Inspection on 05/10/05 for Greenways

This inspection was carried out on 5th October 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Greenways 13/01/09

Greenways 09/01/08

Greenways 16/07/07

Greenways 30/05/06

Greenways 05/01/06

Greenways 02/02/05

Greenways 27/04/04

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

CARE HOMES FOR OLDER PEOPLE Greenways 720 Preston Road Bamber Bridge Preston Lancashire PR5 6AL Lead Inspector Ms Jenny Hughes Unannounced Inspection 5th October 2005 10:00 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 DS0000005926.V252731.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 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 DS0000005926.V252731.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Greenways Address 720 Preston Road Bamber Bridge Preston Lancashire PR5 6AL 01772 339083 01772 339083 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) Ark Care Services Limited Mrs Sandra Clements Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Greenways DS0000005926.V252731.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd February 2005 Brief Description of the Service: Greenway is a residential care home providing 24 hour personal care and accommodation for 29 older people. The home is owned by Mr and Mrs Ajisebutu who also own a second home in the South of England. The home is located in a residential area on the outskirts of Bamber Bridge, close to all local amenities and the motorway network. The home is a two-story building. Accommodation is provided in single bedrooms, the majority of which have ensuite facilities, comprising of a wash hand basin and WC. Although the rooms are pleasantly furnished, service users are also able to take personal possessions with them when they come to live at the home. Bedrooms are located on both the ground and first floor. There is a passenger lift. Accessible toilets and bathrooms are located on both floors near to bedrooms and living rooms. There are three dining areas, two of these are combined lounge with a dining area. A separate conservatory is also available. The home is a no smoking home. On the day of the inspection there were 22 service users resident at the home. Greenways DS0000005926.V252731.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 5 hours, and was one of two inspections, which must be made each year. Additional inspections may be made if necessary. The inspection was unannounced, in that the owners were not aware that the inspection was to take place. The registered manager was interviewed, and five staff and seven residents were spoken to. What the service does well: What has improved since the last inspection? The manager has steadily improved how the information on the care plan is set out, to make it as clear as possible for the staff to follow, and for them to understand the individual needs of the residents. This is still being developed. Medication records are complete, witnessed correctly, and up to date. The manager has achieved the Registered Managers Award, the required qualification for her post. Her assistant has also achieved the same qualification. Induction training is comprehensive for all staff, leading to registration for NVQ Level 2 training. 46 of the care staff now have NVQ qualifications. Greenways DS0000005926.V252731.R01.S.doc Version 5.0 Page 6 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 DS0000005926.V252731.R01.S.doc Version 5.0 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 DS0000005926.V252731.R01.S.doc Version 5.0 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 The home has a detailed assessment that is carried out for all residents. This means that a service is provided that is tailored to the individual’s needs and preferences. EVIDENCE: Individual records are kept for each of the residents, and there is a set procedure for admitting someone to the home, with an assessment form being seen on three selected files. These are used by management to check that staff can give suitable care to each person, before the manager agrees that the home is the right place for them to live. The information in this assessment was informative and appropriate. A resident spoken to said that the manager had discussed what help he needed with him and his son before he moved into the home. One potential resident called at the home with his son to try out the aids there to see if they were suitable for him. Staff welcomed them, and helped the trial visit go as smoothly as possible. Greenways DS0000005926.V252731.R01.S.doc Version 5.0 Page 9 Staff spoken to were aware of the care needs of the residents, following information passed onto them by senior staff. Greenways DS0000005926.V252731.R01.S.doc Version 5.0 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 and 10 Overall, the health and personal care needs of residents are met at this home. Residents benefit from the support of healthcare professionals. The medication at this home is well managed, promoting good health. EVIDENCE: Individual care plans are available, identifying the areas of need for each person, and with instructions for staff for what they must do to meet those needs. The manager regularly reviews the way things are recorded, and tries to improve the information and instructions to staff to make the task required clearer, and so bring improvements to the lives of the residents. Signatures of residents showed that they had been involved in agreeing what care they needed from the staff. Records of any G.P or district nurse input were recorded, and records of individual’s weights and food and fluid intake were seen. A G.P. called to see a resident during the inspection, at the request of the manager, and discussed with her the action to take to improve the resident’s situation. “There’s no problem seeing the doctor if you need one. They just ring up and ask one to call”, said one resident. Greenways DS0000005926.V252731.R01.S.doc Version 5.0 Page 11 Clear, accurate records were seen of the administration of medication. Anyone who wishes to self medicate signs a risk assessment to say that they take responsibility for their own medication. The local pharmacist visits regularly to check the medication in the home, and records were seen detailing everything they looked at. Only named, trained staff administer the medication to residents. Residents sat where they wished in the home. “I like sitting in this room”, stated one resident, “It’s nice and light and you can see people passing”. Another resident, in another room, laughed as she said, “I always sit in this chair. I don’t know why, but my friend comes in here as well. We can watch the telly or talk a lot”. One resident preferred to sit near where the staff passed by on their work about the home. He said he found he could have a good talk with them. Staff spent time and sat and chatted with him as their work allowed. Greenways DS0000005926.V252731.R01.S.doc Version 5.0 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, and 14 There are a variety of activities, and some residents are motivated and stimulated by joining in. The staff have an understanding of the resident’s support needs, evident from the positive relationships, which have been formed between the staff and residents. EVIDENCE: The individual assessments include information on each person’s life history, their religious needs, and which hobbies and activities they prefer. A diary records what activity has taken place on which day, and also which residents have taken part. It also notes what people were doing instead of the organised activity. Activities include ‘Bulls-eye’, board games, bingo, dominoes, music, and a quiz. A singing group called ‘The Land Girls’ also visit the home. “I like the music and singing” said one resident, “I like watching films” said another. “I’m not bothered about doing any of that really. I just like to rest, but they always ask me if I want to join in “, added another, as she was offered a drink by staff. Another resident was setting off on her daily walk outside the home, letting the manager know she was on her way. Visitors call in the home through the day, all recorded in the visitors’ book by the front door, with some service users enjoying trips out with family. Greenways DS0000005926.V252731.R01.S.doc Version 5.0 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): 16 and 18 Residents are confident their concerns will be listened to and acted upon. Staff have an understanding of Adult Protection issues, which protect residents from abuse. EVIDENCE: There is a complaints procedure in place, with a complaints book to record any complaints, which may come to the manager’s attention. No complaints have been received since the last inspection. A resident said she would “tell any of the staff” if she was not happy with something. Staff spoken to knew about the Adult Protection procedure, and what to do if they had any concerns. They said they would always act if they thought a resident was at risk. Also if it were a member of staff causing concern they would inform the manager. All staff attend abuse awareness training. Greenways DS0000005926.V252731.R01.S.doc Version 5.0 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): These standards were not inspected at this visit. EVIDENCE: These standards were not inspected at this visit. Greenways DS0000005926.V252731.R01.S.doc Version 5.0 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, 28, 29 and 30 The standard of some of the vetting and recruitment practices is poor, with appropriate checks not being carried out, potentially leaving service users at risk. Training is provided and this means that residents are provided with appropriate care and attention. EVIDENCE: Both the proprietor and the manager carry out recruitment of staff individually. Four files of staff who were recruited by the proprietor were seen, and found to have incomplete information. None of these staff who were recruited this year had a Criminal Records Bureau Disclosure obtained by the proprietor. A Disclosure had been accepted from their last employer, which is incorrect. Contracts had been signed and dated before references had been returned. Staff recruited by the manager had the correct information. There is a set recruitment procedure in place, which the proprietor had not followed correctly. The inspector issued an Immediate Requirement Notice. This outlined the areas which needed to be corrected when recruiting staff, and the proprietor would need to respond to this in writing. The rota showed which shifts care staff were working each day. Staff are a mix of long term experienced, younger enthusiastic, and those who have had a Greenways DS0000005926.V252731.R01.S.doc Version 5.0 Page 16 change of direction in their careers. Both male and female staff work at the home. One staff member said “I’m on a course at college so I’m not allowed to do any personal care, because I’m too young, but I like to help in other ways. I like working with older people and having a chat with them. Another staff member keeps her eye on me”. “They’re grand lot here, it’s a nice place to work”, said another staff member. All staff have induction training, which prepares them for starting their NVQ Level 2 training. A graph showing all training received is clear to prompt the manager who needs what training. Training completed includes moving and handling, health and safety, food hygiene, medication awareness, palliative care, dementia awareness, risk assessments, and care planning. Six of the thirteen care staff hold NVQ qualifications (46 ). Domestic staff are an important part of the care team, and one was seen following her set routine around the home. “I make sure I have a set part of the home to do in turn, that way I don’t miss anywhere” Residents spoken to said the staff were helpful. Greenways DS0000005926.V252731.R01.S.doc Version 5.0 Page 17 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,and 38 The manager is supported well by the senior staff in providing clear leadership, with staff demonstrating an awareness of their roles and responsibilities. Systems and practices in the home promote and safeguard the health, safety and welfare of the people using the service. EVIDENCE: The registered manager has over 20 years experience in a supervisory capacity, and has achieved the Registered Managers Award. The assistant manager has also achieved the same qualification. Staff spoken to said, “The manager’s really easy to speak to, she’s one of the team. She likes things to be done right though”. Records and staff confirmed the regular fire training for staff. With the last fire equipment check made in January 2005. The manager makes recorded spot Greenways DS0000005926.V252731.R01.S.doc Version 5.0 Page 18 checks on different areas of the home, for instance, identifying any laundry required, and checking all kitchen records are up to date. All maintenance and servicing checks of equipment were correct. Greenways DS0000005926.V252731.R01.S.doc Version 5.0 Page 19 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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 3 Greenways DS0000005926.V252731.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP29 Regulation 19 Schedule 2 Requirement The registered person shall not allow a person to work at the home unless the person is fit to work at the care home, and the employer has obtained in respect of that individual the necessary information and documentation (Timescale of 28/02/05 not met) Timescale for action 31/10/05 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 DS0000005926.V252731.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Chorley Local Office Levens House Ackhurst Business Park Foxhole Road Chorley PR7 1NW 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 DS0000005926.V252731.R01.S.doc Version 5.0 Page 22 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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