Inspection on 19/12/07 for Greenways

This inspection was carried out on 19th December 2007.

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 no outstanding requirements from the previous inspection report, but made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Greenways Greenways 633 Uxbridge Road Pinner Middlesex HA5 3PT Lead Inspector Robert Bond Key Unannounced Inspection 19th December 2007 10:00 Greenways DS0000070330.V354148.R01.S.doc Version 5.2 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 DS0000070330.V354148.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 Adults 18-65. 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 DS0000070330.V354148.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greenways Address Greenways 633 Uxbridge Road Pinner Middlesex HA5 3PT 0208 966 9514 0208 866 9160 greenways@minstercaregroup.co.uk www.minstercaregroup.co.uk Minster Pathways Limited 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) Care Home 14 Category(ies) of Learning disability (7), Mental disorder, registration, with number excluding learning disability or dementia (7) of places Greenways DS0000070330.V354148.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Mental Disorder, excluding learning disability or dementia - Code MD 2. Learning Disability - Code LD The maximum number of service users who can be accommodated is: 14 None. Date of last inspection Brief Description of the Service: Greenways is a new purpose-built three storey detached care home for 14 residents. The home is operated as two separately staffed units for 7 residents each. The unit on the ground floor is registered for people who’s primary care needs come under the heading of learning disability. The unit on the first floor is registered for people who’s primary care needs come under the heading of mental health. The bedrooms, offices and meeting rooms on the second floor are used only by staff members. All the residents’ bedrooms are single, with en-suite shower and toilet facilities. The home has been built to be fully accessible to wheelchair users, and there is a lift to the first floor. The bathrooms have electric ceiling mounted hoists. Each unit has its own kitchen, communal lounge and quite rooms, and a small office. Substantial car parking space exists at the front of the premises, and a large secure garden is at the rear. The home is on a main road that is a bus route to the shops and other facilities in nearby Pinner town centre. Fees range from £1,500 to £2,000 per week. Greenways DS0000070330.V354148.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As this was the first inspection of a new service, I inspected the performance of the home against the anticipated outcomes for most of the 43 National Minimum Standards (NMS) for care homes for younger adults, as published by The Department of Health. I found that 22 outcomes were fully met, whereas 14 outcomes were only partly met. This led me to make 16 requirements. As this is a new service the number of requirements and recommendations is likely to be quite high, but the number is expected to decline significantly at future inspections. I spent four hours at the care home during which time I toured the premises, interviewed the Manager Designate, met the Deputy Manager, spoke to other staff and all the residents present, and examined a range of records. During the inspection, equality and diversity issues were always considered. The home admitted the first person on the 13th November 2007, hence the home had been open for approximately five weeks when this inspection took place. During that time, the Registered Manager who had set up the home had relinquished this role, returning to her previous job of Operations Manager for Minster Pathways Ltd. A Manager Designate, who had not yet applied to the CSCI to become the new Registered Manager for the home, had been working at the home for two weeks only. She was however seen to be already making changes to the staffing structure and the support plan formats that she had inherited. On the day of the inspection, four people had moved in, three on the ground floor, and one on the first floor. What the service does well: The Service User’s Guide is well produced and is user-friendly in that it is illustrated with pictures that residents’ might appreciate. The hallway of the home also contains a pictorial version of the General Social Care Council’s guide for residents. Substantial pre-admission assessments have been undertaken on the current residents of the home. One resident has a personcentred assessment in addition. Each person has a ‘daily care plan folder’ and a ‘health plan folder’. The range of activities and hence the lifestyle available to residents is still under development but a positive start has been made. An ‘activity co-ordinator’ member of staff has been appointed. The home has its own vehicle to convey residents to activities in the community. Cultural and ethnic meal choices are included within the available food menu. A record is kept of what people eat. Each resident has a health plan folder that describes in detail their health care and medication needs, and documents the health monitoring and health interventions that take place. A medication monitored dosage system is about to be introduced and staff will be trained in its use. The homes’ internal complaints procedure and internal protection of vulnerable adults procedures are good. The premises are newly built and purpose designed to meet the needs of residents. Hence floors are level, doors are Greenways DS0000070330.V354148.R01.S.doc Version 5.2 Page 6 wide, there is a lift to the first floor, and the bathrooms have ceiling mounted electric hoists. All the bedrooms are large, single, and with en-suite toilets and showers. The home’s private and communal areas are furnished, equipped and decorated to a high standard. A substantial amount of parking is available at the front of the home, and there is a large and secure garden to the rear. The home is clean and hygienic throughout. Staff members appointed so far are competent and well qualified. A high standard of recruitment processes and checks is being applied. The Manager Designate demonstrated skill and enthusiasm and a commitment to the residents. The home has appropriate quality assurance procedures in place and is closely monitored by the Operations Manager. Risk assessments of the premises have been undertaken and frequent health and safety checks are done. What has improved since the last inspection? What they could do better: The Statement of Purpose should contain details of the new (proposed) registered manager and details of the newly proposed staff structure, which are both being changed from the situation when the home first opened. As the Service Users’ Guide must contain a summary of the Statement of Purpose, it should also contain details of the changing registered manager and of the revised staffing structure so that prospective and actual residents and their relatives are made aware of the correct facts or intentions. The cultural and faith needs of potential residents must be assessed prior to their admission to the care home so that plans can be made to meet those needs from the day of moving in. The care home must keep on file a photograph of every resident, to assist with their identification. Residents’ support plans must be kept under review in line with Minster Pathways company policy in order to meet their changing needs. Greater consistency is necessary concerning the type and quality of assessments and support plans used for residents in order to help guarantee minimum standards of care provision. The extent and range of social and educational activities available to residents needs to be extended to include day centre attendance, for example. Further work must be undertaken to ensure that every resident from the time they move in has a support plan that fully describes their personal care needs and how these are to be met in ways that suit them. The home’s medication policy and procedure must fully describe the medication system that applies specifically at Greenways, together with medication training arrangements for staff. A list of sample staff signatures must also be kept. The home’s advertised complaints procedure must refer to the CSCI and the procedure that will be followed if any complaints about the home are made directly to the CSCI. The home must obtain a copy of the London Borough of Harrow’s Safeguarding Adults policy and reporting procedure document in order to more fully protect vulnerable adults living in the home. The safety of residents must be further enhanced by keeping substances that are hazardous to their health under lock and key at all times. The home must develop safe working practices whereby COSHH Greenways DS0000070330.V354148.R01.S.doc Version 5.2 Page 7 materials are not left unattended where residents could access them, and staff must be trained accordingly. Residents’ bedrooms must be furnished with sufficient tables and chairs of a type to meet the assessed needs and recorded wishes of individual occupants. The CSCI must be supplied with in writing and agree to the proposed staffing arrangements for the home, bearing in mind that registration of the home is based upon the two units being staffed and operated as separate entities. This distinction must be maintained due to the very different needs of the residents within the two units. Minster Pathways Ltd must formally notify the CSCI of the name of the new manager of Greenways so that their fitness to become the Registered Manager can be assessed. All of the records required by regulation for the protection of residents must be kept up to date. The CSCI must be provided with a copy of the home’s Food Safety Act registration certificate. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Greenways DS0000070330.V354148.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Greenways DS0000070330.V354148.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, and 5. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The information available to prospective residents and their relatives and advisors is not wholly accurate as certain arrangements within the home have already changed. The assessments of prospective residents do not always refer to their equality and diversity needs. Prospective residents are enabled to visit the home before moving in, and are issued with contracts subsequently. However there is a lack of consistency in terms of the contracts in use and the type and quality of assessments undertaken. EVIDENCE: I noted that the CSCI registration certificate for the home, a ‘concerns and complaints’ booklet, and the home’s Statement of Purpose and Service Users’ Guide were all displayed in the foyer of the building. These later two documents were approved during the CSCI registration of the home. However as the Registered Manager of the home has already left that position to become once more the Operations Manager for Minster Pathways Ltd., most of the documents on display are already out of date. It will therefore be necessary for the Manager Designate to seek registration with the CSCI to become the new Registered Manager. The Statement of Purpose and Service Users Guide will need to be revised to provide the necessary details concerning the new Registered Manager, and other amendments may also be necessary to these documents, such as the changes to the staffing structure that the Manager Designate described to me. Greenways DS0000070330.V354148.R01.S.doc Version 5.2 Page 10 I examined the assessment of needs documentation for three of the four residents currently living in the home. In each case a pre-placement assessment had been obtained. In one case, a joint assessment with the referral agency concerning whether the applicant should become a permanent resident of the home was according to the Manager Designate still underway and the resident and a relative were involved in the process. On one of the assessments seen, no cultural or religious needs statements appeared. On another pre-placement assessment, cultural and religious needs sections were similarly left blank despite the person being described as ‘Jamaican’. The assessment sections headed ‘distinguishing features’, ‘height’ and ‘weight’ were also not completed, hence describing the person to the Police would be more difficult than necessary if they ever had to reported as a missing person. As the staffing structure is still being refined, as staff are still being recruited, and as new residents are still being assessed, and moving in, I have not assessed the outcome of NMS 3 at this time. I spoke at some length to one resident who had recently moved in and he was quite effusive in his praise, saying that ‘everything was perfect’, and ‘I had a good look round before I moved in.’ I noted two files that contained ‘contracts’, one of which was a ‘service user contract’ signed by both parties, the other was an ‘interim contract’ with the London Borough of Harrow. Greenways DS0000070330.V354148.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, and 9. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Support plans are not yet fully developed for all current residents and are not being reviewed sufficiently frequently. Residents are however consulted about meal choices, and are supported to lead as independent a life as possible. EVIDENCE: I examined three care files and found a good support plan on one, a very limited support plan on the second (bathing was the only aspect covered), and none at all on the third. The Manager Designate reported that the third plan had not yet been written as the resident in question was still undergoing a period of observation and assessment. The good support plan defined the agreed care or support needs, and detailed the interventions necessary to promote independence. Staff signed to say they had read the various aspects of the support plan. The Plan included social activities, personal care, and health. None of the care plan files contained any photographs of the resident, but the Manager Designate showed me a camera bought for the purpose. None of the support plans had been reviewed. I ascertained that Minster Pathways company policy concerning reviews was that support plans should be reviewed after one month of the person moving in. This had not happened but the Manager Designate said reviews were scheduled to take place during the Greenways DS0000070330.V354148.R01.S.doc Version 5.2 Page 12 following month and that she intended to change the support plan format so they would become more outcome focussed. I noted that at least one of the residents has an advocate. The Manager Designate said she wished to further promote the use of advocacy by the care home. The Manager Designate reported that residents are consulted upon the choice of food offered, a key worker system is being set up, and residents are encouraged to assist in running the care home by for example cooking and making their own bed. I noted that on one file I examined, the detailed needs assessment included a list of risk management topics where a risk assessment would be needed. The Manager Designate reported that the full risk assessment was available on her laptop computer. I noted that one support plan was written in a way that promoted the independence of the resident. The Manager Designate added that residents are empowered to achieve the best their ability allows, for example one resident has employment in the community. Greenways DS0000070330.V354148.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14 15, 16, and 17. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The range of activities and hence the lifestyle available to residents is still under development but a positive start has been made. EVIDENCE: Only one of the support plans examined contained an assessment of social care needs and how to meet those needs, however another resident I spoke to had voluntary employment in the community, and strong family links. The Manager Designate reported that arrangements are in hand via Harrow Learning Disability Services and Primary Care Trust for several other residents to attend local day centres and, where appropriate, educational facilities. The reported intention is for each resident to have an individual ‘time management programme’. In the meantime, use is made of the Harrow swimming pool and coffee shops, dvds are watched, community links are being established, and relatives are encouraged to visit. The Manager Designate explained that she has appointed an activity co-ordinator to develop activities for residents within the home and in the wider community. I noted that the home has its own Greenways DS0000070330.V354148.R01.S.doc Version 5.2 Page 14 ‘people-carrier’ vehicle parked outside which the Manager Designate reported will be extensively used to transport residents. I observed good quality interactions between staff members and residents, and noted that staff knock on residents’ bedroom doors before entering, in order to enhance their privacy. The Manager Designate reported that residents are provided with choices of what to eat and these choices are determined on the day rather than in advance. She added that she has introduced a range of cultural and ethnic meals to the menu, and a record is kept of food that is served and eaten. The residents are generally of white British ethnicity but one resident is black and from the Caribbean. Attention must be paid to meeting the assessed cultural and religious needs of all the residents in terms of the lifestyle that is offered to them. Greenways DS0000070330.V354148.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Some residents receive personal support in the way they prefer and require, but the absence of a detailed support plan for at least one person suggests that not every one does. However good health care planning documentation suggests a high level of support to residents in this respect. The need for a revised and more detailed medication policy and procedure is indicated in order to more adequately protect residents. EVIDENCE: As indicated under NMS 6, of the three care files examined, one contained an excellent support plan that provided detailed guidance to staff concerning how to provide personal care support to that resident. One support plan only contained guidance on supporting the resident to bathe, and the third support plan had not yet been written despite that person being resident for several weeks. The key worker system was still being set up and the Manager Designate herself had taken on this role temporarily for the one person who was living in the first floor unit and whose support needs, and whether this care home could meet them, were still being assessed. It was said that a male key worker would be appointed in this instance. I observed care being provided in a sensitive manner, and the resident I spoke to said, ‘the staff here are great.’ None of the current residents have physical disabilities but the home is designed and equipped for this eventuality. For example the bathrooms have ceiling mounted electric hoists. Greenways DS0000070330.V354148.R01.S.doc Version 5.2 Page 16 I noted that each resident had a ‘health plan folder’ that detailed their medication needs, health care needs, contact with health professionals, and health monitoring activity that took place (such as a monthly weight record). The Manager Designate reported that all the residents were registered with one GP practice, unless they wished to and were able to maintain registration with their existing GP. The Manager Designate informed me that 3 out of the 4 existing residents were prescribed medication but were unable to administer it themselves. The home had in place a procedure for medication storage and administration but the Manager Designate said that the arrangements were about to change as she had arranged with Boots The Chemist for their monitored dosage system (MDS) to be introduced. As a result, medication cabinets and medication refrigerators were on order for both units of the home. The home’s CSCI registration report identifies that at the time of registration, the home only had a generic medication policy in place as opposed to one that is specific to the situation at Greenways. I did not check whether a revised policy had been written but whether there is one or not, it will need to be amended to take account of the Boots MDS arrangements and the Boots training for staff at Greenways that has reportedly been agreed. I checked the existing medication administration record (MAR sheet) and found one error in that medication on the day of the inspection had been given to a resident without the member of staff initialling the sheet to confirm that the administration had taken place. A requirement is made under NMS 41 (record keeping). The home did not have a sample list of staff signatures or initials. Greenways DS0000070330.V354148.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home’s existing advertised complaints procedure does not correctly describe the present role of the CSCI with regard to complaints made about the services it regulates. Residents are potentially not sufficiently protected from abuse. EVIDENCE: I examined the complaints notice that is displayed in the home’s entrance foyer for the benefit of visitors. The notice refers to the NCSC (fore-runner of the CSCI) and does not correctly describe the current role of the CSCI in dealing with any complaints it may receive concerning services that it inspects. The Manager Designate reported that no complaints to date had been made about the home. No complaints have been received by the CSCI either. The Manager Designate reported that Safeguarding Adults (Protection of Vulnerable Adults) is included in the home’s induction programme for new staff. I confirmed this by examining the printed induction programme. However the home does not yet have a copy of the London Borough of Harrow’s policy and procedure for reporting suspected abuse. This omission was apparent and discussed with the then Manager Designate in June 2007, it is now made a requirement. An inspection of the records of any monies held by the home on behalf of residents was not undertaken on this occasion. Greenways DS0000070330.V354148.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The premises provide a homely and comfortable environment for residents but one that is not wholly safe. The bedrooms are only basically furnished, without sufficient attention having been paid to the furnishing wishes and needs of residents, and without adequate consideration of how bedroom furnishing can promote independence and lifestyle choices. Toilets and bathrooms however are very well equipped to meet residents’ needs. The home is also very clean and hygienic. EVIDENCE: I toured the home, initially in the company of the Deputy Manager, and then completed the tour with the Manager Designate. Three residents’ bedrooms were visited, with their permission. The premises are newly built and purpose designed to meet the needs of people living in the home. Hence floors are level, doors are wide, there is a lift to the first floor, and the bathrooms have ceiling mounted electric hoists. All the bedrooms are large, single, and with ensuite toilets and showers. The home is furnished, equipped and decorated to a high standard throughout, including private and communal areas. A substantial amount of parking is at the front of the home, and there is a large and secure garden to the rear. Greenways DS0000070330.V354148.R01.S.doc Version 5.2 Page 19 The main identified omission relates to the furnishing of the residents’ bedrooms in that each bedroom contained only one chair and no table. When this was pointed out, the Manager Designate agreed it was an omission and whilst I was still on the premises she said she had placed some additional furniture orders so that each existing resident who was in the habit of receiving a visitor in their bedroom would have a chair for themselves and one for the visitor. In terms of tables, the issue to be determined is whether or not individual residents want a table, and if so, do they want a low ‘coffee’ table, or a table they may sit at. If it is the latter, then the second chair should be a dining chair as opposed to a low easy chair. Attention to this aspect of furnishing will enable the outcomes of NMS 26 to be fully met in terms of meeting residents’ lifestyle needs, and promoting their independence. I checked that lighting, heating, ventilation, hot water and call-bell systems were all operating well, which they were. The home was seen to be very clean and hygienic throughout. I visited one of the two kitchens, and found it to be well equipped but the fridge thermometer showed a reading of 14 degrees Celsius, and the temperature recording system had fallen into abeyance. This issue is taken up again under NMS 41 (record-keeping). The laundry is also well equipped but the Manager Designate reported that additional shelving is required and is on order. At the time of the registration of the home by the CSCI, the home did not have a Food Safety Certificate and so I asked about it. The Manager Designate told me one had been issued and it would be faxed to me but to date it has not arrived. A requirement has therefore been made. I also found that both COSHH (control of substances hazardous to health) stock cupboards in the home were unlocked, with keys left in the doors, despite the cupboards being located within unlocked rooms. A requirement is therefore made under NMS 42 concerning safe working practices and staff training, as well as a requirement under NMS 24 concerning creating a safe environment. I did not issue an ‘immediate requirement notice’ as the Deputy Manager locked the cupboards and removed the keys as I watched. Greenways DS0000070330.V354148.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, and 34. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is insufficient clarity concerning staff roles and the staffing structure as the intended separation of the units of the home is not being fully achieved, to the possible detriment of residents. Staff members appointed so far appear to be competent and are well qualified. A high standard of recruitment processes and checks is being applied. EVIDENCE: On the day of the inspection, there were residents on site, three in the ground floor unit and one in the upstairs unit, who was waiting to go out. There were four staff on duty, including Manager and Deputy Manager, thus the staffing ratio was on the face of it, 1 to 1. The Manager Designate told me that she intended the ratio to remain 1 to 1, or at worst 1 support staff member to 2 residents, according to the needs of the residents. The CSCI registration of the home has been on the understanding that both units of the home would operate separately, under one manager but each having a deputy manager, each with a dedicated staff team, and each having separate night care staffing arrangements. The importance of this is that one unit is for people with primarily learning disability needs whereas the other unit is for those with primarily mental health needs. That difficulties concerning boundaries, separation and risk management are already arising, is suggested by a sign on the outside of the downstairs unit saying that the resident from upstairs must not come into their kitchen. Greenways DS0000070330.V354148.R01.S.doc Version 5.2 Page 21 At present, with only one person resident in the first floor unit, the separate staff team for that unit has not yet been established, and hence the home is being staffed as one unit. This is being achieved by the Manager Designate herself acting as support worker to that one resident (who goes out to do voluntary work most days), and with the waking night support worker for the ground floor unit temporarily covering the first floor unit as well. A second night support worker sleeps in using the staff accommodation on the second floor. These ad-hoc temporary staffing arrangements do not seem to have been approved in advance by the CSCI. A further change to the original staffing structure has been made by the new Manager Designate who reported that she has used a support worker post to create a new post of Activity Co-ordinator. Administration of the home is to be done by the Manager and Deputies sharing the work between them. Recruitment to vacant posts is on-going and job descriptions are in place. The Manager Designate reported that all the staff recruited so far were qualified to at least NVQ 2 level, and that two staff members have psychology qualifications. She added that a full induction programme is undertaken that meets the Skills for Care specification. I examined the recruitment records of two new employees and found that application forms had been completed, interviews had taken place, and all appropriate checks had been undertaken including identification, Criminal Records Bureau disclosure, and references from previous employers. Standards 33, 35 and 36 were not assessed at this inspection as the staff team was still being recruited and hence training needs and supervision regimes had not yet been established. These will be assessed at the next CSCI inspection of the home. Greenways DS0000070330.V354148.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, and 42. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The Manager Designate demonstrated skill and enthusiasm and a commitment to the residents. The home has appropriate quality assurance procedures in place but several record keeping and health and safety aspects must be improved or acted upon. EVIDENCE: The home opened with a Registered Manager in post but she has been promoted to become Operations Manager for Minster Pathways once again. Thus at a crucial stage in developing the work of the new home, recruiting staff, assessing potential residents and assisting them to settle in, a new manager has taken over. She is referred to as the Manager Designate in this report as she has not yet applied to the CSCI to become the new Registered Manager. The Manager Designate told me she had been for many years and until recently the manager of a home for older people, and that she had obtained the Registered Managers Award and an NVQ level 5 in management and care. Greenways DS0000070330.V354148.R01.S.doc Version 5.2 Page 23 The Manager Designate demonstrated enthusiasm, knowledge and commitment to her new role and stated that she had a ‘service user orientated management style’. I noted that in terms of quality assurance, the home has resident questionnaires in place, and that the Operations Manager closely monitors the operation of the home. She was due to visit the home later that day. I observed that the home has a full set of policies, but as noted under NMS 20, the medication policy and procedure will need to be amended and extended. An omission was found in the medication administration record, sample signatures were not on the medication file, and the temperature of the first floor refrigerator had not been recorded for three weeks. Hence management action and additional staff training concerning the importance of accurate recording are indicated. In terms of safe working practices within the home, as previously reported both COSHH cupboards were found to be unlocked. Thus the protocol for keeping cleaning materials under lock and key when not in use must be reenforced and additional staff training in this aspect is also indicated. A risk assessment of the premises had been undertaken and the Manager Designate reported that weekly health and safety checks were done. At the time the home was registered by the CSCI, a Food Safety Act registration certificate had not yet been obtained. The Manager Designate reported that she believed the home did now have one, that it was in the possession of the Operations Manager, and a copy would be faxed to me. As it has not been received, a requirement is now made. Greenways DS0000070330.V354148.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 2 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 2 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 2 32 3 33 x 34 3 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 3 12 2 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 2 3 3 3 2 2 X Greenways DS0000070330.V354148.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No. First inspection of a new service. 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 YA1 Regulation 4,5&Sch 1 Requirement Timescale for action 01/03/08 2 YA2 3 YA6 4 YA6 5 YA12 6 YA18 The Statement of Purpose and the Service Users’ Guide must contain details of the new registered manager and details of the actual or newly proposed staff structure. 14 The cultural and faith needs of potential residents must be assessed prior to their admission to the care home so that plans can be made to meet those needs from the day of moving in. 17(1)(a)Sch3(2) The care home must keep on file a photograph of every resident in order to assist with their identification. 15(2)(b) Residents’ support plans must be kept under review in line with Minster Pathways company policy in order to meet their changing needs. 16(2)(n) The extent and range of social and educational activities available to residents must be extended. 15(1) Further work must be DS0000070330.V354148.R01.S.doc 01/02/08 01/02/08 01/02/08 01/04/08 01/02/08 Page 26 Greenways Version 5.2 7 YA20 13(2) 8 YA22 22(7) 9 YA23 13(6) 10 YA24 13(4)(a) 11 YA26 16(2)© 12 YA31 18(1)(a) undertaken to ensure that every resident from the time they move in has a support plan that fully describes their personal care needs and how these are to be met. The CSCI must be supplied with a copy of the home’s medication policy and procedure that must fully describe the medication system that applies at this particular care home, the training arrangements for staff, and the need to maintain a list of sample signatures of staff administering medication. The home’s advertised complaints procedure must refer to the CSCI and the procedure that will be followed if any complaints about the home are made directly to the CSCI. The home must obtain a copy of the London Borough of Harrow’s Safeguarding Adults policy and reporting procedure document. The safety of residents must be enhanced by keeping substances that are hazardous to their health under lock and key. Residents’ bedrooms must be furnished with sufficient tables and chairs of a type to meet the assessed needs and recorded wishes of individual occupants. The CSCI must be supplied with and agree to the proposed staffing arrangements for the home. The agreed revised staffing structure must appear in the DS0000070330.V354148.R01.S.doc 01/03/08 01/03/08 01/02/08 01/01/08 01/03/08 01/02/08 Greenways Version 5.2 Page 27 Statement of Purpose. 13 YA37 8, 9 and 39 Minster Pathways Ltd must formally notify the CSCI of the name of the new manager of Greenways so that their fitness to become the registered manager can be assessed. All the records required by regulation for the protection of residents must be kept up to date. Protocols for safe working, including keeping COSHH materials securely, must be introduced or re-enforced, and additional staff training provided in order to maintain the safety of residents. The CSCI must be provided with a copy of the home’s Food Safety Act registration certificate. 01/02/08 14 YA41 17 01/02/08 15 YA42 18(1)( c ) 01/02/08 16 YA42 23(5) 01/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Greenways DS0000070330.V354148.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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