were insufficient to ensure that a thorough recruitment procedure had been followed. EVIDENCE: From the staffing rota and observation, there were sufficient care and ancillary staff on duty to meet the needs of the residents. However, there were currently 3 care staff vacancies on the residential unit that were either being covered by the regular staff working extra hours or by Agency staff. The same members of Agency staff were requested as far as possible to ensure continuity of care. Recruitment for a new Handyman was being undertaken. However, the previous person’s name and hours still appeared on the duty rota. There were 15 care staff employed at the home of which 11 had NVQ level 2. This meant that 73 of the carers had a qualification to show that they had the knowledge and skills to deliver good care. Another 2 carers were doing the NVQ course and another 1 had just enrolled. One new member of staff had been recruited since the previous inspection. Recruitment for staff was undertaken by an outside Agency and the home had received verbal confirmation that this member of staff had been vetted and could start work. The details held on file at the home were incomplete: there was no application form; no photograph; no proof of identity; and only one Greenways DS0000034755.V285510.R01.S.doc Version 5.1 Page 17 reference. There was a health reference, character reference and a copy of the CRB available for inspection. Greenways DS0000034755.V285510.R01.S.doc Version 5.1 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 and 38 The Manager was competent and capable. Residents and staff had confidence in her abilities to manage the home. There were health and safety policies and procedures and training given to staff. This ensured that the health, safety and welfare of residents and staff was promoted and protected. EVIDENCE: The manager of the home was registered with CSCI in May 2005. She has experience of managing a service for older people since 2002 and is currently doing the NVQ level 4. There was still no evidence that a representative of the department visited the home on a monthly basis to look at the quality of care and the facilities at the home. This meant that residents did not have opportunities to meet and pass their views onto a senior manager. Questionnaires had not been sent out since the previous inspection so it could not be seen whether these had been Greenways DS0000034755.V285510.R01.S.doc Version 5.1 Page 19 dated or not. Questionnaires will be sent out after April 2006 and will be monitored on the next inspection. There was a work based fire risk assessment for the home. A new fire panel was being fitted to the home. Due to this work the fire system had not been tested since 7th December 2005. Fire drills were held on a regular basis but these did not list the names of staff who had been involved. This meant that it could not be shown if all staff had been involved. Information held on file by CSCI showed that there was a current electrical certificate and that the home was safeguarded against Legionella. However, copies of these certificates were not held at the home. Records were seen to show that servicing engineers visited to test the lift and lifting equipment. The reports of these visits were not held on file at the home. This meant that it could not be seen at the time of the inspection that the building and equipment were safe. The water temperatures were tested by an outside contractor, who visited monthly. Staff had received training in Fire awareness in August and September of 2005. Moving and handling training had been done for 12 staff in 2005 and early 2006. The remainder of staff were booked to update this training. The majority of the staff had received training in First Aid or Health Emergencies. Protection of Vulnerable Adults training was in the process of being booked. 8 staff had done basic Food Hygiene and further courses were being booked. 7 staff had done an infection control course. Greenways DS0000034755.V285510.R01.S.doc Version 5.1 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 2 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X X X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X X 2 Greenways DS0000034755.V285510.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? Yes 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 OP1 Regulation 45Schedule 1 Requirement The registered person must ensure that the Statement of Purpose and the Service Users Guide include all the required elements of this standard. Each resident must have a plan of care that details how their needs in respect of health and welfare are to be met. The plan must be, where practicable, drawn up with the resident or their representative and kept under review. The duty rota must be an exact record of persons working at the home and the hours worked. The records held at the home for each employee must comply with those specified in Regulation 19 and Schedules 2 &4. The registered person must ensure that the home is visited under the requirements of this regulation and the appropriate report completed and a copy forwarded to the CSCI. Timescale for action 31/12/05 2. OP7 15(1) and (2)(b)(c) 31/03/06 3. 4. OP27 OP29 17(2) Schedule 4 19 11/03/06 31/03/06 5. OP33 26 (2-5) 31/12/05 Greenways DS0000034755.V285510.R01.S.doc Version 5.1 Page 22 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 The Statement of Purpose and Residents Guide should be dated when reviewed and copies of the reviewed documents should be forwarded to the CSCI. A copy of the complaints procedure should be attached to the documents. A copy of the letter sent to prospective residents telling them that the home can meet their needs should be kept on file. The weight of a new resident should be recorded in the plan of care as soon as possible after admission. There should be directions to staff on how to respond to episodes of confused or difficult behaviour. A variety of social activities should be made available to all residents. The complaints procedure should contain the time limit in which a complaint will be responded to. Questionnaires should be dated when completed. Confirmation that the work on the fire panel has been completed and the weekly tests resumed should be forwarded to CSCI. The names of the staff who have attended the fire drill should be included in the record. Copies of certificates relating to the safety of the building and equipment should be held on file at the home. 2. 3. 4. 5. 6. 7. 8. 9. 10. OP3 OP8 OP8 OP12 OP16 OP33 OP38 OP38 OP38 Greenways DS0000034755.V285510.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Greenways DS0000034755.V285510.R01.S.doc Version 5.1 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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