CARE HOMES FOR OLDER PEOPLE
Greenways 720 Preston Road Bamber Bridge Preston Lancashire PR5 8JP Lead Inspector
Mrs Marie Cordingley Unannounced Inspection 9th January 2008 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.V353961.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Greenways DS0000005926.V353961.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Greenways Address 720 Preston Road Bamber Bridge Preston Lancashire PR5 8JP 01772 339083 01772 334633 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 Vacant Post Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Greenways DS0000005926.V353961.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home is registered for a maximum of 30 service users in the category of OP - Old age, not falling within any other category. 16th July 2007 Date of last inspection Brief Description of the Service: Greenways is a residential care home providing 24-hour personal care and accommodation for 30 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 en-suite 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 a combined lounge with a dining area. A separate conservatory is also available. The home is a no smoking home. The fees at the home range from £310.50 - £360 per week. There are additional charges for hairdressing and newspapers. Greenways DS0000005926.V353961.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes.
The inspection of this home included an unannounced site visit which was carried out by two inspectors. As the visit was unannounced, the acting manager, staff and residents didn’t know it would be taking place until we arrived. Throughout the visit we held discussions with residents, staff members and the acting manager. We also viewed a selection of documents such as staff personnel files and residents’ care plans and carried out a tour of the building. As part of this inspection a case tracking exercise was carried out. This involved us looking closely at selected residents’ care from the point of their admission to the home. Prior to our visit, we wrote to residents, their relatives, staff members and visiting professionals such as doctors and social workers, and asked them to complete a questionnaire about their opinion of standards within the home. A number of completed questionnaires were returned to us. We also asked the owners of the home to complete a comprehensive self assessment (AQAA), about all aspects of the service and its management. Unfortunately this self assessment was not returned to us despite several requests. Greenways DS0000005926.V353961.R01.S.doc Version 5.2 Page 6 What the service does well:
We received a good response to our satisfaction survey and were sent completed questionnaires from several residents, relatives and staff members. We also received a completed survey from a health care professional who visits the home regularly. All the responses we received were very positive and a number of people made some additional comments about the home. These included; ‘Every resident is treated as an individual and supported to lead the life they choose as much as possible.’ ‘The staff are full of kindness all of the time.’ ‘The home is friendly, loving and caring.’ ‘The home has changed in such a good way.’ ‘They provide first class care to my mother, nothing is too much trouble.’ None of the people who completed a questionnaire raised any concerns about the service provided at Greenways. The positive responses we received to our written survey were reflected in the discussions we had with residents during our visit. All the residents we spoke to expressed satisfaction with the home. One resident said ‘’The staff are very kind and are very good to me.’’ Another resident said, ‘’The girls (staff) are kindness itself.’’ During our visit we spent time with a number of carers and talked to them about their roles. Carers had a good understanding of their roles and spoke about residents with sensitivity and respect. In addition, the carers we talked with demonstrated a sound understanding of individual resident’s needs and principles of good care. All the carers we spoke to told us that there was a strong sense of team work at Greenways and spoke of the commitment of all staff to provide a good quality service for residents. In addition, carers felt very well supported and said that the acting manager and assistant manager were always on hand to give guidance and advice. A number of people who responded to our written survey were very complimentary about the food provided at the home. One resident wrote ‘’The food is absolutely first class.’’ A resident we spoke to during our visit told us, ‘’The food is always very good and there is always as much as you can eat.’’ Accommodation at Greenways is homely and comfortable and every resident is provided with their own bedroom. We carried out a tour of the home and found that all areas were clean and warm. Greenways DS0000005926.V353961.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection?
The home has made a number of significant improvements in several areas. This was reflected in our findings during the inspection and by comments we received from residents, their relatives, staff and a visiting professional. The system used for planning residents’ care has improved and there are written care plans in place for each resident. The care plans we viewed contained a better amount of information to help carers understand each resident’s needs and the support they require. Carers we spoke to had a good understanding of resident’s needs. Whilst we did find that care plans had improved, we have made some recommendations in this report to assist the home in making further improvements. Risk assessments in areas such as falling, pressure sores and moving and handling are more comprehensive and now provide clear guidance for staff in maintaining people’s safety. Each resident now has an individual moving and handling plan which clearly describes the processes staff should follow to assist them safely. In addition, all staff members have been provided with refresher moving and handling training since the last inspection. Written procedures for the protection of people from abuse (Safeguarding Procedures) have now been reviewed and improved. The procedures clearly describe the actions that need to be taken in the event that there are concerns that a person has been the victim of, or is at risk from any kind of abuse. In addition, the procedures are in line with the Department of Health guidance ‘No Secrets.’ In line with a requirement made at the last inspection, the home’s complaints procedure has been improved and all staff have received training in how to recognise and deal with concerns. We found evidence during this inspection that the provider and acting manager now take complaints seriously and respond appropriately when concerns are raised. The home have introduced a new procedure for investigating complaints which includes a ‘record of investigation.’ This record acts as a prompt and assists the person investigating the complaint to ensure that they have taken all the necessary measures. Procedures for the receipt, storage, administration and disposal of medication are greatly improved and help ensure that residents’ medicines are handled safely. In addition, regular checks are made of records and medicines to ensure that all staff are following the correct procedures. Greenways DS0000005926.V353961.R01.S.doc Version 5.2 Page 8 There are careful systems in place to ensure that only suitable people are employed at the home. All the necessary pre-employment checks are now carried out for all candidates, including references, Criminal Records Bureau checks and a full employment history. Where gaps are evident in a candidate’s employment history, they are fully investigated. The home now uses a standard induction pack to train all new staff members. The induction covers a number of areas such as principles of good care and is in line with ‘Skills for Care’ standards. In line with a requirement made following the last inspection of the home, accidents are now carefully recorded and all staff have been made aware of the importance of recording all details accurately. In addition, the management team monitor accidents to identify any trends or patterns. What they could do better:
Residents are provided with a Service User Guide which provides information about daily life at the home such as arrangements for mealtimes and activities. However, we noted that there is information in this guide which is out of date and no longer relevant, for example, details of staff and managers who no longer work at the home. The Service User Guide must be updated regularly so that people are provided with accurate and relevant information. We tracked the care of the most recently admitted resident and were unable to find evidence that the home had carried out a pre-admission assessment. This means that the home had admitted the resident without first ensuring that they could meet his needs. Unless someone is admitted to the home in an emergency, assessments should always be carried out prior to their arrival so that the person can be assured the home is right for them and will meet their needs. The home has introduced a new assessment tool called ‘My Life.’ This will enable carers to gain some insight into a resident’s social history as opposed to the current format which focuses more on people’s daily care needs. A social history is important in helping carers understand an individual and plan their care in a more individual way.
Greenways DS0000005926.V353961.R01.S.doc Version 5.2 Page 9 However, at the time of the inspection the home had not yet started to use this tool, we recommended that it be implemented as soon as possible. Since the last inspection, the home have improved their care planning procedures and we found evidence that people’s care plans are reviewed regularly. However, not all the care plans we looked at as part of our case tracking exercise provided an accurate account of people’s needs. For example, one resident’s needs had changed significantly and she needed much more help than her care plan described. In addition, the current format for care planning is not user friendly or efficient. We recommended that the format for care planning be reviewed and improved so that staff can easily identify when new information has been added and access the new information quickly. Safeguarding procedures have been improved a great deal and now outline the correct processes that should be followed in the event that an allegation of abuse is made. However, these procedures could be further improved by adding contact details of relevant agencies such as local social services departments. A written checklist has been developed for assessing the ability of staff members to handle resident’s medicines safely. The document is very thorough and covers all the relevant areas such as administration and recording of medicines. However, at the time of our visit the checklist had not been used and no assessments had been carried out. We recommended that the checklist be implemented as soon as possible. It is important that managers satisfy themselves that any staff member dealing with residents’ medicines is competent to do so It is recommended in the National Minimum Standards that at least 50 of carers in every home hold National Vocational Qualifications in care at level 2 or above. Greenways have not yet met this standard. Currently there are 6 out of 19 staff members who hold the qualification. However, there are a further 3 staff members due to complete the training in the near future. We were able to confirm that residents are offered a number of choices for breakfast and evening meals on a daily basis. However, we found that residents are not routinely offered an alternative for their main meal at lunchtime. Residents should always be given a choice of main meal. In addition, available options should be clearly displayed so that all residents are aware of them. Greenways DS0000005926.V353961.R01.S.doc Version 5.2 Page 10 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 DS0000005926.V353961.R01.S.doc Version 5.2 Page 11 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.V353961.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 3. Standard 6 is not applicable to this home. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People considering a move to the home are not provided with relevant, up to date information. The home admits people without fully knowing if they can meet their needs. EVIDENCE: We were able to confirm that all the people who live at the home had been provided with a Service User Guide. This is a document that provides information about daily life at the home such as the arrangements for mealtimes and activities. However, when we viewed this document we found that it included information that was out of date and no longer relevant, for example details of managers and staff who no longer work at the home.
Greenways DS0000005926.V353961.R01.S.doc Version 5.2 Page 13 During our visit we tracked the care of the most recently admitted resident. We were unable to find evidence that the home had carried out a preadmission assessment. In addition, the acting manager was unable to provide us with a social services assessment in respect of this person. The home had carried out an assessment of the resident’s needs, but this had not been done until his arrival. Unless someone is admitted to the home in an emergency, assessments should always be carried out prior to their arrival, so that the person can be assured the home is right for them and will meet their needs. Currently, the home assess residents’ daily care needs but there is little information gathered about people’s social histories, such as relationships, previous employment and significant life experiences. It is important that carers obtain this type of information so that they can recognise and value people’s individuality and plan their care accordingly. We were advised during our visit that a tool had been developed to gather social history information but had not yet been implemented. We recommend that it be utilised as soon as possible. Greenways DS0000005926.V353961.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ care plans don’t consistently reflect the care they need and don’t contain enough information for staff to provide person centred care. This means that people may be at risk of not receiving all the support they need. EVIDENCE: In discussion, carers demonstrated a good understanding of residents’ individual needs. However, much of this information is passed between staff verbally as the home are not using written care plans effectively. We viewed a number of residents’ care plans which had been improved since the last inspection but still contained fairly basic information. We found that
Greenways DS0000005926.V353961.R01.S.doc Version 5.2 Page 15 there were a number of occasions where a resident’s circumstances had changed, but their care plan had not been updated to reflect changes in the level or type of help they needed. Some residents’ care plans didn’t give a true picture of their daily care needs. For example, we read daily care notes of one resident that indicated he had Diabetes, but when we viewed his care plan there was no reference to this condition or his related dietary needs. The care plans that we viewed were difficult to work with and we found it difficult to locate and access information. In addition, various pieces of information were stored in a number of different records, which means it is easy for carers to miss things that have been written down. We recommended that the whole system for recording residents’ daily information and care planning be reviewed, and made more efficient and user friendly. The process used for assessing and managing areas of risk that affect residents are much improved. Risk assessments are carried out for all residents in relation to areas such as falling, developing pressure sores and moving and handling. There is a comprehensive moving and handling plan in place for every resident which contains clear guidance to ensure that carers follow safe procedures at all times. Procedures for handling people’s medication have improved greatly since the last inspection and there are now much safer systems in place for the storage, administration and disposal of medicines. The acting manager of the home carries out regular checks of medicines and records to ensure that people are given the correct amounts of medicines at the correct times. A checklist has been developed to assist the manager in assessing the competence of carers in dealing with medication. This is a comprehensive document which covers all the relevant areas. However, at the time of our visit the checklist had not been used. We recommend that the checklist is implemented as soon as possible. We also advised the acting manager to monitor the temperature of the medication storage room to ensure that medicines are being kept in the correct conditions. Throughout our visit we observed carers interacting with residents in a kind and respectful manner. People we spoke to and those who took part in our written survey told us that they felt their privacy and dignity was respected at Greenways. One relative of a resident who visits the home several times each week told us ‘’The staff treat the residents with the utmost respect and dignity at all times.’’ Greenways DS0000005926.V353961.R01.S.doc Version 5.2 Page 16 Greenways DS0000005926.V353961.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People have opportunities to take part in activities but these are not always planned in accordance with their individual needs or capabilities. Residents are provided with nutritious meals, however they would benefit from having a choice of main meal on a daily basis. EVIDENCE: There are a number of activities regularly provided at the home including arts and crafts and quiz games. In addition, visiting entertainers such as musicians perform at the home on a regular basis. However, during our case tracking exercise we found that little attention was paid to people’s individual preferences in relation to hobbies and activities when developing their care plans. It is important to explore this area when developing a resident’s care plan so that their individual preferences can be catered for and activities planned in a person centred way. Greenways DS0000005926.V353961.R01.S.doc Version 5.2 Page 18 In viewing records of activities and speaking to residents and staff, we found that there is rarely opportunity for people to enjoy activities outside of the home. Several people commented that they would like the chance to take part in outings in their local community. We made a recommendation that consideration be given as to how regular outings can be provided. People we talked to and those who took part in our written survey were very complimentary about the quality of food provided at the home. One resident wrote ‘The food is absolutely first class.’ The majority of people’s care plans we viewed included details of the foods they particularly like or don’t like. However, we tracked the care of one resident who had Diabetes and associated dietary needs, and found that this was not addressed in his care plan (although in discussion, carers did show awareness of his dietary needs and how to meet them). Menus and records of meals served show that residents are provided with a wholesome and nutritious diet. In addition, we were able to confirm that there are a variety of different options available for breakfast and evening meals on a daily basis. During our visit, one resident told us that she had asked for some chips and we noted that they were being prepared for her. However, we couldn’t find any evidence that people are given a choice for their main meal at lunchtime. There was only one meal being prepared on the day of our arrival and no staff or residents were aware of any alternatives available. Records we viewed showed that the same meal is nearly always served to every resident each day. We made a recommendation (which has also been raised in previous inspection reports) that residents be offered a choice for their main meal each day and that menus be displayed so as to ensure that all residents are aware of the options available. Greenways DS0000005926.V353961.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents who raise concerns are taken seriously and their complaints are thoroughly investigated. However, some residents may not know how to go about raising concerns formally, as the complaints procedure is only available in a written format. EVIDENCE: The complaints procedure has recently been improved to provide more accurate and up to date information for anyone wishing to raise a concern. However, the document is written in a very ‘matter of fact’ way that doesn’t encourage people to express their views. In addition, the complaints procedure is only provided in a written format. This means that a person with a visual impairment for example, would not be able to access it. The home now keeps a record of all complaints raised, action taken in response to the complaint and subsequent outcome. We viewed this record and found that there had been three concerns raised since the last inspection, and that these had all been dealt with by the acting manager and owner of the home appropriately.
Greenways DS0000005926.V353961.R01.S.doc Version 5.2 Page 20 Safeguarding procedures have been improved a great deal and now outline the correct processes that should be followed in the event that an allegation of abuse is made. However, these procedures could be further improved by adding contacts detail of relevant agencies such as local social services departments. There is a clear system for staff to report concerns about colleagues and managers (Whistleblowing). Staff members we talked with were aware of these procedures and were confident that they would be supported in the event that they ‘blew the whistle’ on bad practice. Greenways DS0000005926.V353961.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People at Greenways are provided with homely, comfortable accommodation which is generally well maintained, but there are some areas that need to be updated. EVIDENCE: We carried out a tour of the home and found that all areas were clean, warm and comfortable. The majority of areas within the home are well maintained and nicely furnished, but there are some areas that require an update, particularly the first floor bathroom area.
Greenways DS0000005926.V353961.R01.S.doc Version 5.2 Page 22 There was some work ongoing at the time of our visit and we were advised by the acting manger that a maintenance worker had recently been employed on a full time basis. We recommend that a rolling programme be put in place to ensure that all areas are maintained to a high standard. All residents of the home have their own bedroom. We viewed a selection of people’s bedrooms which were nicely furnished and contained personal items such as pictures and ornaments. However, we noted that the locks on some people’s bedroom doors were broken or missing. All residents should have lockable rooms and be provided with keys, unless they don’t want a key or are unable to use one safely. The home has dedicated laundry facilities and procedures to control the spread of infection. All carers are provided with training in infection control as part of their induction. Greenways DS0000005926.V353961.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Careful processes are followed to ensure that only suitable people are employed to work at the home. Staff are well supported and understand their roles, but more careful monitoring of staff members with performance issues would result in a safer service for people. EVIDENCE: All the staff members we spoke to had a good understanding of their roles and also demonstrated a good understanding of individual residents’ needs. Carers told us that they felt Greenways provided a good quality service and they talked of the common goal of ensuring residents were well cared for. One staff member who responded to our written survey wrote ‘The team gives 100 to each individual resident.’ Carers also told us that the acting manager and deputy manager were very supportive and always on hand to give guidance and support. We were able to confirm through our discussions and through viewing staff files that individual one to one meetings (supervision) take place for most staff on a regular basis. However, we viewed the file of one staff member and found
Greenways DS0000005926.V353961.R01.S.doc Version 5.2 Page 24 that this person had not received any formal supervision for over a year. This was despite the fact that there had been some concerns about her conduct in the past. We viewed personnel files for a number of people and found that all the necessary pre-employment checks had been carried out prior to their arrival at the home. Such checks included a Criminal Records Bureau disclosure and references from previous employers. In addition, all new staff members had been asked to provide a full employment history and where any gaps existed, they had been investigated. In our discussions, staff members told us that they felt the training programme at Greenways was very useful and in particular, new staff members were very complimentary about their induction training. The home has recently introduced an improved induction pack which is now in line with Skills For Care standards. Records we viewed demonstrated that carers are provided with training in a number of areas to help them carry out their roles, including moving and handling and health and safety. However, we would recommend that the core training for carers be reviewed and additional training added in areas such as dementia care and care planning. It is recommended in the National Minimum Standards that at least 50 of staff members in every care home should hold a National Vocational Qualification in care at level 2 or above. At the present time the home are falling short of this standard with 6 out of 19 staff members holding the qualification. However, the acting manager is addressing this shortfall and there are some staff in the process of completing their awards. Greenways DS0000005926.V353961.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of this home have worked hard to achieve improvements which have resulted in a safer environment and improved quality of life for residents. The appointment of a permanent registered manager will help ensure that further required improvements are addressed. EVIDENCE:
Greenways DS0000005926.V353961.R01.S.doc Version 5.2 Page 26 The home is currently without a registered manager. However, there is an acting manager in place who demonstrated throughout the inspection that she has the appropriate skills and experience to manage the service well. It is important for the consistency of the service that a manager is proposed for registration as soon as possible. The home has made a number of significant improvements since their last inspection and these have been reflected in comments from residents, their families, staff members and other professionals. However, despite several requests the owner failed to provide us with the self assessment document (AQAA) that we asked them to complete. There are some processes in place to assess the quality of the service provided including resident and relative satisfaction surveys which are carried out on a regular basis. However, we could not find any evidence that results from such surveys are routinely analysed or passed on to residents or other stakeholders. There were some results of satisfaction surveys in the home’s Service User Guide but these dated back to 2004. The home has a health and safety policy in place which is supported by a number of separate procedures including infection control and fire safety. However the acting manager was unable to confirm if a fire risk assessment had been carried out. We made a requirement in respect of this matter. Greenways DS0000005926.V353961.R01.S.doc Version 5.2 Page 27 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 1 x 1 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 2 Greenways DS0000005926.V353961.R01.S.doc Version 5.2 Page 28 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 OP9 Regulation 18(1)(a) Requirement All care staff that handle medicines should be assessed as competent and if necessary receive further training to help ensure residents receive their medicines correctly. (Timescale 24/10/07 not fully met) Residents’ individual preferences in relation to activities and pastimes must be recorded so that suitable, fulfilling and enjoyable activities can be provided. (Timescale 30/09/07 not fully met). An up to date Service User’s Guide must be provided to all prospective residents so that they can make an informed choice about whether they want to move to the home. An assessment must be carried out for any prospective resident prior to their admission (wherever possible) so that they can be assured that their needs
DS0000005926.V353961.R01.S.doc Timescale for action 29/02/08 2. OP12 16 (2) (n) 29/02/08 3. OP1 5 (1) 29/02/08 4. OP3 14 (1) (a) (b) (c) & (d) 16/01/08 Greenways Version 5.2 Page 29 5. OP7 15 (1) 6. OP16 22 (2) & (6) 7. OP36 18 (2) 8. OP31 8 (1) (a) 9. OP38 23 (4) (a) will be met at the home. Residents’ care plans must contain an accurate and up to date picture of all their daily care needs so that carers have guidance in the support they require. The home’s complaints procedure must be made available in formats that are appropriate for the needs of every resident so that all residents have equal access to the information. All staff must be appropriately supervised to help safeguard the wellbeing and safety of residents. A manager must be proposed for registration with the Commission to ensure the service is managed effectively. A fire risk assessment must be completed and made available to all residents, staff and visitors at all times. 31/01/08 29/02/08 16/01/08 31/03/08 31/01/08 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. 2. Refer to Standard OP3 OP7 Good Practice Recommendations The ‘My Life’ tool should be used for the purpose of gathering social history information. Systems for care planning and recording daily information about residents should be reviewed and made more user friendly. Positive behaviour support plans should be developed for people who require support in this area so that staff can support people confidently and consistently.
DS0000005926.V353961.R01.S.doc Version 5.2 Page 30 3. OP7 Greenways 4. 5. OP13 OP15 The activities programme should be reviewed to provide regular opportunities for people to take part in activities in their local community. A system should be introduced to ensure that all residents are provided with and aware of an alternative main meal choice each day. The complaints policy and procedure should be rewritten with a view to encouraging residents and/or their representatives to report any concerns they may have about the home. The temperature of the medication storage room should be monitored to ensure that medicines are being kept in the correct conditions. Safeguarding procedures should be updated to provide relevant contact details of appropriate agencies such as local social service departments. A rolling programme of maintenance should be implemented to ensure that all areas of the home are maintained to a good standard at all times. All residents should be provided with a lockable room and key unless they do not wish to have one or unable to use a key safely. A minimum of 50 of carers should hold National Vocational Qualifications in level 2 or above. The home should develop a training matrix to enable training needs to be monitored more easily. Results of quality assurance processes such as satisfaction surveys should be provided to residents and other stakeholders. Meetings for residents should be held on a regular basis. Self monitoring systems which include the home’s management reviewing performance in areas such as complaints management and staff training should be introduced. An annual development plan should be introduced. 6. OP16 7. 8. 9. OP9 OP18 OP19 10. OP19 11. 12. 13. OP28 OP30 OP33 14. 15. OP33 OP33 16. OP33 Greenways DS0000005926.V353961.R01.S.doc Version 5.2 Page 31 Greenways DS0000005926.V353961.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 DS0000005926.V353961.R01.S.doc Version 5.2 Page 33 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
