Inspection on 05/09/05 for Greenways

This inspection was carried out on 5th September 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 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 27/01/06

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 Hawthorn Road Bognor Regis West Sussex PO21 2UW Lead Inspector Lynne ODonnell Unannounced Inspection Monday 5 September 2005, 01:00pm th 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 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 H60-H11 S14542 Greenways V246486 050905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Greenways Address 227 Hawthorn Road, Bognor Regis, West Sussex, PO21 2UW Telephone number Fax number Email 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 Methodist Care Group Mrs Mavis Eileen Stevens Care Home 41 Category(ies) of PC Care Home only 41 registration, with number of places Greenways H60-H11 S14542 Greenways V246486 050905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7 February 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 ensuite facilities. There is a large well-maintained garden accessible to Service Users. The home is owned by Methodist Homes. Greenways H60-H11 S14542 Greenways V246486 050905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced Inspection which took place over a 7-hour period, during the afternoon and evening. During the inspection the Inspector undertook a tour of the home, spoke with residents and staff and examined care plans and other related documentation. Care plans contained information on the personal, health and social care needs of the residents and were seen to be reviewed regularly and it was clear that residents were involved in the care planning process. Residents spoke very highly of the care provided and the staff team with comments including ‘I feel lucky to be here’, ‘if you can’t be at home this is the best place to be’, and ‘I think that this is one of the best (homes)’. Since the last inspection conversion works to the loft area have been completed. This has provided five further ensuite bedrooms and three studio apartments. The rooms have been finished to a high standard. The home is now registered to accommodate up to 41 residents. What the service does well: What has improved since the last inspection? Greenways H60-H11 S14542 Greenways V246486 050905 Stage 4.doc Version 1.40 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 H60-H11 S14542 Greenways V246486 050905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Greenways H60-H11 S14542 Greenways V246486 050905 Stage 4.doc Version 1.40 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 standard(s) 3, 5 All residents have their needs assessed prior to moving into the home. Residents and/or their representatives are able to visit the home prior to moving in. EVIDENCE: The records of three new residents were reviewed. These showed that a full needs assessment had been carried out with the resident prior to admission. The assessment covered all aspects of personal, health and social care needs. These assessments are reviewed with the resident 6 weeks after moving in to ensure that all needs are being met. All residents spoken with advised that they had been able to visit the home prior to moving in with some staying on a short term basis before making a final decision on moving. Greenways H60-H11 S14542 Greenways V246486 050905 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9. All residents have a plan of care in place which has been drawn up and agreed with each individual resident. The health care needs of residents are monitored and met. Medication is administered and managed in accordance with the homes policies and procedures EVIDENCE: Six care plans were reviewed during this inspection. These all contained relevant information on health, personal and social care needs. Residents were aware of their care plans and those reviewed included documentation to demonstrate that they had been agreed with the residents. Residents spoken with were satisfied that their needs were being met by the staff team. Comments included ‘the carers really do care’ and ‘the staff are very kind and provide me with help as I need it.’ The care plans are reviewed monthly with the residents. Greenways H60-H11 S14542 Greenways V246486 050905 Stage 4.doc Version 1.40 Page 10 It was clear from the care plans that residents’ health was monitored. Any changes to health care needs are recorded and appointments are made with doctors or other health care professionals as needed. The home benefits by being in the same grounds as the local health centre and the Registered Manager confirmed that they have a good relationship with the doctors and other staff there. All medication is kept securely and all records seen in relation to its administration were up to date. A number of residents self-administer their medication. This follows an individual assessment and residents have lockable space within their rooms for the safe keeping of their medication. Greenways H60-H11 S14542 Greenways V246486 050905 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 14, 15 A range of social, religious and recreational activities are provided within the home. Residents are able to maintain contact with family and friends. Residents are able to exercise choice and control over their lives. There is a varied and balanced menu within the home. EVIDENCE: An activities co-ordinator is employed within the home who ensures that a variety of activities are available to the residents. A weekly plan/diary of events is produced and provided to all residents. The weekly plan seen during the inspection included church services, shopping trips, knitting, library, music and movement, art groups, visiting shop and crosswords and board games. The activities co-ordinator is supported by the rest of the staff team and a large and active group of volunteers. Residents spoken with confirmed that they chose which activities that they wished to participate in with some enjoying the shopping trip into town earlier in the week. One resident commented that ‘there is a good range of activities’. Another resident advised that there is a church service held twice a week. Greenways H60-H11 S14542 Greenways V246486 050905 Stage 4.doc Version 1.40 Page 12 With the exception of mealtimes residents confirmed that other aspects of daily living are flexible to suit individual preferences. Residents confirmed that their visitors are able to come to the home at any time. It was clear through discussions with residents that their personal autonomy and choice are maximised. Residents confirmed that they were able to bring personal belongings with them when they moved into the home and this was further demonstrated in those rooms seen by the Inspector. Those residents spoken with were generally satisfied with the meals served. The menus seen showed that a wide variety of meals were served. Residents were pleased that they always had a choice of meals. They also advised that the accompanying vegetables with any meal are served separately at the table, which they can then serve themselves. Comment books are kept within each of the dining rooms for residents to record any comments with regards to the meals. Within each of the dining rooms there are facilities to make drinks and snacks throughout the day. Greenways H60-H11 S14542 Greenways V246486 050905 Stage 4.doc Version 1.40 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 standard(s) 16 There is a clear and accessible complaints procedure in place. EVIDENCE: Residents were clear as to who they would speak with if they had any issues or concerns. One complaint had been referred to the Commission in relation to the lift. This was dealt with in an appropriate way by the Registered Manager with a full response given. Greenways H60-H11 S14542 Greenways V246486 050905 Stage 4.doc Version 1.40 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 standard(s) 19, 20, 23, 24, 26 The home provides a safe and well maintained environment. There are a range of safe and comfortable internal and external communal rooms and spaces. Residents rooms suit their needs. Residents private accommodation is safe and comfortable. The home is clean, pleasant and hygienic. EVIDENCE: There are a range of lounge, dining and other seating areas throughout the home. The main lounge is on the ground floor and is large, light and well Greenways H60-H11 S14542 Greenways V246486 050905 Stage 4.doc Version 1.40 Page 15 furnished. The large well maintained garden can be accessed via the lounge, and this also provides a range of seating areas. Residents private accommodation is situated over three floors, which are accessible via a passenger lift. There have been a number of problems with the lift over recent months, with several breakdowns, which has been a concern for some residents. The Registered Manager advised that a specialist company has looked at the lift and a number of repairs have been carried out which appear to have rectified the problem. All resident rooms have ensuite facilities. Three of the new rooms also provide small kitchenette facilities. All residents spoken with advised that they were able to bring their own furniture and possessions with them if they chose to do so. If they choose not to then all necessary furnishings can be provided. Policies and procedures are in place with regard to infection control. Training is also provided for staff. The laundry is sited separately and provides adequate provision. In addition a washing machine and dryer are also available for Service User use. This is again provided in a separate room. Greenways H60-H11 S14542 Greenways V246486 050905 Stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29. Residents needs are met by sufficient suitably qualified staff. Residents are supported and protected by the homes recruitment policy and procedures. EVIDENCE: Staffing rotas showed that there are four care staff on duty during the day and evening with two waking night staff. In addition there are cooks and domestic staff employed throughout the week. Residents spoke very highly of the staff team with comments including ‘the staff are magnificent’ and ‘the staff are very kind’. Staff spoken with during the inspection were able to demonstrate an understanding of the care needs of the residents. Recruitment records seen for three new members of staff were seen and these demonstrated that the Registered Manager operates a thorough and robust procedure with all the required checks and documentation in place prior to the commencement of employment. Greenways H60-H11 S14542 Greenways V246486 050905 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 36. The home is well managed by a Manager who is qualified, competent and experienced. Staff are appropriately supervised. EVIDENCE: The Registered Manager has a number of years experience in managing the care home and has an NVQ qualification in management and care at level 4. Records seen showed that staff receive formal supervision and the outcomes of this are recorded. Staff spoken with also confirmed that they received supervision both on a formal and informal basis. Greenways H60-H11 S14542 Greenways V246486 050905 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 4 x x 4 4 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 x x x x 3 x x Greenways H60-H11 S14542 Greenways V246486 050905 Stage 4.doc Version 1.40 Page 19 No 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 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. 1. Refer to Standard Good Practice Recommendations Greenways H60-H11 S14542 Greenways V246486 050905 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Ridgeworth House Liverpool Gardens Worthing 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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