Inspection on 27/01/06 for Greenways

This inspection was carried out on 27th January 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Greenways 11/09/08

Greenways 29/06/06

Greenways 05/09/05

Greenways 07/02/05

Greenways 14/06/04

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

CARE HOMES FOR OLDER PEOPLE Greenways 227 Hawthorne Road Bognor Regis West Sussex PO21 2UW Lead Inspector Mrs L O’Donnell Unannounced Inspection 27th January 2006 2.30 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 DS0000014542.V280382.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 DS0000014542.V280382.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Greenways Address 227 Hawthorne Road Bognor Regis West Sussex PO21 2UW 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) 01243 823732 home.boy@mha.org.uk www.methodisthomes.org.uk Methodist Homes for the Aged Mrs Mavis Eileen Stevens Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Greenways DS0000014542.V280382.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Up to 41 male and/or female service users over 65 years of age may be accommodated. No service users under 65 years of age may be admitted. Date of last inspection 5th September 2005 Brief Description of the Service: Greenways is a Care Home situated near the town centre of Bognor Regis. It is a purpose built Care Home registered to accommodate up to forty-one Service Users in the category OP (old age, not falling into any other category). The home is divided into four wings with accommodation over three floors, accessed by a vertical lift. All rooms are for single occupancy and each has en-suite facilities. There is a large well-maintained garden accessible to Service Users. The home is owned by Methodist Homes. Greenways DS0000014542.V280382.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced Inspection, which took place during the afternoon and early evening of 27th January 2006. Prior to the Inspection, the previous inspection report was reviewed along with any correspondence received since the last inspection. During the inspection the Inspector spoke with residents, visitors and staff. Records in relation to care planning, meals, quality assurance, resident finances and health and safety issues were reviewed. Residents spoke very highly of the staff team and the care provided at the home with comments including, ‘I am very happy here’, ‘the home has lived up to expectation’, ‘ the staff are very kind and do all that they can’. However some concerns were raised in relation to the choice and presentation of meals and this needs to be addressed by the Registered Provider. What the service does well: What has improved since the last inspection? What they could do better: The choice and presentation of meals must be reviewed and improved upon to ensure that residents are provided with a choice of well-presented and nutritious meals and food. Greenways DS0000014542.V280382.R01.S.doc Version 5.1 Page 6 Adult protection procedures must be reviewed to ensure compatibility with the agreed West Sussex procedures for the protection of vulnerable adults. 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 DS0000014542.V280382.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 DS0000014542.V280382.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): 6 Intermediate care is not a service offered at the home. EVIDENCE: People requiring respite care can be accommodated at the home, however intermediate care is not a service that is offered. Greenways DS0000014542.V280382.R01.S.doc Version 5.1 Page 9 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, 10 Each resident has a care plan in place, which provides details of their health, personal, and social care needs. Residents consider that they are treated with respect and that their right to privacy is promoted by the staff. EVIDENCE: Each resident has a care plan in place. During this inspection a sample of care plans were reviewed. These provided information on residents health personal and social care needs. They were seen to be reviewed regularly, with the residents where possible. Residents, when asked, were aware of their care plans. All residents spoken with were satisfied that their care needs were met by the staff team, with all speaking highly about the care provided. Comments included, ‘the staff are excellent,’ ‘I cannot fault the staff’. Greenways DS0000014542.V280382.R01.S.doc Version 5.1 Page 10 During the inspection staff were observed to treat residents respectfully and all residents spoken with confirmed that the staff team upheld their privacy and dignity. Greenways DS0000014542.V280382.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 Daily living routines are flexible and a range of activities is provided within the home. Residents are able to maintain contact with family and friends. The choice and presentation of meals should be improved. EVIDENCE: All residents spoken with confirmed that routines of daily living were flexible and that they were able to exercise choice in relation to getting up/going to bed, leisure and social activities and personal and social relationships etc. Social interests of residents are recorded within their care plans. Residents advised that they were able to pursue their own interests or participate in the activities arranged within and by the home. There is an activities co-ordinator employed at the home who arranges a variety of activities. Within the communal areas the activities arranged for the forthcoming week are displayed. This weeks activities were seen to include, music and movement, crosswords, knitting, shopping trips, scrabble, bible study, church services. Greenways DS0000014542.V280382.R01.S.doc Version 5.1 Page 12 The home also benefits from having a large, active and supportive group of volunteers who fundraise and support residents in activities and outings. A quarterly newsletter is produced which provides further information about events within the home and other articles. Residents confirmed that they can have visitors to the home at any reasonable time and that their visitors can have lunch with them if they wish. The way in which the menus are managed has changed slightly since the last inspection. Previously residents were provided with a choice of a minimum of four main meals at lunchtime. Now there is one main meal but with a choice of two alternatives. Whilst this still gives residents a choice the way in which this is managed needs to be reviewed, as on occasion this has led to limited choice for residents. Examples given to the Inspector included one day on which the main meal was Roast Pork and the alternative was pork chop, a further example was from a resident had chosen chicken as an alternative and then found that chicken was the main meal the following day. In addition a number of residents were unhappy with the presentation of some meals. This relates in particular to the accompanying vegetables, which on many occasions are overcooked, having little or no texture or flavour. Through discussion with residents this obviously affects their enjoyment of the meals, and in addition will impact on the nutritional value of the meals served. Residents did however advise that some meals were well cooked and enjoyable. A minority of residents spoken with were generally satisfied with the meals they had. It was evident however that there is a lack of consistency in the standards of food and meals prepared and this must be addressed. Concerns regarding meals were discussed with the Registered Manager, who was aware of these issues through either discussions with residents, their relatives, or through information recorded in the comment books, which are kept within the dining rooms. She advised that menu and meal provision is being reviewed and that they are in the process of developing ways in which consultation with residents about this issue can be improved, i.e. small group meetings with residents, the cook and senior management staff. In addition the Registered Providers have produced a dietary advice booklet, which is also to be used as part of this process of improvement. Greenways DS0000014542.V280382.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Whilst it is considered that residents are protected from abuse, the homes policy and procedure must be reviewed to ensure its compatibility with the locally agreed West Sussex adult protection procedures. EVIDENCE: The Registered Provider has produced a policy and procedure in respect of adult protection, including a ‘whistle-blowing’ policy. Staff also receive training about this procedure within their induction training. The Registered Manager advised that this would be reinforced through staff supervision. However the Registered Provider must review their policy and procedure to ensure that it is compatible with the West Sussex policies and procedures produced following the publication of the Department of Health’s ‘No Secrets – the protection of Vulnerable Adults’. Particularly in relation to the investigation of any concerns or allegations raised. The Registered Manager advised that the Registered Provider has arranged for managers to receive training in abuse awareness and adult protection in February 2006 and that this training will then be cascaded throughout the staff team. Greenways DS0000014542.V280382.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 Private accommodation for residents is well furnished, and equipped to meet their individual needs. EVIDENCE: All rooms within the home are for single occupancy. However couples can be accommodated within the home as was observed during the inspection. This is achieved either through sharing rooms, or by having adjacent/nearby rooms. The Registered Provider will provide all required furnishings for residents. However a number of residents spoken with advised that they had been able to bring their own furniture and possessions, and were able to personalise their rooms as they wished. All rooms within the home have ensuite facilities. Greenways DS0000014542.V280382.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 30 The current staff team are able to meet the assessed needs of the residents. Staff receive appropriate training to enable them to meet the needs of the residents. EVIDENCE: On the day of inspection there were six staff on duty for the morning shift, five in the afternoon, and two waking night staff. The details of the staff on duty are displayed within the main entranceway/hallway of the home. Staffing rotas seen showed that staffing levels were relatively consistent with a minimum of 4/5 staff on duty during the day. It was noted that since the last inspection an additional member of staff has been employed to assist at peak times in the morning. Staff spoken with considered generally that staffing levels were appropriate, however both staff and residents advised that there could be periods in the day when the staff team were very busy. There is a staff-training programme in place with an overview of all mandatory training for staff. In addition all staff have individual training records. Staff spoken with considered that they had appropriate training to meet the needs of residents. Greenways DS0000014542.V280382.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35, 38 There is a quality assurance and quality-monitoring tool in place. There are appropriate policies and procedures in place to safeguard resident finances. The health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: It was clear through records seen and discussions with the Registered Manager that there is an ongoing self-monitoring tool in place to measure how the home is meeting its aims and objectives. Greenways DS0000014542.V280382.R01.S.doc Version 5.1 Page 17 An internal audit is undertaken twice a year and this will concentrate on different aspects of service delivery. The last audit took place in November 2005 and looked at areas including admissions and spirituality. The Registered Manager advised that they have six nominated auditors who take it in turns to carry out the audits and these include, two staff members, a volunteer, and residents and relatives. Feedback is sought from residents through questionnaires. From all of the information gathered areas for improvement are identified and an action plan is produced. Examples of these were seen during the inspection. In addition a management review of the home is carried out twice a year. From the management review meetings an action plan and development plan for the home is produced. Feedback is also sought through regular resident meetings and comment books kept within the dining areas of the home. The Registered Providers have produced a finance manual, which covers all aspects of financial management, including resident finances. Some residents have chosen to keep small amounts of money in the homes safe and individual record is kept of all deposits and withdrawals and receipts/invoices are kept for all expenditures. A sample of these records were seen during the inspection and all were accurate and up to date. After discussing the management of these the Registered Manager is to introduce checks on all balances following each transaction All records seen in relation to maintenance of equipment and service agreements were up to date. There are policies and procedures in place for all health and safety issues including safe working practices, and staff also receive training in these areas. Risk assessments are in place and all incidents and accidents are recorded and audited. Greenways DS0000014542.V280382.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X X X X X 4 X X STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 3 Greenways DS0000014542.V280382.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP15 Regulation 16 (2 i) Requirement The Registered Provider must provide, in adequate quantities, suitable, wholesome and nutritious food which is varied and properly prepared and available at such time as my reasonably be required by service users. Timescale for action 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP18 Good Practice Recommendations Robust procedures for responding to suspicion or evidence of abuse or neglect to ensure the safety and protection of residents, must be in place, in accordance with the Department of Health guidance, ‘No Secrets’. Greenways DS0000014542.V280382.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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 DS0000014542.V280382.R01.S.doc Version 5.1 Page 21 - 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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