Inspection on 29/06/06 for Greenways

This inspection was carried out on 29th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 27/01/06

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 V Gay Key Unannounced Inspection 29th June 2006 08:30 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.V301506.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 DS0000014542.V301506.R01.S.doc Version 5.2 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.bog@mha.org.uk home.fxg@mha.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.V301506.R01.S.doc Version 5.2 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 27th January 2006 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 five wings with accommodation over three floors, accessed by a vertical lift. All rooms are for single occupancy and each has ensuite facilities. There is a large well-maintained garden accessible to Service Users. The Registered Manager is Mavis Stevens. The home is owned by Methodist Homes. Greenways DS0000014542.V301506.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced Key Inspection, which took place on 29 June @ 830am. Prior to the Inspection, the previous inspection report was reviewed along with any correspondence received since the last inspection. Where there have been no changes the report remains the same. During the inspection the Inspector spoke with residents, and staff. Records in relation to care planning, meals, quality assurance, accidents and health and safety issues were reviewed. No family visitors were present, however a visiting professional spoke highly of the home. Four residents were case tracked to ensure their needs were being met. This included new admissions since the previous inspection. Files of four new staff members were examined as part of the inspection process. Residents praised the home in very respect comments included the following “ You couldn’t fault the care…staff are so good they give their all…the food is good so much choice…and the manager is approachable” No requirements were made during this inspection. What the service does well: What has improved since the last inspection? Since the previous inspection the menus have been revised following some concerns raised during the previous inspection in respect of the quality and presentation of the food. Greenways DS0000014542.V301506.R01.S.doc Version 5.2 Page 6 The Registered Manager acted promptly and arranged a meeting with the residents. Thirty-five of the residents attended and issues raised were shared with the cook and staff at a later meeting. The outcome was positive and systems were put in place to address some of the matters raised. The inspector joined the residents for lunch and the meal served was very good. The vegetables were steamed for those residents who prefer them to be firmer and there was plenty of choice. No adverse comments were made to the inspector regarding the choice, quality and quantity of the food. Adult Protection procedures have been reviewed and all staff are soon to receive instructions regarding Protection Of Vulnerable Adults. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Greenways DS0000014542.V301506.R01.S.doc Version 5.2 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.V301506.R01.S.doc Version 5.2 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): 3,6, Residents receive a Statement of Purpose and Service Users Guide to enable them to decide whether Greenways can meet their needs. No resident moves into the home without having his/her needs assessed first. Intermediate care is not being provided at Greenways. Quality in this area is good. This judgement was made using available evidence, including a visit to this service. EVIDENCE: This standard was met at the previous inspection so the inspector checked for compliance only. Greenways DS0000014542.V301506.R01.S.doc Version 5.2 Page 9 Assessments were examined and care plans case tracked. These were found to be a true reflection of the resident and information included emotional and social interests. It was however agreed that care plans could be expanded and tidied up. The assessment format included the necessary information as stated in Schedule 3 and 17 (2) of the Care Regulations Four service users files were examined, including a recently admitted resident. Daily care needs together with risk assessments of the environment were in place. The plan is reviewed by the Registered Manager monthly or as needs dictates. GP visits are recorded and District Nurses support is documented. The social and recreational interests of residents are recorded. Residents said the home met their varying needs and that the staff were attentive and kind. Residents said they could spend their day as they wish with, no pressures placed upon them. One resident told the inspector that she did not wish to engage in social activities and that her wishes were respected. Medication is safely stored and suitably recorded. Residents said their privacy and dignity was respected, and staff were seen to address resident in a respectful manner during the inspection. Greenways DS0000014542.V301506.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Residents health, personal and social care needs are set out in individual care plans. Residents can make their own decisions about how they wish to spend their time. Medication procedures in the home are being well managed. Residents feel they are treated with respect and their rights and privacy are up held. Quality in this area is good. This judgement was made using available evidence including a visit to this service. EVIDENCE: Residents care plans were examined as part of the case tracking process. It was agreed that although care plans contained the relevant information they were in need of a “tidy up” and could be expanded. The inspector noted that entries made and information recorded met the standard. Greenways DS0000014542.V301506.R01.S.doc Version 5.2 Page 11 Residents care plans showed that GP’s visited by request and other health related services were provided. A dependency assessment tool and physical needs chart gave a clear indication of what assistance was needed and what residents could do for themselves. Residents were encouraged to remain as independent as possible within their own physical ability. One resident said “ The staff assist me in the morning, and help me get dressed they are so kind… Another resident said no restrictions were imposed on her and that she was free to spend her time as she wished. Residents spoke highly of the attention given to them by the staff. Residents have the opportunity to join in exercise classes and to go out with the care staff. Equipment is in place to promote independence and assist residents with their daily tasks of living. The medication record was up to date and the senior member of staff had duly completed and signed for the early morning drugs round. Residents who choose to manage their own medication are encouraged to do so following a risk assessment. Staff were seen to knock on residents doors and to wait permission before entering. A visiting hairdresser said the home in her opinion was “one of the best”. Judgement Quality in this area is good. Judgement has been made using available evidence including a visit to the service. Judgement Descriptor Greenways DS0000014542.V301506.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15, Emotional and social care needs of the residents are met The routines in the home are flexible and meet with the service users wishes. The service users have contact with their families and friends. The meals are varied, well balanced and served at times convenient to the residents. Quality in this area is excellent. This judgement was made using available evidence including a visit to this service. EVIDENCE: There is a wide range of activities and outings on offer to the residents. An activities person is employed to broaden the scope of activities available to residents , a programme is displayed in the home. There is a monthly newsletter that informs residents of forthcoming events, together with weekly programmes which are displayed on the notice boards. Good practice was observed, that staff also remind residents daily of what’s on in the home. Greenways DS0000014542.V301506.R01.S.doc Version 5.2 Page 13 On the day of this unannounced inspection residents attended a religious service, which they said they enjoyed. Residents said staff welcomed their families when they visited the home. Residents said they could furnish and personalise their rooms. People living at Greenways are able to make the day-to-day decisions about how they want to live their life. A resident said “ I am able to maintain contact with all my friends and family wherever possible”. A newly admitted resident said she was so pleased with her accommodation, which included a kitchenette area for her to prepare light snacks. Meal times are served in one of the four the dining rooms or in the residents own room. The menus were seen to be varied containing fresh produce. Likes and dislikes are noted and the cook consults daily with residents to ensure the meal was to their liking. The inspector spoke to the cook, who confirmed that the menus had been reviewed following a meeting with the residents. The food is of a high standard, and offers a choice of menu. Residents told the inspector “ We prefer are vegetable firmer than the majority so the cook steams them for us which is really nice” Residents said the overall presentation of the food had improved. The inspector joined the residents for lunch. The meal was appetising and generous in quantity and residents enjoyed their meal. Judgement Quality in this area is excellent. This judgement has been made using available evidence including a visit to the service. Greenways DS0000014542.V301506.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18, Residents and their relatives are confident that their complaints will be listened to, and taken seriously as stated in the Service Users Guide. Robust recruitment practices are being followed to ensure the right kind of people are being employed to care for vulnerable persons. Quality in this area is good. This judgement was made using available evidence, including a visit to this service. EVIDENCE: Residents are listened to and understand how to make a complaint should they wish to. Regular training sessions for staff, plus policies and procedures regarding abuse, ensure that, as far as is possible, the people who live Greenways are protected from bad practice. There is a complaints procedure included in the Statement of Purpose and Service Users Guide. Residents spoken with said they knew who to complain to should the need ever arise. Greenways DS0000014542.V301506.R01.S.doc Version 5.2 Page 15 Residents meetings and Quality Assurance surveys encourage residents and their families to comment on the standard of service. Examples seen showed that if a concern was raised then action was promptly taken. A senior staff member said that she had received training in Adult Protection as part of the National Vocational Qualification level 2 and 3, which 43 of the staff have now obtained. The designated person in charge confirmed that any incident or allegations of abuse would be dealt with following the West Sussex County Council procedures in place. The complaints records showed that any sign of dissatisfaction is dealt with promptly. Training for staff in the Protection Of Vulnerable Adults is being arranged for later this month. All staff have Criminal Records Bureau enhanced checks done before working in the home to ensure they are safe to work with vulnerable people. Staff told the inspector that training in specialist subjects is always on offer to them. Judgement Quality in this area is good; judgement has been made using available evidence including a visit to the service. Greenways DS0000014542.V301506.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Residents live in a safe, well-maintained environment. Standards of hygiene and cleanliness throughout the home are good. Quality in this area is excellent. This judgement was made using evidence available, including a visit to this service. EVIDENCE: A tour of the home revealed attractively presented accommodation that was well proportioned, clean and fresh. Greenways DS0000014542.V301506.R01.S.doc Version 5.2 Page 17 There is a large attractive garden leading from the lounge area, which residents said they made good use of in the summer months. One resident was tending plants in one of the greenhouses on the day of inspection. The home is suitably equipped with aids and adaptations to promote residents independence and assist with their mobility requirements. The laundry is well equipped clean and organised to ensure residents clothing is laundered to a good standard. Bathroom and toilets were clean and contained hand washing facilities and paper towels. Staff on duty confirmed that they had attended fire training on what action to take in the event of a fire. These sessions were recorded. Greenways DS0000014542.V301506.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30, Residents are in safe hands at all times. A robust recruitment procedure is followed to ensure the right types of staff are employed to care for vulnerable people. 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. Quality in this area is good. This judgement was made using evidence available, including a visit to this service. EVIDENCE: The inspector saw the duty board and asked residents if there were sufficient staff for the help and support they needed. They confirmed that staff were always available and one said “she was waiting for a member of staff to assist her to the hairdressers salon”. A cook, cleaners and handyperson are employed and were on duty at the time of the inspection. Greenways DS0000014542.V301506.R01.S.doc Version 5.2 Page 19 Records and discussion with residents and staff showed that there was a nucleus of long serving staff that knew the residents needs and wishes very well. Four staff files were examined; this included any new members of staff employed since the previous inspection. They contained the necessary documentation required by Schedule 4 and Regulation 17 (2) of the Care Homes Regulations. The home is well on its way to achieving 50 of its care staff trained to National Vocational Qualification level 2 or 3. Three staff interviewed said they felt well supported by the manager, and that training courses and induction training are provided. Records evidenced that staff on duty were competent and trained to carry out their duties. Greenways DS0000014542.V301506.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 The Registered Manager is qualified, competent, and experienced to run the home and meets its stated purpose. 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: Greenways DS0000014542.V301506.R01.S.doc Version 5.2 Page 21 Residents live in a home that is run and managed by a person who is fit to be in charge, of good character and able to discharge her responsibilities fully. The Registered Manager is progressive in her outlook towards staff development and encourages staff to attend courses in relevant topics. Staff on duty confirmed that training was always available to them. The administrator confirmed that any monies held on behalf of residents were recorded and receipted as appropriate. Since the previous inspection the company have undertaken an internal audit as part of the Quality Assurance process. The audit took place in June 2006 and the home was judged on standards and values. A copy of the published results was available to the inspector. Residents told the inspector that their opinions are actively sought and that meetings are arranged approximately at eight weekly intervals. Minutes are available, of these meetings and the actions taken in response. The accident record was examined as part of the case tracking process, and any incident involving the well being of the residents was recorded. Staff also meet regularly as a team and individually for supervision. Procedures are followed to promote and protect the health and safety of the residents. Regulation 26 Reports are submitted monthly to the Commission for Social Care Inspection. Record keeping in the home is of a good standard. Greenways DS0000014542.V301506.R01.S.doc Version 5.2 Page 22 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 4 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 4 X X Greenways DS0000014542.V301506.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? 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. Standard Regulation Requirement Timescale for action 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 DS0000014542.V301506.R01.S.doc Version 5.2 Page 24 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. 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