Inspection on 16/11/05 for Greenwood House

This inspection was carried out on 16th November 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Greenwood House 29/07/09

Greenwood House 10/08/07

Greenwood House 18/09/06

Greenwood House 17/08/05

Greenwood House 16/02/05

Greenwood House 04/06/04

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

CARE HOMES FOR OLDER PEOPLE Greenwood House South Parade Peterborough PE3 6BG Lead Inspector Nicky Hone Unannounced Inspection 16th November 2005 13:55 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 Greenwood House DS0000035290.V264627.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Greenwood House DS0000035290.V264627.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Greenwood House Address South Parade Peterborough PE3 6BG 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) 01733 569362 01733 569434 Peterborough City Council Susan Elizabeth Clayton Care Home 40 Category(ies) of Dementia (3), Dementia - over 65 years of age registration, with number (8), Old age, not falling within any other of places category (32), Physical disability (3) Greenwood House DS0000035290.V264627.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Up to three service users aged between 60 and 64 years may be accommodated at any one time These three services users will fall within categories PD and DE only Date of last inspection 17th August 2005 Brief Description of the Service: Within a few minutes walk of Peterborough city centre, Greenwood House is set in its own grounds at the end of a residential cul-de-sac. Service user accommodation is on two floors, and consists of 4 units. One unit is for 8 people with dementia care needs; the other units offer a number of respite places, and accept people who are admitted from hospital on an ‘interim care’ basis, as well as offering permanent care to frail elderly people. Each unit has its own lounge, dining-room, bathroom, toilet and kitchen facilities, and there is a laundry, main kitchen and staff facilities. The gardens are well kept and attractive, and one upstairs lounge opens onto a large balcony with garden furniture and an array of tubs and hanging baskets. The home is owned by Peterborough City Council: the management of the home transferred to Greater Peterborough Primary Care Partnership on 01 April 2004. There is a day centre which operates from a separate lounge in the building: the manager of the home is no longer responsible for the management of the day centre. Greenwood House DS0000035290.V264627.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection of this service for the 2005/6 inspection year and was unannounced. An unannounced inspection took place on 17/08/05. Not all standards have been inspected this time; the reader should read both reports to get a more complete picture of the service offered at Greenwood House. During this inspection, the inspector spoke to several residents, staff and the manager. The manager had completed a pre-inspection questionnaire, and 12 questionnaires sent out by the home on behalf of the CSCI were returned (six from residents, six from relatives). What the service does well: What has improved since the last inspection? The requirements made following the last inspection have been met, therefore residents now receive a statement of terms and conditions of residence and their personal money is kept more safely, as well as the home having a programme for decoration. Greenwood House DS0000035290.V264627.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Greenwood House DS0000035290.V264627.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Greenwood House DS0000035290.V264627.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 5 The new statement of terms and conditions gives residents a clear picture of their rights and expectations in the home. EVIDENCE: A statement of terms and conditions of residence has been produced and sent to each service user and/or their relatives to be signed. Not all have been signed and returned, but several examples were seen on files. The home has decided that for respite clients who visit the home frequently, the statement will be given to them to sign annually, not at every visit. The relatives of one service user were visiting at the time of the inspection. They explained they had turned up unannounced to look at the home before agreeing that their relative could move in, and they were shown round and made very welcome. They were able to choose which of two rooms their relative would prefer. Greenwood House DS0000035290.V264627.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 The systems for the administration of medication are not good enough to make sure residents are not put at risk. EVIDENCE: Care plans are completed in great detail and contain a lot of information about the individual. The manager is considering completing a brief profile on each resident which can be kept discreetly in their bedroom to remind staff of their basic preferences for personal care: for example, one resident said she gets exhausted when she has to keep on explaining her preferred bed-time routine to different staff. Records of the administration of medication were not completed correctly: records checked in one unit had signatures missing, so it was not clear whether or not the medication had been administered; and codes used in place of signatures were not clearly defined. Medications (eye drops and a tube of cream) found in two fridges in the unit kitchens were not in locked containers and were being stored amongst food items. The tube of cream was not named. An immediate requirement notice was left at the home regarding these issues. Greenwood House DS0000035290.V264627.R01.S.doc Version 5.0 Page 10 There was evidence on one of the files checked that the service user had decided she wishes to keep her own medication: she had signed her care plan to confirm this. Greenwood House DS0000035290.V264627.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Some activities and entertainments are organised for the residents to make their lives more interesting, but there is still room for improvement in this area. Residents enjoy meals cooked by the home’s chef. EVIDENCE: All the residents, and the relatives, spoken to confirmed that visitors are made welcome at the home. One resident said the staff do not have much time to take her out, which she would like to do more often. One staff member tries to take people out on her days off and said she that although she loves the job, she would like more time to do things with the residents during the course of the day. Entertainment is organised from time to time: on the evening before the inspection a singer had put on a performance for everyone who wanted to attend. Staff are trying to make more time for activities: in the respite unit there have been several art and craft sessions, and residents have helped staff to make, for example, decorations for the Holloween and Bonfire parties, and Christmas cards. Residents, and staff, confirmed that there is not much time for organised activity. The record of activities is not completed as well as it should be, so the amount of activity carried out is not accurately evidenced. The manager said that two staff have now completed the “full of beans” course Greenwood House DS0000035290.V264627.R01.S.doc Version 5.0 Page 12 which trains staff in ways to keep older people occupied. Residents were offered the opportunity to go on holiday as part of a group from another home going to Blackpool for a few days, but none were interested. Residents spoken to confirmed that they are encouraged to make choices in all areas of their lives. For example, residents can have meals in their bedroom if they prefer; they choose what time they get up and go to bed; and choose where and how to spend their day. Residents complemented the chef on the choice and quality of the meals provided, but commented that different cooks employed when the chef is not on duty provide meals which are sometimes not so good. Cooked breakfast is available if requested, and residents are encouraged to help themselves to hot and cold drinks from the unit kitchens. The manager must make sure that the quality of the food remains high at all times. Greenwood House DS0000035290.V264627.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Residents and relatives are aware of how to comment on, or complain about, the service so that their views are heard. Staff training in the protection of vulnerable adults, and the home’s procedures, ensure that protection from abuse is given high priority. EVIDENCE: Two of the residents, and the relatives spoken to were clear about who they would complain to if anything was not right, but they had not needed to: “little niggles” were always sorted out quickly. The relatives had been given a copy of the complaints procedure. The manager reported that 26 of the staff have received training on the protection of vulnerable adults, and that ‘awareness of abuse’ is a topic which has been added to the induction programme for all new staff. Peterborough’s policy and procedures for the protection of vulnerable adults is on display in the staff room and is one of the policies the manager insists the staff must sign to say they have read. Greenwood House DS0000035290.V264627.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23, 26 Residents benefit from living in a comfortable, reasonably well decorated home which is kept clean and smells fresh. EVIDENCE: Two residents said they liked their bedrooms and had been able to bring some of their own things. One person was very grateful that a “very nice” electric bed had been provided. One bedroom was being decorated at the time of the inspection: the room had been painted in the colours chosen by the resident and a new carpet had been fitted. Several areas of the home had been decorated in the last year, and some carpets replaced. A plan of re-decoration has been produced. There are still some areas, such as the dining room in Mallards, which need to be decorated. One resident said he was quite content and is quite satisfied: he said “we’re kept clean and well fed”. A tour of the communal areas of the home was carried out: the home was very clean and tidy. In a response to the CSCI questionnaire one person commented that the home “could smell better”: this Greenwood House DS0000035290.V264627.R01.S.doc Version 5.0 Page 15 was not evidenced during the inspection as there were no unpleasant smells anywhere. The home smelt clean and fresh. Greenwood House DS0000035290.V264627.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29, 30 Excellent staff training records show that a wide range of training is offered to all staff, to make sure they know how to offer a good quality service to the residents. Good recruitment practices ensure residents are protected. EVIDENCE: The managers said that recruitment has been successful recently and almost all the vacant posts have now been filled, which means that fewer hours are being covered by agency staff. One service user said she likes the staff, but sometimes finds it difficult to communicate with staff for whom English is not their first language. One relative who completed and returned a CSCI questionnaire said “I believe there is a need for more permanent care assistants thereby reducing dependence on ‘temps’”: the manager feels this issue will be addressed when the newly appointed staff are inducted and on the rota. The manager said that training of staff is going very well, and she keeps detailed records. Staff confirmed that they are offered a wide range and number of courses, some of which are voluntary, some compulsory: one person said “Sue [manager] is excellent at making sure we get on courses”. The personnel files of two staff were inspected: all documentation required by the regulations was available, for example, evidence that a Criminal Record Greenwood House DS0000035290.V264627.R01.S.doc Version 5.0 Page 17 Bureau check had been undertaken, two references, a photograph, proof of identity and so on. The manager reported that two of the assistant managers are undertaking NVQ level 3 in care; nine staff have been awarded NVQ level 2, and eight more are undertaking level 2. The manager is to be congratulated on the training records that are kept: they are clear and detailed and show at a glance which staff have completed training and when. Greenwood House DS0000035290.V264627.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 Service users are consulted regularly about all aspects of the service offered, and there is evidence that their views are acted on. The system of safekeeping residents’ personal money has been improved to make sure residents’ financial affairs are protected. EVIDENCE: The home asks residents to complete quality assurance questionnaires on a different topic each month, and a longer questionnaire is sent out annually from the Greater Peterborough Primary Care Partnership. The results of the questionnaires are collated into a report which is displayed in the home, and the manager said that any comments are acted on wherever possible. The home has recently put into operation a revised system for safeguarding residents’ finances, following a requirement made at the last inspection. This was checked and is a more satisfactory way of ensuring residents’ personal allowance is kept safe. Greenwood House DS0000035290.V264627.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 X X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X 3 X X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X X Greenwood House DS0000035290.V264627.R01.S.doc Version 5.0 Page 20 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 OP9 Regulation 13(2) Requirement Records of the administration of medication must be completed correctly. An immediate requirement notice was issued at the time of the inspection regarding this Medications which require refrigeration must be stored appropriately. An immediate requirement notice was issued at the time of the inspection regarding this Medications must be labelled with the person’s name for whom they were prescribed and be used only for that person. An immediate requirement notice was issued at the time of the inspection regarding this Timescale for action 16/11/05 2 OP9 13(2) 16/11/05 3 OP9 13(2) 16/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Greenwood House DS0000035290.V264627.R01.S.doc Version 5.0 Page 21 No. Refer to Standard Good Practice Recommendations Greenwood House DS0000035290.V264627.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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