Inspection on 17/10/06 for Greenways

This inspection was carried out on 17th October 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 01/03/06

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 Key Unannounced Inspection 09:00 17th October 2006 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.V308372.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. Greenways DS0000034755.V308372.R01.S.doc Version 5.2 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 Old age, not falling within any other category registration, with number (28) of places Greenways DS0000034755.V308372.R01.S.doc Version 5.2 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: 28 in the category of OP 1st March 2006 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. 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 two-storey 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. Prospective residents obtain information about the home through the Statement of Purpose and the Service User’s Guide. The fees charged in October 2006 were £354-00 per week. Greenways DS0000034755.V308372.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Greenways on the 17th October 2006. The previous inspection was done on 1st March 2006 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 21 residents at the home, 18 in the residential unit and 3 in the Intermediate care unit. Information was obtained from staff records, care records, survey forms and policies and procedures. Information was also got from talking to residents and staff members. Wherever possible the views of residents were obtained about their life at the home and have been included in the report. What the service does well: The service ensured that a thorough assessment was undertaken before a prospective resident was admitted to the home. This meant that their needs were known and arrangements could be made to ensure that these were met. Residents were cared for in a friendly and professional manner. A resident said, “The girls are marvellous in the way they look after you”. Residents were able to make choices about their daily routines. This meant that they had some control over their lives. They said, “The staff get me up about 9.00 am. Sometimes I use the buzzer and at other times they come in and say ‘Are you ready’ and I say ‘Just a bit longer’ and they leave me to sleep” and “You can go to bed and get up when you want.” Visitors were welcome to come at any time. This meant that residents could keep contact with their family and friends. A resident said, “My son comes every other day. The staff are marvellous with him – get him a brew and have a laugh with him”. The home provided a diet that was varied, nutritious and to the liking of residents. This meant that they that their nutritional needs were met and they enjoyed their food. They said, “. The food’s good, you get a choice and there’s a nice variety” and “If you don’t like what’s on the menu they’ll always make you something else.” The home provided a clean and pleasant place for residents to live. There were a variety of areas for residents to sit and relax. This meant that they could Greenways DS0000034755.V308372.R01.S.doc Version 5.2 Page 6 have a choice of where they would like to spend their time. A resident said, “My room’s beautiful, it’s got everything I need”. The Intermediate Care unit ensured that residents reached their full potential of independence before returning home. This meant that they could be confident that they would be able to cope at home when they were discharged. Nearly all of the Care staff had received training to at least National Vocational Qualification level 2. This meant that they had the skills and knowledge to do their job. What has improved since the last inspection? What they could do better: There must be a plan of care for short term residents so that the staff know what their needs are and how to meet these. Records of food provided must be kept. This is so that it can be seen that residents are offered and take a nutritious and balanced diet. There must be evidence to show that all staff have received training in Safeguarding Adults. This is so that they know the right actions to take should they witness or suspect that anything is wrong. The number of staff on duty must be enough to meet the needs of the residents. Whilst the use of Agency staff is unavoidable at times there should Greenways DS0000034755.V308372.R01.S.doc Version 5.2 Page 7 always be a sufficient ratio of the home’s staff on duty. A resident said, “They’re short staffed though. Sometimes there’s only 2 on and that’s not enough. They have Agency sometimes – the trouble is you don’t know them. I know they’re checked out but it’s not the same as your own staff. You feel better when they’re on.” Staff said, “Sometimes there are periods when there’s only 2 carers on duty. A lot of Agency staff are being used – it helps it they come on a regular basis but it can be a ‘nightmare’ otherwise.” The duty rota must be accurate. This is so there is a record of who was working in the home at any given time. The details relating to the recruitment of staff must be held on file at the home. This is so that it can be seen that a through procedure has been followed and that residents are safeguarded. There should be evidence to show that any new staff have received a thorough Induction. This is so that it can be shown that they have been given the knowledge to do their work correctly. All staff must receive annual training in: moving and handling; first aid; and basic food hygiene. This is so that they keep up to date with their skills and knowledge in these subjects. 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.V308372.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 Greenways DS0000034755.V308372.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, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information was available to enable prospective residents to make an informed choice about whether they wished to live at the home. Residents could be confident that their needs could be met at the home. The Intermediate Care unit increased the independence and confidence of residents prior to them returning home. EVIDENCE: The Statement of Purpose and Service User’s Guide had been reviewed and updated. This meant that prospective residents received current and accurate information about the home and the services it provided. 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 at the home. A letter was then sent to the prospective resident telling them Greenways DS0000034755.V308372.R01.S.doc Version 5.2 Page 10 whether the home could meet their needs or not. A copy of this letter was kept on file. The Intermediate Care Unit was a separate unit to that accommodating older people. It had a capacity to take 5 residents, all of which had a single bedroom. There was also a lounge, dining kitchen, assisted bathroom, and Physiotherapy room. Support was provided from a multi-disciplinary team of Carers, Physiotherapist, Occupational Therapist and a District Nurse. The Coordinator, Physiotherapist and Occupational Therapist carried out pre admission assessments. A letter was then sent confirming that the unit could meet the assessed needs of the prospective resident. Greenways DS0000034755.V308372.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Not all of the care plans fully identified residents’ needs and told staff how to meet these. Medication practices were safe. Residents felt they were treated with respect. EVIDENCE: Three plans of care on the older persons unit were examined. For two of these there was a long-term care plan that gave details on the resident’s assessed needs and how these were to be met. There was evidence of consultation with the resident or their relatives. Relatives were invited to the care plan review and these were done monthly. The other plan was in respect of a resident who had been admitted as an emergency 10 days previously. Despite the resident having some health problems there were no directions in the care plan folder for staff to follow. This meant that the resident might not get the care they needed on a consistent basis. These details were available but had been filed in the office along with the risk assessments. Daily notes were now being written on each resident. This meant there was information for staff on their daily care, health and condition. Greenways DS0000034755.V308372.R01.S.doc Version 5.2 Page 12 Two of the plans included assessments for moving and handling and nutritional state. Weights were recorded. There was no specific fall risk assessment in the plan of care. Details on other risk assessments done were filed in the resident’s folder in the office. This meant that staff did not have ready access to the information contained in them. The District Nurses took responsibility for: pressure sore risk assessments; wound care; and continence assessments. Where continence aids were required these were recorded in the plan of care but did not include the type and size of aid to be used. The use of pressure mattresses and cushions was recorded in the care plan. Arrangements were made for medical input as and when required. District Nurses were seen on visits to specific residents. One plan of care for a resident on the Intermediate Care unit was examined. There was evidence of involvement of a physiotherapist and occupational therapist. A moving and handling and falls risk assessment had been completed. There was no care plan completed under the ‘goal planning’ section as the resident was reluctant to co-operate with the process. Staff had invited the relatives to a meeting to try to resolve this. Long-term goals had been written. Daily notes were written each day. The procedures for the control of medications were very thorough. The medications were kept in a separate room and a record of the temperatures of the area and the fridge was kept. There was some good practice seen when checking the medications. This included good records of medications ordered, received, administered and returned. The prescriptions were seen by the home before they were dispensed. There was a photograph of the resident so that they were correctly identified before being given their medication. All residents had given a written authorisation about whether they wished the staff to keep and administer their medications for them. The Controlled Drugs were correctly stored and recorded. All staff that administered the medications had received training to do this. This meant that they had the skills and knowledge to do this correctly. Handwritten entries on the Medication Administration Recording charts had not been signed or witnessed. This meant the details might be incorrect. There was no information on the criteria to be used for when ‘as required’ medication was to be given. This meant that it might not be given in a consistent manner. There was one gap on the chart for a resident indicating that the medication had not been given, although the tablet was missing from the blister pack. This meant the records were not fully accurate. The preferred term of address was recorded and used by staff. Residents had access to a telephone. All care was given in private, including visits from other health professionals. Staff were seen to approach residents in a pleasant manner. They made provision for religious needs to be met and were aware of the diverse needs of the residents. Greenways DS0000034755.V308372.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were able to make choices about their life at the home so that their lifestyle met their preferences. Resident’s social, cultural and recreational needs were met through links with their family and friends being maintained and opportunities to undertake activities within the home. Residents were served a varied and nutritious diet that was to their liking. EVIDENCE: The residents’ interests were noted in long-term care plan. There were also details of their social contacts noted as well. Records of activities done were kept. These were rather limited at the moment but a new Activity Co-ordinator had been employed and was due to commence doing 22 hours per week purely for activities. She was doing a survey at the moment to discover what residents would like to do. Any known family contact was noted in the long-term care plan. There were no restrictions on visitors. Residents said that visitors could come anytime. The known preferred retiring and/or rising were noted in the long-term care plan. One plan included information on the lounge that the resident preferred Greenways DS0000034755.V308372.R01.S.doc Version 5.2 Page 14 to sit in. Residents spoken to said that they could choose when they went to bed and got up. Staff said that they asked residents and respected choices. The choices of food for the next meal was displayed in the dining room. Alternatives were available. The residents were asked what they’d like to eat at lunch and tea so that their choice could be prepared. Any menu changes were done through consultation with the residents. A meeting had been held in September with the residents to resolve issues that had been raised about food. There was a Cook on duty each day. Records were not kept of the food cooked and what each resident had chosen to eat. This meant that it could not be demonstrated that a nutritious diet had been offered and taken. There was sufficient food in stock including fresh fruit, vegetables and salad. There was a cleaning rota that was signed to show that the task had been completed. Fridge and freezer temperatures were kept. There was a residents’ kitchen available so that residents and relatives could make themselves drinks as and when they wanted. The tables were nicely set which contributed to a nice social atmosphere in which meals could be taken. Appropriate assistance was given by staff at mealtimes. Greenways DS0000034755.V308372.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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were confident that their concerns would be listened to and acted upon. Residents were protected from abuse and harm. EVIDENCE: The procedure for making a complaint was in the Service User’s Guide. Blackburn with Darwen Borough Council’s leaflets were also available. No complaint had been made to the home since the last inspection. If any were made, these would be recorded on the appropriate form and the investigation and action taken recorded. No complaints had been made directly to CSCI. Residents spoken to said that they felt able to approach staff if they had any concerns or worries. Residents and relatives were invited to make written comments about the home and these were kept on file. They had made some very praising comments and these showed that there was a high regard for the staff, facilities and care given. Procedures for Safeguarding Adults were available. These were Blackburn with Darwen Borough Council’s own procedures and complied with ‘No Secrets’. The Council’s whistle-blowing procedure, called Speak Out, was also available to staff. There were no records to show that Safeguarding Adults training had been given to staff. A member of staff spoken to said that she had not done this within the last two years. Greenways DS0000034755.V308372.R01.S.doc Version 5.2 Page 16 Greenways DS0000034755.V308372.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. 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. Residents lived in a pleasant, safe and well-maintained environment. EVIDENCE: The building was well maintained, clean and nicely decorated and furnished. A Handyman worked 30 hours per week and did all the minor repairs and decoration. Larger items of repair were done by Capita and staff said that they were very prompt in dealing with these. There were four lounges, one of which was designated as a smokers lounge. This meant that residents had a choice of where they could spend their day. There was a large dining room. There were sufficient bathrooms and toilets all of which were large enough to assist disabled residents. There was a lift to the first floor. Aids for assisting residents included bath hoists, mobile hoists and a stand-aid. There was a call system to all areas. Residents had locks to their Greenways DS0000034755.V308372.R01.S.doc Version 5.2 Page 18 bedroom doors and lockable storage space for valuables. They were able to bring in their own possessions if they wished to. The laundry had two domestic style washers. They did not have a sluice programme but did a hot wash, which reduced the risk of cross infection. There were two dryers. There was a sink with liquid soap and paper towels. There was a drying room where the clothes were sorted before being returned to residents. The laundry was done by the care staff. There were policies and procedures for infection control. A Carer was seen to sort laundry for washing without wearing plastic gloves or an apron. This put her at risk of infection. Greenways DS0000034755.V308372.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. 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. Staffing levels were sufficient to meet residents’ needs. The details held at the home were insufficient to ensure that a thorough recruitment procedure had been followed. Not all staff had received training updates to ensure that they were competent to do their jobs. EVIDENCE: From the staffing rota and observation, there were sufficient care and ancillary staff on duty to meet the needs of the residents. However the comments from residents and staff indicated that there were staffing shortages at times. Also, a number of hours were being covered by Agency staff, which was negatively commented upon by both residents and staff. The same members of Agency staff were requested as far as possible to ensure continuity of care. The Handyman was on leave but his hours still appeared on the duty rota. The files for three new members of staff were examined. There was evidence that references and a Criminal Records Bureau clearance had been done for two of these staff. The other person had been redeployed form another home. There were details on file for this person. The staff folder did not include a photograph of the staff member. All new staff did a three-day Induction course at the start of employment. Further training was then given at Greenways and an Induction booklet Greenways DS0000034755.V308372.R01.S.doc Version 5.2 Page 20 completed. These were not seen so it could not be determined whether this complied with the Skills For Care 12 week common induction standards. All staff had completed fire safety training. Not all staff had completed mandatory training in: moving and handling; Safeguarding Adults; and basic food hygiene. Over 90 of the care staff had received training in NVQ in care. Greenways DS0000034755.V308372.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well managed. Residents were able to give their views on how the home was run and these were acted upon. Resident’s financial interests were safeguarded. The health, safety and welfare of staff was not fully promoted and protected, as training updates had not been completed. EVIDENCE: The Registered Manager has the appropriate skills, training and experience to manage the home. She was now taking responsibility for the management of the Intermediate Care Unit. The home had the Quality Assurance award from Blackburn with Darwen Borough Council. The Quality Assurance systems within the home could not be determined as the ‘audit’ file was unavailable for examination. The Greenways DS0000034755.V308372.R01.S.doc Version 5.2 Page 22 operation/development plan was also not available for examination. Surveys for residents were done individually. This meant there was no overview of results. The senior staff said that if any issues were raised an action plan would be done. Resident meetings and staff meetings were held. This meant that both groups of people could have the chance to make their views known to the Manager. There was evidence that a representative of the department had started to visit the home to look at the quality of care and the facilities at the home. This meant that residents had opportunities to meet and pass their views onto a senior manager. No member of staff was an appointee for any resident. There were records to show the payment of personal allowances, either as cash or into savings. Small amounts of cash were kept on the premises. Three of these were checked and found to be correct. There was a safe in the office and records kept of all valuables and money deposited with staff. A fire drill had been done in July 2006. All the staff that attended were named. The fire alarms were tested weekly. The extinguishers and alarm system were serviced. Portable Appliance Testing had been done. All other appliances had been services as required and there were certificates to demonstrate this. All staff had not yet received updates in safe working practices. Greenways DS0000034755.V308372.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Greenways DS0000034755.V308372.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15(1) and (2)(b)(c) Schedule 4 (13) 13(6) 13(3) 17(2) Schedule 4 19, Schedule 4 Requirement Each resident must have a plan of care that details how their needs in respect of health and welfare are to be met. There must be records of food provided for residents so that it can be determined that their diet is satisfactory. All staff must receive training in prevention of abuse. Arrangements must be made to prevent the spread of infection. There must be a duty roster and a record of whether the roster was actually worked. (Previous time frame of 11/03/06 not met) The registered person must ensure that the documents required under Schedule 2 of the Care Homes Regulations 2001 have been obtained. (Previous timescale of 31/12/05 not met) All staff must receive training appropriate to the work they are to perform. Timescale for action 30/11/06 2 OP15 31/10/06 3 4 5 OP18 OP26 OP27 31/12/06 31/10/06 31/10/06 6 OP29 30/11/06 7 OP30 18 (1)(c) 31/12/06 Greenways DS0000034755.V308372.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 Refer to Standard OP8 OP8 OP8 OP9 OP30 OP33 Good Practice Recommendations Details should be readily available to staff on the resident’s health care needs. These should be filed in the plan of care. A falls risk assessment should be done on all residents. The type and size of continence aid should be recorded in the plan of care. Hand written entries should be signed and witnessed. There should be criteria as to when ‘as required’ medications should be given. The Induction training given to new staff should comply with the Skills For care 12-week Common Induction standards. The manager should ensure that there are quality assurance systems to monitor the care and services provided at the home. Information from residents’ surveys should be collated and made available to interested parties. The development plan for the home should be available for examination. All staff should receive annual updates in safe working practices. 7 8 OP33 OP38 Greenways DS0000034755.V308372.R01.S.doc Version 5.2 Page 26 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.V308372.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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