Inspection on 01/06/06 for Greenwood

This inspection was carried out on 1st June 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Greenwood 26/06/07

Greenwood 27/02/06

Greenwood 22/09/05

Greenwood 28/02/05

Greenwood 06/10/04

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

CARE HOME ADULTS 18-65 Greenwood 16 Dalmeny Road Bexhill on Sea East Sussex TN39 4HP Lead Inspector Nigel Thompson Unannounced Inspection 1st June 2006 09:30 Greenwood DS0000041681.V289729.R01.S.doc Version 5.1 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 Greenwood DS0000041681.V289729.R01.S.doc Version 5.1 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. Greenwood DS0000041681.V289729.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Greenwood Address 16 Dalmeny Road Bexhill on Sea East Sussex TN39 4HP 01424 210383 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) chris.davies@eastsussex.gov.uk www.eastsussex.gov.uk/socialcare East Sussex County Council Mr Christopher Davies Care Home 16 Category(ies) of Learning disability (16) registration, with number of places Greenwood DS0000041681.V289729.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That a maximum of sixteen (16) service users are accommodated. That only service users with a learning disability are accommodated. That service users will be aged between eighteen (18) years and sixtyfour (64) years on admission. 27th February 2006 Date of last inspection Brief Description of the Service: Greenwood is run by East Sussex County Council (ESCC). It is a purpose built property on two floors, set in its own grounds in Bexhill-on-Sea. It is situated near to the town centre with its shops and access to main rail routes. Accommodated are a maximum of sixteen adults with a learning disability for periods of respite care or short-term care for periods up to six months. Service user accommodation comprises of sixteen single bedrooms, and there is a range of communal areas for service users to access. The majority of bedrooms and communal areas are on the ground floor. There is also a one bedroom self contained flat on the first floor which is currently used to provide more specialised respite care and meet the individual needs of one service user. A garden is at the side of the home and a central courtyard is accessible. Information about the service, including the Statement of Purpose, Service User’s Guide and CSCI reports is made available to prospective service users or their relatives, on request, as part of the admission process. The current range of fees per night at Greenwood, as of 1 June 2006, is £7.20 (Aged 18-24), £8.91 (Aged 25-60) and £13.49 (Aged 60-65). Greenwood DS0000041681.V289729.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over six and a half hours in June 2006. It found that many of the National Minimum Standards that were assessed had been met or partially met and the overall quality of care provided was generally good. Service users spoken with during the inspection expressed satisfaction with the home, the staff and the service provided. The purpose of this inspection was to assess compliance with the requirements of the previous inspection and to generally monitor care practices at the home. Of the eight statutory requirements made following the last inspection, it was found that seven had been met. On the day of the inspection there were fourteen service users living at the home, however the nature of respite care is such that this figure fluctuates on an almost daily basis. The inspection process involved a tour of the premises, examination of the home’s documentation and records and discussion with the registered manager. Four service users and three members of staff were also spoken with. The focus of the inspection was on the quality of life for people who live at the home. In order that a balanced and thorough view of the home is obtained, this report should be read in conjunction with previous inspection reports. What the service does well: A committed management structure and dedicated support staff continue to work hard developing and maintaining the evidently stimulating, open and inclusive atmosphere within the home. Service users are encouraged and supported to make decisions about their lives. Where appropriate and practicable, they are involved and regularly consulted on many aspects of life in the home, including menu planning and activities. Effective quality monitoring systems, including satisfaction surveys for service users and their relatives and carers, demonstrate the home’s commitment to maintaining and improving standards. Greenwood DS0000041681.V289729.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The manager at Greenwood must be able to demonstrate that it is able to meet the needs of people moving in to the home and therefore it is important that an individual’s care and support needs are thoroughly assessed before being admitted. In the case of people who have previously been in the home for respite care, it is essential that their assessed needs be reviewed to ensure that any changes are identified. Individual care plans, developed from a comprehensive assessment, should be drawn up with the involvement of the service user or a representative and be regularly reviewed. Up to date policies and procedures relating to adult protection must be implemented and staff should receive specific and updated training on recognising and dealing with abuse. Some thought should be given to improving the current stark appearance of many service users’ rooms. Please contact the provider for advice of actions taken in response to this Greenwood DS0000041681.V289729.R01.S.doc Version 5.1 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Greenwood DS0000041681.V289729.R01.S.doc Version 5.1 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 Greenwood DS0000041681.V289729.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Prospective service users are provided with sufficient information to decide whether the home is able to meet their specific needs. However there is a potential risk for service users and staff as the individual care and support needs of prospective service users are not always comprehensively assessed before they move into the home. EVIDENCE: Information is available to prospective and existing service users in the form of the revised and recently updated Statement of Purpose and Service User Guide, which have clearly been produced to a high standard and are both comprehensive and informative. Since the last inspection, as required, a copy of the most recent inspection report is now displayed on the notice board. To ensure that the information is more readily accessible to service users, edited details of the report including: ‘What we are doing well’ and ‘What the inspector would like us to improve’ have been thoughtfully and imaginatively reproduced in large print, on the notice board, with the use of illustrations. Greenwood DS0000041681.V289729.R01.S.doc Version 5.1 Page 10 This represents good practise and demonstrates the open and inclusive atmosphere within the home. The manager confirmed that following a referral to the home, a member of a specialist Assessment Team will visit the prospective service user and carry out a comprehensive Social Care Assessment (SCA), including the reason for referral, any personal care needs, mobility issues, social and cultural needs and family involvement. Although such assessments were in place for new referrals to the home, it was noted that in the many cases, where service users had received respite care previously at Greenwood, there was no evidence of an updated assessment having been carried out. In one care plan that was examined, relating to a service user who had been admitted to the home in February this year, the most recent SCA was dated 08.06.2004. As discussed with the manager, without an up to date assessment of an individual’s needs, it is difficult to demonstrate the suitability of the service and the service user cannot be assured that the home is able to meet their needs and aspirations. There was, however, evidence that the ‘Risk assessment report’ and ‘Risk management guidelines’ had been updated on 08.03.2006. According to the manager, many referrals to the home are made to provide respite for carers and don’t necessarily indicate any significant change in the service user. However he did acknowledge the importance of obtaining more up to date information regarding an individual’s care and support needs. Service users spoken with, including one person admitted during the inspection, supported what the manager had said and confirmed that their needs were generally met within the home: ‘It’s okay, I like it here. ‘ ‘I come here to give my mum a break – I hope she’s alright’. Greenwood DS0000041681.V289729.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users’ care plans enable staff to meet their assessed needs in a structured and consistent manner but do not always reflect current or changing support needs. Satisfactory and effective systems for consultation enable service users to make choices and decisions about their day-to-day living. EVIDENCE: Service users’ care plans are in place and are clearly and directly linked to the individual’s assessed needs. Plans examined contained comprehensive details of their personal, psychological and emotional support needs and were found to be accurate and generally well maintained. The front page of each care plan consists of a comprehensive ‘Individual Profile’, containing details including: ‘Day care’, ‘Medical/physical information’, Likes/dislikes’ ‘Communication’, ‘Personal care needs’ and ‘Objectives’. Care plans were also found to contain details of action to be taken by staff to meet the individual’s assessed needs. A variable number of personal and Greenwood DS0000041681.V289729.R01.S.doc Version 5.1 Page 12 environmental risk assessments were found to be in place for each service user. There was some evidence of ‘Interim reviews’ being held, however, due to the nature of respite care, they were found to be irregular and inconsistent. There was also little evidence of service users or their relative or representative being routinely involved in the care planning or reviewing process. Staff spoken to during the inspection confirmed that, despite the limited verbal communication of some service users, effective and regular interaction and consultation takes place constantly throughout the home. Monthly service users’ meetings are held and there is a regular Service User Forum, involving service users and staff. The meetings have an open agenda and everyone is encouraged to contribute to the discussions. Meetings are well attended and minutes are taken. At the end of their stay at Greenwood, service users are asked to complete evaluation/feedback forms, which are also sent out to relatives and carers. The manager confirmed that information from these responses is collated and used to improve the overall quality of service provision. Service users are consulted regarding many aspects of their day-to-day living, including menu planning and leisure activities. This was confirmed by service users, spoken with during the inspection: ‘They ask me what I want to do and what I like to eat – and I get what I like. It’s okay’. Service users are actively encouraged, enabled and supported to participate in daily routines within the home and have the opportunity to partake in decision making, including selecting the colour scheme for the communal lounge and day room. Greenwood DS0000041681.V289729.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users maintain contact with family and friends as they wish and benefit from appropriate occupation and leisure activities and from good quality menus, that are balanced and nutritious, reflecting their individual likes and preferences. EVIDENCE: Service users’ social and recreational interests are identified and recorded as part of the pre-admission assessment process and are generally met both inside and outside the home. Leisure and educational facilities and activities provided within the home include DVDs, music and karaoke, computer and games consoles, arts and crafts and sports and gym equipment. Greenwood DS0000041681.V289729.R01.S.doc Version 5.1 Page 14 From discussions with service users, it is evident that many enjoy attending local day centres and they are also enabled and supported by the staff to participate in the local community. ‘I like walking around the town and shopping’. ‘I enjoy going to the day centre – it’s good fun’. The manager confirmed that although individual involvement in the community remains variable, service users have the opportunity to access facilities and activities outside the home, including bowling, cinema, theatre, pubs and clubs and local sporting events. Visiting in the home is unrestricted and service users may see friends or relatives in the lounge or in the privacy of their own room. The manager confirmed that service users are encouraged and supported, as they wish, to maintain links with their family and develop and maintain friendships outside the home, despite their relatively short time at Greenwood. As part of their induction programme, the manager confirmed that all staff receive instruction on the principles of dignity and respect. This was evident, during the inspection, from direct observation of staff interacting sensitively and professionally with service users. As previously documented, service users continue to be consulted regarding many aspects of their day-to-day living, including menu planning and their individual occupational and leisure activities Service users are provided with a varied, wholesome and nutritious diet. At lunchtime a choice of main meal is available and special diets are catered for. As part of a four week rolling menu, a daily menu is displayed in the dining area, reflecting service users’ preferences and including seasonal variations. Service users, spoken with during the inspection, expressed satisfaction with the standard of the meals provided: ‘The food here is good – I like it’. A member of staff confirmed that there are proposals to ensure that information regarding menus is made more accessible to service users. In future, wherever possible, the menu on display will incorporate illustrations or photographs of the ‘dish of the day’. Greenwood DS0000041681.V289729.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Staff demonstrate an awareness and sound understanding of service users’ individual care and support needs. Service users are protected by the home’s medication policies and procedures and their physical and emotional needs are met in a structured and consistent manner and in a way they choose. EVIDENCE: All service users are registered with either their own GP or with a local surgery, as a temporary patient, whilst receiving respite care. The manager confirmed that individuals also have access to other health care professionals, including dieticians, speech therapists, physiotherapists, chiropodists and dentists, as required, either via the surgery or a community service. In service users’ care plans that were examined, it was noted that individual levels of dependency and support are monitored and their personal and health care needs are recorded. Greenwood DS0000041681.V289729.R01.S.doc Version 5.1 Page 16 Staff spoken with during the inspection had clearly developed awareness of service users’ support needs and confirmed that communication between staff was generally effective, enabling care to be provided in a structured and consistent manner: ‘Handovers are usually pretty thorough. We discuss any changes, so everyone knows what’s going on’. ‘Yes there is consistency. We work as a team and even the relief staff know the routines’. Detailed policies and procedures on the handling, administration and recording of medication have recently been reviewed and implemented. Medicines are stored and recorded appropriately and Medication Administration Records (MAR sheets) were found to be accurate and well maintained. All staff responsible for administering medication have received appropriate and updated training and are individually assessed and authorised to do so. This was evidenced by staff, spoken with during the inspection and also supported by training records that were examined. Following a previous requirement and recent discussions with the CSCI Pharmacist Inspector, the manager is currently reviewing medication policies and procedures, relating to service users while they are away from the home. The manager confirmed that, following risk assessments, there are currently no service users who self-administer their own medication. Greenwood DS0000041681.V289729.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Service users, staff and visitors feel able to express any concerns, confident that they will be listened to and acted upon. However, service users are at potential risk from abuse, through inadequate staff training and lack of updated and relevant policies and procedures. EVIDENCE: A detailed compliments and complaints policy and procedure is in place and forms part of the recently updated Statement of Purpose. The manager confirmed that no complaints have been received since the previous inspection. The CSCI has not received any complaints in relation to Greenwood. Service users and members of staff spoken to confirmed that they would have no hesitation speaking to the manager or making a complaint if necessary and each person was confident that they would be listened to. Although documentation including ‘East Sussex and Brighton and Hove MultiAgency Policy and Procedures’, ‘Adult Protection Framework (2004)’ and ‘Standards of Conduct Handbook (1996) were in evidence in the office, no updated policies and procedures, relating to adult protection and abuse, were made available for inspection. Greenwood DS0000041681.V289729.R01.S.doc Version 5.1 Page 18 According to the manager, all policies and procedures are reviewed regularly and departmentally by the Policy Unit, based at County Hall. There was also insufficient evidence of staff having recently undertaken appropriate training in adult protection and abuse. Staff spoken with during the inspection were unable to confirm they had received any such training and a comprehensive training database, updated on the day of the inspection, indicated that only three members of staff had undertaken Adult Protection training during the last twelve months. Greenwood DS0000041681.V289729.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The service is accessible, safe and clean and remains clearly suitable for it’s stated purpose. Service users benefit from pleasant accommodation that is comfortable, generally well maintained and decorated to a satisfactory standard. EVIDENCE: The physical environment at Greenwood is well maintained and remains largely unchanged since the previous inspection. Levels of cleanliness and hygiene remain satisfactory throughout. The sixteen single bedrooms, all of which meet the minimum space requirements, were found to be clean and generally well maintained. Only one bedroom has en-suite facilities, but there are sufficient toilets and a selection of assisted bathing facilities to meet individual service users’ personal care needs. Greenwood DS0000041681.V289729.R01.S.doc Version 5.1 Page 20 All communal areas are safe and accessible, including the two communal lounges, a dining room, and a large activities area. The manager confirmed that by the nature of short-term respite care, service users do not generally remain at the home very long and are often not in their room long enough to personalise it. This was evident by the basic, stark and minimalist appearance of many service users’ rooms. Proposed improvements planned for the near future include replacement floor covering in the dining room and one of the bathrooms. The manager also confirmed that redecoration is planned for nine areas within the home, including service users’ rooms and communal areas. Greenwood DS0000041681.V289729.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users are protected and benefit from the home’s recruitment policy and procedures and from sufficient trained, competent and appropriately supervised staff on duty at all times to meet their assessed care and support needs. EVIDENCE: Staffing levels within the home remain adequate, despite a continuing reliance on agency or relief staff. The staff rota indicated that a vacancy exists in two of the three teams. One member of staff is also currently unavailable, having taken a career break. However, the manager was able to confirm that, to ensure consistency and continuity of care, the use of agency staff was kept to a minimum and a ‘Relief register’ has now been implemented. Therefore, wherever possible, relief staff at Greenwood will have had previous experience of working in the home and consequently will be aware of the needs of the service users and the day to day routines. Greenwood DS0000041681.V289729.R01.S.doc Version 5.1 Page 22 The manager also confirmed the need for flexibility regarding the number of staff on duty, based on the unpredictable nature of the service and the changing needs of service users. A rota is also in place for night staff indicating that two staff are on duty each night between 9.30pm and 07.30am. The rota also includes details of Day care staff as well as kitchen, domestic and maintenance staff. Through direct observation and discussion it is evident that staff work closely and professionally with service users, both individually and collectively, and are clearly able to demonstrate the appropriate attitude, skills and competencies necessary to meet their varied and often complex needs. A welcome development since the previous inspection has been the review of recruitment procedures. The managers are now directly involved in the interview and selection process involving staff who will be working in the home. Thorough recruitment procedures are in place, however the manager confirmed that no new members of staff have been appointed since the previous inspection. Documentary evidence was made available for inspection, including details of employees’ satisfactory Criminal Records Bureau (CRB) disclosures. A staff training database has recently been developed and implemented, which clearly identifies what specific training has been provided for which member of staff and when. As well as effectively highlighting individual training requirements, the database also records dates of formal staff supervision sessions. The manager confirmed that currently there are 41 of care staff with the National Vocational Qualification (NVQ) level 2 or above. Staff spoken with during the inspection confirmed the many training opportunities available and expressed satisfaction with the choice and overall standard of training provided: ‘There’s always training going on about something or another’. ‘The training here is very good – and there’s so much of it’. Greenwood DS0000041681.V289729.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users benefit from effective management, comprehensive quality monitoring systems and are protected by thorough health and safety checks and guidelines and generally efficient record keeping. EVIDENCE: The registered manager has been in his current post since 2000 and before that worked as a Resource Officer in learning disability services from 1994. He holds the ‘Institute of Management Certificate’, NVQ level 4 in Care and is shortly due to complete the ‘Registered Manager’s Award’ (RMA). The atmosphere within Greenwood remains relaxed, open and inclusive. The manager has a consultative approach to running the home, with staff and service users being directly involved in many decision making processes. Greenwood DS0000041681.V289729.R01.S.doc Version 5.1 Page 24 Staff and service users, spoken with during the inspection confirmed how approachable and supportive the manager and the deputy manager are. Effective quality monitoring systems are in place, including the Periodic Service Review (PSR), carried out in the home by a member of care staff and the monthly Service Monitoring, undertaken by a Resource Officer. Feedback is routinely sought through satisfaction surveys, from both service users, (‘Tell us what you think’) and their relatives or carers, (‘Did we get it right?’). Responses to recent surveys indicate a high level of satisfaction with the home and the services provided: ‘I liked going out feeding the horses, the pub trip and shopping’. ‘It’s all very nice’. ‘Thanks for all the care given. He always enjoys his time with you’. ‘Staff and cooks are trusted and loved’. The manger confirmed that the health, safety and welfare of service users and staff is of paramount importance within the home and staff training is provided in many aspects of safe working practices, including moving and handling; food hygiene; fire safety and first aid. This was supported by documentary evidence and confirmed through discussions with members of staff, during the inspection. Documentary evidence has been received of professional servicing having been carried out recently in respect of the home’s catering equipment, portable electrical appliances, fire alarm systems and emergency lighting. Up to date reports and certificates are also in place for electrical installations and gas safety equipment. COSHH assessments and guidelines are in place. Temperature regulators are fitted to all hot water outlets, accessible to service users. All accidents, incidents and injuries are recorded and reported, as required. Greenwood DS0000041681.V289729.R01.S.doc Version 5.1 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 3 2 2 3 2 4 X 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 3 25 3 26 2 27 x 28 3 29 3 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 X 3 X X 3 X Greenwood DS0000041681.V289729.R01.S.doc Version 5.1 Page 26 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 YA2 Regulation 14 (1) a) Requirement It is required that new service users are only admitted to the home on the basis of a full and up to date needs assessment, carried out by a person suitably qualified and competent to do so. It is required that the assessment of a service user’s needs be kept under review It is required that the registered person is able to demonstrate the home’s capacity to meet the assessed needs of individuals admitted to the home. It is required that a care plan, generated from a comprehensive assessment, be drawn up with the involvement of the service user or a representative and be kept under review. It is required that a clear policy is in place to follow around the administration of medication when the service user is absent from the home. (Previous timescales of 30.11.2005 & 30.04.2006 not met). It is required that service users be protected from potential DS0000041681.V289729.R01.S.doc Timescale for action 30/06/06 2. 3. YA2 YA3 14 (2) (a) & (b) 14 (1) (d) 30/06/06 31/07/06 4. YA6 15 (1) & (2) (b) 31/07/06 5. YA20 13 (2) 31/07/06 6. YA23 13 (6) 31/07/06 Greenwood Version 5.1 Page 27 abuse by appropriate staff training and relevant and up to date policies and procedures. 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 YA26 Good Practice Recommendations It is recommended some thought be given to improving the current stark appearance of many service users’ rooms. Greenwood DS0000041681.V289729.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Greenwood DS0000041681.V289729.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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