Inspection on 03/10/05 for Greenways

This inspection was carried out on 3rd October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Greenways 09/02/07

Greenways 30/11/04

Greenways 21/06/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Greenways Greenways 3 Grove Road Epsom Surrey KT17 4DQ Lead Inspector Sandra Holland Announced Inspection 3rd October 2005 10:40 Greenways DS0000013659.V253958.R01.S.doc Version 5.0 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 DS0000013659.V253958.R01.S.doc Version 5.0 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 DS0000013659.V253958.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Greenways Address Greenways 3 Grove Road Epsom Surrey KT17 4DQ 01206 752266 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 Solutions Limited Trinidad NG Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Greenways DS0000013659.V253958.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 30-65 YEARS 12th May 2005 Date of last inspection Brief Description of the Service: Greenways is a care home which provides accommodation and support for up to five adults with learning disabilities. The service is owned and managed by Care UK and Hyde Housing Association manage the building and its maintenance. The home is a large detached property situated on a corner plot, in a residential area on the outskirts of Epsom town centre. Local shops, public transport and leisure facilities are all available nearby. A car is run by the service to transport service users to places of interest, to day care services and to educational classes at local colleges. There is limited off-street parking alongside the house as well as controlled on-street parking in local roads. Greenways DS0000013659.V253958.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was the second to be carried out in the Commission for Social Care Inspection year, April 2005 to March 2006. Mrs. S. Holland, Lead Inspector for the service, carried out the inspection. Mrs. T. Ng, Registered Manager was present representing the service. A number of records and documents were examined and areas of the home were inspected. All five of the service users who live at the home and five members of staff were spoken with. The people who live at the home prefer to be known as residents and that is the term that will be used throughout the report. It will be necessary to read the reports of both inspections, to fully assess how the home has met the requirements of the National Minimum Standards. Where there have been limitations in the residents’ ability to communicate, the information for this report has been obtained from speaking to other residents, from visitors to the home, from staff and from observing the body language and facial expressions of residents. The inspector thanks the residents and staff for their time, assistance and hospitality. What the service does well: What has improved since the last inspection? Annual reviews have been arranged for residents. Greenways DS0000013659.V253958.R01.S.doc Version 5.0 Page 6 The medication cupboard has been fitted to a solid wall. 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 DS0000013659.V253958.R01.S.doc Version 5.0 Page 7 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 DS0000013659.V253958.R01.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this inspection. EVIDENCE: Greenways DS0000013659.V253958.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7. Service users are supported to make decisions. EVIDENCE: The manager stated that residents are supported by the staff team and by their families, to make decisions affecting their daily lives. The selection of a recent holiday was an example given. Staff obtained a number of holiday brochures for residents to look through and a meeting was held to discuss this and to make a choice. A foreign holiday was chosen by the group, although one resident had not been abroad before. The manager advised that this resident was assisted to prepare gradually for the holiday, with discussions and reassurance. Staff and a resident advised that the holiday had been a success and much enjoyed by all. A small number of photographs of the holiday were seen, as the majority were still to be developed. Residents at the home are registered on the electoral roll, but the manager stated that the residents do not have the capacity to differentiate between the candidates, so do not go to vote. Greenways DS0000013659.V253958.R01.S.doc Version 5.0 Page 10 Greenways DS0000013659.V253958.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15, 16 and 17. Residents are encouraged and supported to be involved with their families and friends. The meals served are well balanced and appetising. EVIDENCE: A resident returned to the home on the day of inspection, having spent the weekend with his family. This is a regular arrangement, with the resident spending every third weekend with his family. A member of staff kindly drove the resident’s parent to make a local travel connection. Another resident spends a day with his family, every other weekend and is visited on a weekly basis by his parent. This resident’s parent also visits him whilst he attends a day centre. One resident spoke of making a new friend whilst on a recent holiday and photographs were seen of another resident sharing his birthday with his twin brother. The manager advised that the resident’s brother has noticed a marked improvement in his brother’s behaviour and is keen to take him to visit his home. Greenways DS0000013659.V253958.R01.S.doc Version 5.0 Page 12 It was pleasing to see that the home maintains an individual photograph album for each resident, in which to keep a record of events and progress in residents’ lives. A family member has recently provided photographs of his relative as a baby and young man. These have made a more complete picture of the whole life of the resident. In another album, a photograph was seen of a resident receiving an award for his artwork, at an adult education class. The resident was very smartly dressed and well presented to receive his award. Residents were treated with respect by staff, were addressed appropriately and encouraged to join in with conversations. Staff advised that the privacy of resident’s bedrooms (and bathrooms when in use), is respected and that staff do not enter unless invited. The manager stated that residents are offered keys to their bedrooms, but that currently none are held. She advised that this is recorded in their care plan. Meals in the home are taken in the attractively presented dining room and residents and staff eat together, family style. The lunch on the day of inspection was well balanced, nutritious and enjoyed by all. A choice of drinks was available at the table and residents were encouraged to choose and help themselves. Residents took part in the clearing away after the meal and in the preparation of hot drinks for those who wanted them. Greenways DS0000013659.V253958.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20. Medication requiring refrigeration must be securely stored. EVIDENCE: Most medication is stored securely in the medication cupboard, but it was noted that medication requiring refrigeration was stored in the household fridge in the kitchen. To safeguard residents, who have open access to the fridge, any medication requiring refrigeration must be stored in a separate, locked, container. Greenways DS0000013659.V253958.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22. A complaints policy and procedure is in place, but is not accessible to residents. EVIDENCE: The manager stated that due to the limitations of the residents, the complaints policy has been conveyed to them verbally, although no record has been made of this. From the feedback forms returned by residents’ families, it was clear that they are aware of the home’s complaints policy. As it is a requirement that residents are informed of the complaints policy, it is required that this is provided in a format suited to the needs of the residents, such as in a pictorial format, for instance. If there is no format that meets residents’ needs and verbal explanation is the only method, this should be carried out and recorded in the resident’s care plan as such. Currently, the procedure for recording a complaint and the loose-leaf recording forms are stored in the office. This restricts access and a supply of forms and the procedure should be made available to all. The current complaints procedure does not require the manager to be involved so there is no way of the manager (or inspector), knowing how many complaints have been generated. It is required that a recording system be maintained. The manager advised that monies are held for safekeeping for each resident and that the amounts and records held are checked at each staff shift handover. These were checked and were correct, with the amounts present accurately matching the record held. Further, detailed records were seen of residents’ financial accounts. These were recorded appropriately and Greenways DS0000013659.V253958.R01.S.doc Version 5.0 Page 15 effectively and the manager advised that each resident is able to sign for withdrawals from his own account. A requirement has been made. Greenways DS0000013659.V253958.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 28. The home provides a comfortable environment that meets the needs of those living there. EVIDENCE: The home is a large detached house, which blends well into the community. It is decorated and furnished in an attractive, homely style. All areas seen were clean, fresh and airy. The premises, including the garden areas are well maintained. A newly arrived resident was keen to show me his room, which he said he liked and had settled into. The resident had brought a selection of his belongings with him, which reflected his main interests and he talked with staff about going out on visits, to follow these interests. It was noted that staff had left their belongings in the residents’ lounge and a member of staff accessed her mobile phone from her bag stored there. The manager stated that provision is available for staff to store their belongings in the staff sleepover room, which is kept locked. Staff must use the storage made available, to prevent their belongings being a hazard to residents and to safeguard their valuables. Greenways DS0000013659.V253958.R01.S.doc Version 5.0 Page 17 A requirement has been made. Greenways DS0000013659.V253958.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34 and 35. A small staff team, under the leadership of the manager, supports residents. EVIDENCE: The residents are supported by a small team of staff under the leadership of the manager and her deputy. Staff advised that they all share the support of residents with tasks within the home, including shopping, cooking, laundry and assisting with personal care. The personnel file of a recently recruited member of staff was seen and it was noted that a complete employment history had not been obtained. This is required to ensure that there are no gaps in employment history that are unaccounted for. It was noted that a new member of staff has commenced employment before a CRB clearance had been obtained in respect of that person. This must only be permitted if a nominated member of staff, who works as far as possible, the same shifts, supervises the new person in their work. The new member of staff must not be allowed to escort residents away from the home, unless accompanied by the nominated supervisor. The manager stated that a staff training chart and individual staff training records are maintained and these were seen. Staff undertake mandatory and Greenways DS0000013659.V253958.R01.S.doc Version 5.0 Page 19 other, training courses, including fire safety, protection of vulnerable adults, medication, food hygiene, moving and handling and first aid. A requirement has been made. Greenways DS0000013659.V253958.R01.S.doc Version 5.0 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 and 42. The home seeks the views of those involved to assess the service provided. Health and safety matters are well managed. EVIDENCE: The manager stated that a survey of the views of those using the service provided is carried out annually. The manager advised that she is planning to revise the survey before it is re-issued to ensure that it reflects the service offered. It is recommended that the survey is extended to those people outside the home, who are involved in the support of residents, such as families, general practitioners, day service providers and care managers. A number of records relating to health and safety were examined, including fire prevention, gas safety, electrical safety, the temperature of the hot water supply and prevention of contamination by Legionella bacteria. Food hygiene records were also seen, including fridge and freezer temperature records, the temperature record of hot foods served and the record of food actually served (as may differ from the menu). All the records were maintained to the required frequencies and were within the appropriate ranges. Greenways DS0000013659.V253958.R01.S.doc Version 5.0 Page 21 A recommendation has been made. Greenways DS0000013659.V253958.R01.S.doc Version 5.0 Page 22 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 Score 2 x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x 3 x x x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x 2 x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x x 3 2 3 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Greenways Score x x 2 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 3 x DS0000013659.V253958.R01.S.doc Version 5.0 Page 23 YES 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. 1 Standard YA20 Regulation 13 (2) Requirement The registered person must make arrangements for the recording, handling, safekeeping, safe administration and disposal of medication. Specifically, medication required to be stored in a refrigerator, must be stored in one allocated for that purpose, or if in a household refrigerator, in a separate, locked container. The home’s complaints procedure must be made available and be appropriate to the needs of the residents. The registered person must provide for staff – (i) facilities for the purpose of changing and (ii) storage facilities. The registered person must not employ a person to work at the care home unless he has obtained in respect of that person, the information and documents specified in Schedule 2 of The Care Homes Regulations 2001 (As Amended). Specifically, a full employment history must be obtained. Unmet from 12/05/05. Where a registered person DS0000013659.V253958.R01.S.doc Timescale for action 07/11/05 2 YA22 22 (2) 02/01/06 3 YA28 23 (3) (a) (i-ii) 19 (1) (b) 07/11/05 4 YA34 07/11/05 5 YA34 (a-c) 19 (11) 03/10/05 Page 24 Greenways Version 5.0 permits a new worker to start work, prior to a CRB clearance being obtained in respect of that person, the registered person must (a) appoint a member of staff, who is appropriately qualified and experienced, to supervise the new worker pending receipt of, and satisfying himself with regard to, the outstanding information in relation to a criminal record certificate; (b) so far as is possible ensure that the staff member is on duty at the same time as the new worker and (c) ensure that the new worker does not escort residents away from the care home premises unless accompanied by the nominated staff member. 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 39 Good Practice Recommendations It is recommended that any survey carried out to assess the quality of the service provided is distributed to external supporters of residents. Greenways DS0000013659.V253958.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 DS0000013659.V253958.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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