Inspection on 09/02/07 for Greenways

This inspection was carried out on 9th February 2007.

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 found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Greenways 03/10/05

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 Unannounced Inspection 9th February 2007 11:00 Greenways DS0000013659.V327694.R01.S.doc Version 5.2 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.V327694.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 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.V327694.R01.S.doc Version 5.2 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.V327694.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 30-65 YEARS 18th February 2003 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 people carrier vehicle 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. The fees at this service range from £ 1044.00 to £ 1292.00 per week. Greenways DS0000013659.V327694.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out by the Commission for Social Care Inspection (CSCI) under the “Inspecting for Better Lives” process. Mrs Sandra Holland, Regulation Inspector carried out the inspection over five and a half hours. Mrs Trinidad Ng, Registered Manager was present representing the service. The inspector met with all five people who live at the home and spoke to four members of staff. A number of records and documents were sampled including resident’s individual plans, staff files, medication administration records (MAR) and staff training records. The inspector also carried out a tour of the premises. A full review of the information held about the home was carried out prior to the visit to the home. A number of CSCI feedback cards were supplied to the home for distribution to residents, relatives or visitors and healthcare professionals. Five feedback cards were completed and returned by residents, who had been supported by staff to do this. Three feedback cards were completed and returned by resident’s relatives and one by a healthcare professional and all feedback was very positive. A pre-inspection questionnaire was supplied to the home and this was completed and returned. Some of the information supplied in the questionnaire will be referred to in this report. A small number of residents at the home do not use verbal communication and their responses have been assessed by observing their body language, facial expressions and interactions with staff. The inspector would like to thank residents and staff for their time, hospitality and assistance. The people who live at the home prefer to be known as residents and that is the term that will be used throughout this report. What the service does well: Greenways DS0000013659.V327694.R01.S.doc Version 5.2 Page 6 Residents are very effectively supported to maintain their life skills, to develop new skills and to be actively involved in the running of the home. Staff members and residents were observed to have a relaxed, friendly relationship and there is warm, homely atmosphere in the home. The individual plans for residents are well written, regularly reviewed and give staff clear guidance as to how residents like and need to be supported. Residents are supported by the home to be a part of their local community and there is a good range of activities for them to take part in. The home has its own vehicle to enable residents to get to their activities. A number of residents were very proud to show their bedrooms and the home in general and all residents appear very happy with the service provided. The home supports and encourages residents to keep in contact with their family and friends. Residents are well supported by a small team of staff and it is clear that staff are dedicated to the needs of residents. Members of staff spoken with said that they are happy working at the home and some had worked there for a number of years. The home is effectively managed in an open way and it is clear that all aspects of the home are led by the wishes and needs of those living there. What has improved since the last inspection? Medication that needs to be kept cool is now stored in a separate medication fridge. The complaints procedure has been made available in a way that is more suited to the needs of the residents. Facilities for staff to store their belongings have been made available and are being used. All the required information and documents have been obtained before a person is employed to work at the home, including a full employment history. Any person who is employed before a Criminal Record Bureau (CRB) clearance has been obtained is supervised by a nominated person. A survey to assess the quality of the service provided has been supplied to people outside the home who are involved in the support of residents. Greenways DS0000013659.V327694.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Greenways DS0000013659.V327694.R01.S.doc Version 5.2 Page 8 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.V327694.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4. Quality in this outcome area is excellent. Standards 2 and 4 were assessed. This judgement has been made using available evidence including a visit to this service. The needs of a prospective resident have been fully assessed before their admission to the home. EVIDENCE: The manager was able to provide information about the assessment process which would be carried out to ensure the home could meet the needs of a prospective resident. This was detailed in relation to the most recently admitted resident, who joined the home just over a year ago. As most prospective residents would be supported financially by a local authority, a care management assessment would be carried out and a copy would be obtained by the home. The home would also carry out their own assessment. Any prospective resident would be invited to visit the home on a number of occasions, usually of increasing length. The prospective resident would be invited to stay for a meal and possibly overnight, if it appeared that the home was suitable. A particular emphasis of the assessment would be to ensure that Greenways DS0000013659.V327694.R01.S.doc Version 5.2 Page 10 the prospective resident was compatible with the existing residents and to minimise any effects a new member of the household may have on them. Feedback was supplied to CSCI by a supporter of the most recently admitted resident and this complimented the home on the way in which the admission process had been managed, including trial visits and how well the new resident had settled. Greenways DS0000013659.V327694.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is excellent. Standards 6, 7 and 9 were assessed. This judgement has been made using available evidence including a visit to this service. Detailed and informative individual plans are available to guide staff to the support needs of residents and these include the support required to manage risks. Residents are well supported to make decisions. EVIDENCE: Comprehensive individual plans have been drawn up for each resident to describe their support needs and the services and facilities the home needs to provide to meet these needs. The individual plans that were seen and were in good order, contained the required information and had been regularly reviewed. For residents who do not use verbal communication, a very detailed “communication passport” has been developed, with the involvement of others who support the resident. The passport gives clear and effective guidance Greenways DS0000013659.V327694.R01.S.doc Version 5.2 Page 12 about how the resident communicates, what their signs mean and what certain behaviours and moods may indicate. Where necessary, behavioural guidelines have been drawn up to inform and guide staff to anticipate behaviours which may challenge, what to avoid to prevent these and how to manage them if they should occur. From speaking to staff, it was clear that they had a good knowledge and understanding of the residents’ specific needs. Assessments have been carried out of any risks to the residents, including risks involved in mobility, personal care and bathing, fire, choking and vulnerability to abuse. These were very detailed and included ways to prevent risks and how to manage them to minimise the risks to residents, whilst enabling them to be independent. It was clear that residents require support in many activities of daily living, including making decisions. Staff advised that if residents require support to make decisions, they offer choices such as of food, clothes to wear and things to buy when out shopping. Staff were observed to offer residents choices and to respect the choices which were made. For larger decisions such as where to go on holiday, staff advised that they offer residents a selection of brochures and photographs to support them to make a choice. Staff also agree differing options with residents, such as whether to go abroad or stay in Britain. Residents known preferences, likes and dislikes are taken into account when supporting them to make decisions, staff advised. Greenways DS0000013659.V327694.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is excellent. Standards 12, 13, 15, 16 and 17 were assessed. This judgement has been made using available evidence including a visit to this service. Residents are very effectively supported to take part in a range of activities and to be active members of their community. Residents are offered and supported to plan, a well balanced diet. EVIDENCE: It was pleasing to hear residents talk about the activities they take part in and enjoy. Each resident’s preferred activities are recorded in their individual plan. The range of activities include attendance at adult education classes, including art and design and gardening. Resident’s leisure activities include visits to pubs and restaurants, aromatherapy sessions, visits to places of interest and bowling. Residents were observed to be coming and going to their planned or spontaneous activities throughout the inspection and a resident walked to the Greenways DS0000013659.V327694.R01.S.doc Version 5.2 Page 14 local shopping centre during the course of the inspection. The manager advised that residents are not able to hold jobs due to the limitations of their disabilities. The manager stated that residents are actively supported and encouraged to maintain family contacts. Families are welcomed to visit residents and staff also support residents to go to visit their families. One resident is able to go to for weekend stays with their family and letters from residents’ families were seen in their individual plans. From information supplied at the inspection, it was clear that residents are offered a well-balanced and varied selection of meals, which take their personal preferences into consideration. Staff stated that meals for the week ahead are usually discussed and planned, to enable shopping for the required items to take place and residents said that they take part. Staff stated that residents make individual choices for their breakfast and lunch and this is taken at a time of their choosing to fit in with their activities. The main meal of the day is served in the evening and is taken family style as a group with staff. Residents were actively encouraged to make their own choices at lunch and to take part in laying the table and clearing it after the meal. Greenways DS0000013659.V327694.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is excellent. Standards 18, 19 and 20 were assessed. This judgement has been made using available evidence including a visit to this service. Service users receive support in the way that they prefer and their healthcare needs are well met. Medication is appropriately managed. EVIDENCE: Staff were observed to provide personal support discreetly and in a manner that actively promoted residents’ independence, privacy and dignity. Residents were encouraged to be independent and staff offered support only if it was needed. When support was required it was offered in a sensitive manner and residents’ preferences for being assisted by staff of the same or opposite sex, were recorded in their individual plan. The manager stated that a key-worker is allocated to work closely with each resident, to ensure they are effectively supported. A secondary key-worker is also allocated to ensure residents receive consistent support during any absences of the key-worker. Greenways DS0000013659.V327694.R01.S.doc Version 5.2 Page 16 From records seen, it is clear that residents are supported by a number of healthcare professionals and that their healthcare needs are well met. Service users have received support from healthcare professionals including their general practitioner (GP), an occupational therapist and an optician. The manager stated that the residents’ GP is very understanding and supportive. As the service users can become agitated if they have to visit the surgery, the GP is very willing to visit the home when required. Records showed that in response to changes in service users’ needs or health, staff have taken appropriate action and promptly requested referrals to the GP or specialists if needed. Medication is supplied by a national pharmacy the manager advised, and is stored appropriately in a central, locked cupboard. All staff who have received training in this administer medication. The amounts of medication held were checked with the medication administration record (MAR) and were correct with no gaps in the MAR noted. Sample signatures of staff authorised to administer medication were held, along with a signed authorisation by the service users’ GP, for the administration of homely remedies that can be purchased and do not need to be prescribed. It was noted as good practice that a detailed profile of the medications prescribed for each resident is also held. This clearly states why the medication is required, any specific instructions regarding administration and any possible side effects. Greenways DS0000013659.V327694.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. Standards 22 and 23 were assessed. This judgement has been made using available evidence including a visit to this service. The home’s complaints procedure has been drawn up in a way that is more suited to the needs of residents and staff are aware of their responsibilities in the safeguarding of residents. EVIDENCE: The manager stated that the complaints procedure had been made available in a format which was more suited to the needs of residents. A copy was seen in each resident’s individual plan and had been drawn up with more easy to read wording and pictures. Relatives who had completed and returned the CSCI feedback cards indicated that they are aware of the home’s complaints procedure. As some residents use non verbal methods of communication, it was clear that they would have to rely on staff to understand or recognise that they were unhappy or dissatisfied in any way. Staff stated that residents are able to communicate their unhappiness in specific individual ways. This would usually be shown by a change in behaviours, which staff would monitor to find out why it has developed. Staff said they would report any changes to the manager to ensure that appropriate support was provided and any relevant procedures were followed. From speaking to staff it was clear that they are aware of their responsibilities in safeguarding residents. Staff stated that they would report any concerns or Greenways DS0000013659.V327694.R01.S.doc Version 5.2 Page 18 suspicions of abuse to the manager or person in charge. If needed, staff knew that they could also refer any concerns to an area manager or to other agencies outside the home. In the event of an allegation of abuse, the manager stated the home would follow the Surrey Multi-Agency Procedure for the Protection of Vulnerable Adults. A copy of the procedure is kept in the home, but was seen to be out dated. An up dated copy was immediately obtained from the internet & was printed out to be available for use in the home. Other forms of guidance were also available to staff, including Best Practice guidelines in the safeguarding of adults, the home’s policies and procedures relating to the prevention and reporting of abuse and a separate “Whistleblowing” policy. All staff had signed to indicate that they read these documents. It was noted that some staff have not received specific training in the safeguarding of adults and other staff had received this training three or four years ago. All staff had received an introduction to safeguarding adults as part of their Certificate for Working with People with Learning Disabilities (CWPLD). Residents’ monies for day-to-day use are securely held for safekeeping and individual records of these are maintained. Staff advised that these are checked by two staff at the change of each staff shift and to further safeguard service users, the manager advised that she also reviews service users’ spending. The amounts of monies held were checked with the records held and these accurately matched. A requirement has been made regarding Standard 23. Greenways DS0000013659.V327694.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is excellent. Standards 24 and 30 were assessed. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable, safe environment which is suited to the needs of those living there and is very clean and hygienic. EVIDENCE: The home is attractively decorated in cheerful colours and is bright and airy. It is well furnished and equipped in a homely style to meet residents’ needs. Each resident has their own bedroom and three residents were very willing and happy to show their rooms. These had been made individual with their own belongings including televisions, music centres, pictures, ornaments and soft toys. It was observed that residents had open access to all areas of the home and were welcomed to join staff working in the office. A number of photographs of residents and staff were displayed in the home, which help residents to Greenways DS0000013659.V327694.R01.S.doc Version 5.2 Page 20 remember holidays, days out and other events such as birthdays the manager advised. An enclosed garden is freely available to residents and is accessible from the dining room. Residents spoke of assisting with garden maintenance and photos showed them taking part in this. The home is of a similar size and style to neighbouring properties and blends well with its surroundings. All areas of the home were seen to be very clean and well presented and appeared hygienic. Liquid hand cleanser and paper towels were provided in all appropriate places. A separate laundry room is available and was positioned away from food storage and preparation areas. Personal protective equipment is provided including aprons and gloves, and these are available to staff in all required places. Greenways DS0000013659.V327694.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is good. Standards 32, 34 and 35 were assessed. This judgement has been made using available evidence including a visit to this service. Residents are effectively supported by a small team of staff who are appropriately recruited and trained. EVIDENCE: From the information supplied at the inspection it was clear that residents are supported by a very small team of staff. Staff advised that they provide support to residents in all aspects of running the home, including shopping, cooking, domestic and laundry tasks. Staff also provide support with transport and a variety of activities. Staff were observed to interact well with residents, listening to what they said and giving time for residents to respond. Staff were open, cheerful and welcoming. A small number of staff are undertaking National Vocational Qualifications (NVQ) in care at level 3, although the home has yet to meet the recommended target of fifty percent of trained staff. The manager stated that there had been Greenways DS0000013659.V327694.R01.S.doc Version 5.2 Page 22 delays in staff undertaking NVQ qualifications because of difficulties finding suitable assessors. Recruitment records for staff were seen to contain the required records and documents. To safeguard service users all staff are required to undertake a Criminal Record Bureau (CRB) disclosure and these had been carried out. Staff training records were seen and covered training required by law and training to develop knowledge and skills. These included food hygiene, first aid, fire safety and health and safety. As noted at Standard 23, all staff need to receive updated training in the safeguarding of adults. The staff team is made up of male and female staff although the resident group is male. The staff group is of mixed cultural and racial backgrounds and the residents describe themselves as British. The manager stated that staff had been booked to attend training in equality and diversity but had not been able to attend as the course was cancelled and this will be rearranged. Greenways DS0000013659.V327694.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42. Quality in this outcome area is excellent. Standards 37, 38, 39 and 42 were assessed. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well run home and their health, safety and welfare is promoted and protected. EVIDENCE: It was evident that the manager is very experienced in the support and care of residents with learning disabilities, is well qualified and experienced for her role and is ably supported by a deputy manager. The management team have created an open and inclusive atmosphere and provide clear direction and leadership. From the outcomes for residents and the standard of the records maintained, it is clear that the service is effectively managed. Greenways DS0000013659.V327694.R01.S.doc Version 5.2 Page 24 To review the quality of the service provided, a questionnaire titled “How are we doing” was supplied to residents and others involved in their support, in April 2006. Residents were supported by their key-workers to complete these, the manager stated and summary of the responses received was supplied at the inspection. The majority of responses indicated that residents were happy with the service provided and other people thought the service was good. An audit of the home was also carried out by Care UK, the organisation responsible for running the home, in October 2005. This concluded that the home was very effectively managed, had a stable staff team and welcomed support and contributions from residents’ families. The auditors stated that they were impressed with the high standards of care provided. As previously mentioned, the CSCI feedback cards were supplied to the home to obtain independent views of the quality of the service. Five residents, three relatives and a healthcare professional completed these and returned them. All indicated satisfaction with the support and care provided. From information supplied in the pre-inspection questionnaire, it is clear that the required maintenance and checks on systems and equipment in the home are carried out appropriately, and to the required frequency. This is to promote the safety and welfare of all who live and work there. The fire safety system was being maintained by a contractor on the day of inspection. During the tour of the home no hazards to the health or safety of residents were observed and the home’s insurance certificate and health and safety at work poster were displayed as required. Greenways DS0000013659.V327694.R01.S.doc Version 5.2 Page 25 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 Standard No Score 1 X 2 4 3 X 4 4 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 x 4 4 3 X X 3 x Greenways DS0000013659.V327694.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA23 YA35 Regulation 18 Requirement The registered person must ensure that staff receive training appropriate to the work they are to perform. Specifically, all staff must receive updated training in the safeguarding of adults. Timescale for action 11/05/07 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 DS0000013659.V327694.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V327694.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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