Inspection on 10/09/07 for Greenwood Lodge Care Home

This inspection was carried out on 10th September 2007.

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 found no outstanding requirements from the previous inspection report, but made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Greenwood Lodge Care Home 28/08/08

Greenwood Lodge Care Home 27/03/08

Greenwood Lodge Care Home 28/02/06

Greenwood Lodge Care Home 08/09/05

Greenwood Lodge Care Home 11/02/05

Greenwood Lodge Care Home 22/06/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Greenwood Lodge Care Home 49-55 Gotham Lane Bunny Nottingham NG11 6QJ Lead Inspector Steve Benson Key Unannounced Inspection 10th September 2007 09:30 Greenwood Lodge Care Home DS0000026441.V341886.R03.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Greenwood Lodge Care Home DS0000026441.V341886.R03.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Greenwood Lodge Care Home DS0000026441.V341886.R03.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greenwood Lodge Care Home Address 49-55 Gotham Lane Bunny Nottingham NG11 6QJ 0115 984 7575 0115 921 3672 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) MGB Care Services Limited Vacant Care Home 19 Category(ies) of Learning disability (19) registration, with number of places Greenwood Lodge Care Home DS0000026441.V341886.R03.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th September 2006 Brief Description of the Service: Greenwood Lodge is a home for people with learning disabilities, some of whom have additional physical disabilities. Most of the residents are under 65 but a few are over and have regular reviews. The accommodation is provided on two floors and all but one of the bedrooms is single. There is a two bedroom flat next door which accommodates two residents. The home is situated in the village of Bunny, which has limited public transport links. There are secured gardens at the home and car parking to the front and side of the building. A portacabin provides extra office space and a relaxation and craft room for residents. The acting manager said on 10/09/07 that the fees for the service range from £379.65 - £1267 per week depending on dependency needs. There are additional charges for toiletries, hairdressing, and newspapers in addition to this amount. Further information about the home is available from the acting manager and a copy of the last inspection report is available in the office. Greenwood Lodge Care Home DS0000026441.V341886.R03.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first visit to the home since 1st April 2007 by The Commission for Social Care Inspection. Prior to the visit an analysis of the home was undertaken from information gathered over the last year including that from the Annual Quality Assurance Assessment they completed. . The visit centred on looking at the key National Minimum Standards for younger adults. The site visit lasted for 5½ hours and the main method of inspection used was called case tracking which involved selecting 3 residents and tracking the care they receive through the checking of their records and observing them. Other residents were spoken with and additional records were seen. A discussion was held with the acting manager and the staff on duty and care practices were observed. It was not possible to have a discussion with any of the residents present. The premises were not inspected in detail but various areas of the home were visited as part of the inspection. Survey forms sent to the home by The Commission for Social Care Inspection had been completed by 2 residents and 2 staff. The registration certificate was checked and found to be incorrect, as it still showed the name of the previous manager, and a new one has been requested. What the service does well: The home has systems in place to assess the needs of any prospective new resident. There is a system in place to assess any risks faced by residents. Residents are supported to maintain contact with their families by phone and receiving visits. Routines in the home provide flexibility to suit residents’ preferences. Residents have access to healthcare services to promote their well being. Routine health and safety checks are being carried out to ensure the safety of the residents. Greenwood Lodge Care Home DS0000026441.V341886.R03.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Staff should follow care plans when working with residents and make sure that agreed behaviour management interventions are followed so that the residents’ behaviour is appropriately managed. More ways must be found to increase the opportunities residents have to make choices so they hold some control over their lives. Staff must interact with residents to promote residents respect, dignity and rights and feel that staff are interested in them. Residents must be consulted on what they want to do recreationally and appropriate provision made to ensure their needs, wishes and aspirations are met. A review must be held of how mealtimes are organised so that residents receive the help and support they need to eat their meals. Personal care must be provided in an appropriate manner which respects the residents’ privacy and dignity and staff must tell residents what assistance they are going to be provided with. Medication must be given according to residents’ preferences and Medicine Administration Records must be fully completed to protect residents. Residents must be supported to access the complaints procedure so they can comment on and influence the running of the home. Staff must receive training in safeguarding adults and ensure that they prevent residents from being abused. The home must be kept properly maintained and clean and measures must be followed to prevent the risk of the spread of infection. This will ensure that residents live in a safe and homely environment Greenwood Lodge Care Home DS0000026441.V341886.R03.S.doc Version 5.2 Page 7 There must be sufficient staff on duty at all times to meet the needs of the residents. The home must have a registered manager so that residents live in an appropriately managed home. The Annual Quality Assurance Assessment must be fully completed and be a true reflection of services provided in the home. 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. Greenwood Lodge Care Home DS0000026441.V341886.R03.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Greenwood Lodge Care Home DS0000026441.V341886.R03.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are adequate or appropriate systems in place to assess any prospective new resident if the occasion arises. EVIDENCE: Records showed that there has not been a new admission to the home for over three years. This was not reflected in the Annual Quality Assurance Assessment, which described practices of assessing, visiting and providing information to prospective residents, which have not taken place within the home. The acting manager said there is a pro forma to assess any prospective resident with and she would use that if a referral were received, however there have not been any referrals since she has been at the home. Staff said there had not been new admission since they had stated working at the home. Greenwood Lodge Care Home DS0000026441.V341886.R03.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans are not being followed and residents’ opportunities to make choices are limited by how these are offered. EVIDENCE: A sample of three care plans were looked at and these contained a lot of information which made it more difficult to extrapolate information on how to meet peoples assessed needs when require. The information seen in care plans gave clear guidance as to what needs to be done. When a resident is involved in preparing their care plan these are written in the first person. Staff described different uses of care plans, some saw them as a place to record information but others said they used them to refer to and were able to demonstrate this, showing where a resident’s support needs when showering had been updated. Greenwood Lodge Care Home DS0000026441.V341886.R03.S.doc Version 5.2 Page 11 At one point a resident was seen showing signs of anxiety and began shouting. Staff did not intervene and when asked what should happen the acting manager said the care plan states to take the resident for a walk, and asked a member of staff to do this. Staff said that residents have some opportunities to make choices but they felt that more could be done to provide them with greater choice. Staff said that some of the residents have difficulty expressing choices. A member of staff was seen giving residents a choice of sandwiches or soup for lunch verbally. During periods of observation there was no use made of pictures, symbols or other methods to assist residents with making choices. An information notice board in the dining area was not up to date. In completed survey forms one resident said they sometimes make decisions about what they do each day and another said they always did. There were risk assessments seen in care plans and the acting manager said that she is now making these more detailed. There were risk assessments seen for residents a taking a shower, making a drink, going swimming and fire safety. Greenwood Lodge Care Home DS0000026441.V341886.R03.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents do not have sufficient opportunities for them to take part in activities or to leave the home. There is not enough interaction between staff and residents and mealtime arrangements do not meet the needs of residents. EVIDENCE: Residents were seen sitting in and moving between the various living areas with a television on in one lounge and music playing in the conservatory. There was little interaction seen between some staff and residents during the morning, although there were some staff who were spending time with residents and talking with them. One resident was seen with a puzzle in front of him but was not doing anything with it. During a period of observation no one came to assist or encourage him with this. Some staff were seen preparing some residents to go out for a walk in the afternoon. Greenwood Lodge Care Home DS0000026441.V341886.R03.S.doc Version 5.2 Page 13 The manager said that there are 3 residents who go out to day centres; the remainder do not fit the criteria to be offered a place. As a result residents are dependent upon the activities organised within the home for their development and to fill their time. Staff said they are constrained by staffing levels, transport and finance as to how much activity they are able to provide for residents and said that they thought there should be more. Activity records showed that residents only leave the home two or three times a week. In completed survey forms two residents said they could do what they want during the day. Staff said that they try to offer residents things to do during the day. The manager said they hold a weekly disco in a local hall where friends from other homes can come. There is a monthly faith and light service at a local church and residents go out to the local shops and pub. Details of these were included in the Annual Quality Assurance Assessment. The acting manager said that they used to have a mini bus but due to a lack of drivers this was changed for a car with another home owned by the same providers. Staff said as a result it is more difficult to take residents in wheelchairs out. Staff said that some residents have contact with their families and residents can use the phone. There were not any visitors to the home during this visit. They acting manager said that each morning a carer is allocated to get each resident up. Personal care is provided before breakfast and the day is organised around mealtimes. Residents get ready for bed at about 8.00 pm. Residents were seen coming down for breakfast at different times. The main meal is had in the evening and dishes include corned beef hash, spaghetti bolognaise and chicken curry. There is a different type of fish on Fridays and a roast dinner on Sundays. A lighter meal is had at lunchtime with such things as sandwiches, hot dogs, cheeseburgers and soup. Lunchtime was observed and there was very little interaction between some of the staff who were serving meals and assisting resident to eat. One resident was known to try to take other residents food and was seen taking a sandwich from another resident’s plate, but staff did not see this. When the resident concerned was given her dinner she sat down and ate it. When this was fed back to the acting manager she agreed it would be better to make sure this resident is given her meal first. There was another resident seen having difficulty feeding herself and when she had almost finished a member of staff sat down to assist her. The acting Greenwood Lodge Care Home DS0000026441.V341886.R03.S.doc Version 5.2 Page 14 manager said that the resident should have been assisted to eat the whole meal. The member of staff then took the plate away which still had some food on, and the resident was then seen eating scraps that had fallen on her tray. The resident was then seen struggling to try to tear off a plastic apron she had on and no staff noticed this. . Another resident was seen struggling to open a packet of crisps and did not receive any assistance and ended up going to the kitchen to get them opened. It was also noted that there was an inconsistent use of plastic cups and plates and crockery ones. Staff said that these were used as some residents throw them, however these were being used for residents who did not. A member of staff was seen encouraging one resident to eat and spent time with her giving encouragement and praise. The member of staff got the resident to have a banana as well. Greenwood Lodge Care Home DS0000026441.V341886.R03.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Personal support is not provided appropriately. Residents are at risk from inconsistent medication administration and recording practices. EVIDENCE: There was a screen placed across one of the bathroom doors leaving the door open, and residents were receiving personal care in there. The acting manager explained that this has been like that for 4 days because there had been problems with the light. The acting manager said it had been reported to head office. Staff were seen assisting residents and this was frequently done with little interaction from staff to residents, for example a member of staff took a resident by the arm and walked him into the conservatory then left him without speaking to him. Greenwood Lodge Care Home DS0000026441.V341886.R03.S.doc Version 5.2 Page 16 The Annual Quality Assurance Assessment described personal care as being flexible and tailored to the needs of the individual. This was not evident through periods of observation carried out. The acting manager said that they follow care plans when providing personal care and they try to allocate carers of the same gender. Staff said that they follow good practices when providing personal care including closing doors and attending to people in private. The acting manager said the dentist; chiropodist and optician all visit the home. A consultant psychiatrist and speech and language therapists also provide services and resident will go out to see the doctor if they need to. The acting manager said that where possible well being checks are carried out. Staff said that they thought the arrangements for healthcare are good and residents get the care they need. The nurse on duty was seen giving out medication and was following safe practices when doing this, however a resident was seen to refuse to take his medication when he came into the dining room and the acting manager said that he prefers to take his medication after his breakfast. This was not noted in the care plans. The acting manager told the nurse this who then gave it to him when he had finished his breakfast and took it without any problem. There were a number of gaps seen on the Medicine Administration Records. Greenwood Lodge Care Home DS0000026441.V341886.R03.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The complaints procedure is not managed effectively and staff are not aware of their roles and responsibilities to protect residents, leaving them at risk of abuse. EVIDENCE: There is a complaints procedure, which is displayed in the home. This uses symbols to help residents understand it. There were no complaints recorded in the complaints log, however the acting manager said that a social worker had complained about an odour in the home and this had not been recorded. Staff said they knew the complaints procedure was displayed in the home and were aware that there had been a complaint about an odour. In completed survey forms two residents said they knew how to make a complaint. The acting manager said that there have been 5 incidents of alleged abuse reported through the adult protection procedures. One of these concerned a member of staff who was dismissed following an allegation of forced feeding and 4 assaults between residents. It is recorded in the Annual Quality Assurance Assessment that there have been 5 referrals made to the Protection of Vulnerable Adults register. The Greenwood Lodge Care Home DS0000026441.V341886.R03.S.doc Version 5.2 Page 18 acting manager said the member of staff who was dismissed was placed on the Protection of Vulnerable Adults register. Not all of the staff have received training on safeguarding adults and staff said they had a slight idea what they should do if they came across any form of abuse. There were some residents who were known to be subject to unpredictable behaviour or behaviour which challenges and one was seen shouting towards another resident and waving her fist in the lounge. The other resident stood up and put his fists up, but then sat down again. This was not witnessed by a member of staff, although the acting manager said there is meant to be a member of staff in the communal areas at all times. Greenwood Lodge Care Home DS0000026441.V341886.R03.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is in a poor state of repair and not kept suitably clean, making it an unsuitable environment for residents to live in. EVIDENCE: It was stated in the Annual Quality Assurance Assessment that the physical environment of the home is clean, safe, comfortable and homely, however this was not found to be the case. There was a maintenance file seen which had a long list of outstanding repairs in. These included 06/06/07 Fire door hard to close, 26/04/07 kitchen window wood rotten causing a health hazard – food hygiene, July 07 DE window can’t close water leaks when it rains, GD window leaking, GH window can’t close properly, 02/08/07 water temperatures getting too high at the flat, 16/08/07 Light broken in activity room and 04/09/07 grip coming up outside the laundry door making a trip hazard. A resident was seen going into the laundry. Greenwood Lodge Care Home DS0000026441.V341886.R03.S.doc Version 5.2 Page 20 The acting manager was asked to contact head office to express concern at the light not working in the bathroom, which she did and arrangements were made for an electrician to come to the home later in the day. There were broken drawers seen in some residents’ bedrooms. Staff said that things don’t seem to be repaired and that the home could be kept cleaner. Staff said that protective clothing is provided, but they were seen attending to residents without using any. The dining tables and chairs felt sticky and the cleaner was seen mopping the lounge carpet with a floor mop. Greenwood Lodge Care Home DS0000026441.V341886.R03.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are occasions where there are insufficient staff on duty to support residents placing them at risk. EVIDENCE: The acting manager has assessed their minimum staffing levels to be 1 nurse and 5 care staff during the day and 1 nurse and 2 care staff at night. In addition the home employs a cook, cleaner and activities coordinator. The cook was on leave and a member of care staff was covering the duties in the kitchen and no provision for covering care staff’s role was made leaving a member of staff short to support residents. Staff said there are occasions when the staffing levels are not maintained and said that there had only been 1 nurse and 3 care staff on yesterday afternoon. The acting manager was unaware of this but when she checked the rota found this to be the case. The acting manager said that it was unacceptable to run a shift with that staffing level. Greenwood Lodge Care Home DS0000026441.V341886.R03.S.doc Version 5.2 Page 22 In completed survey forms 1 member of staff said there are never enough staff on duty and another said there usually is, but that it is becoming increasingly harder now some residents need one to one support. The acting manager said there had been quite a turnover of staff recently and that some staff from other homes owned by the provider had come to help out. The acting manager said that staff files for recently appointed staff were at had office as they were still being made up but assured that the correct recruitment practices are followed. Staff files seen for longer standing staff showed the correct procedure had been followed. The manager said a training coordinator has been appointed at head office, which has improved the amount of training provided. Training in equality and diversity had been booked but had been cancelled so is being rearranged. Staff said that they have been provided with a lot of training. There is one member of staff who has completed National Vocational Qualification training level 2 and two are currently working towards this qualification. Greenwood Lodge Care Home DS0000026441.V341886.R03.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are not appropriate management systems in place for running the home and quality monitoring systems are not being implemented properly. EVIDENCE: The acting manager has worked at the home for 2 ½ years and has been the acting manager since February 2007 and is committing an offence under the Care Standards Act 2000 by managing a care home without being registered. This must be rectified with urgency to avoid enforcement action and is now subject to a warning letter. The acting manager has not yet submitted and application to be the registered manager. Greenwood Lodge Care Home DS0000026441.V341886.R03.S.doc Version 5.2 Page 24 Regular visits to the home are made in accordance with Regulation 26 and these visits include completing a questionnaire with residents. The senior operations manager completed the Annual Quality Assurance Review, however this was not a proper reflection of the home and important sections such as ‘what we could do better, how we have improved in the last 12 months and our plans for improvement over the next 12 months were not completed. Staff said they did not know about any quality assurance systems. A sample of health and safety checks were looked at and this were being properly completed. Staff said the fire alarm is tested weekly and the fridge and freezer temperatures are regularly checked. Greenwood Lodge Care Home DS0000026441.V341886.R03.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 1 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 1 13 1 14 X 15 3 16 3 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 3 2 X 1 X 1 X X 3 X Greenwood Lodge Care Home DS0000026441.V341886.R03.S.doc Version 5.2 Page 26 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 (2) Requirement Staff must follow care plans when working with residents and make sure that agreed behaviour management interventions are followed and individuals needs met. Residents must have opportunities to make choices about their daily lives. Staff must maintain good working relationships with residents to show respect and maintain their dignity. Residents must be consulted upon and provision made regarding recreational activities of their choice. A review must be held of how mealtimes are organised so that residents receive the help and support they need to eat their meals and maintain their dignity. Personal care must be provided in an appropriate manner which respects the residents’ privacy and dignity and staff must tell residents what assistance they are going to be provided with. Medication must be given according to residents’ DS0000026441.V341886.R03.S.doc Timescale for action 17/10/07 2. 3. YA7 YA7 12 (2) 12 (4)(5)(b) 16 (2) (m) and (n) 12 (4)(a) 01/11/07 17/10/07 4 YA7 01/11/07 5 YA17 01/11/07 6 YA18 12 (4)(a) 17/10/07 7 YA20 13 (2) 17/10/07 Greenwood Lodge Care Home Version 5.2 Page 27 8 YA22 22 (2) 9 YA23 12 (1)(a) 10 11 YA24 YA24 23(2)(b) 23 (2)(b) 12 YA32 18 (1)(a) 13 YA37 18 (1)(a) 14 YA39 24 preferences and Medicine Administration Records must be fully completed. Complaints and corresponding outcomes must be recorded to help residents’ views to be heard in the running of the home. Staff must receive training in safeguarding adults and ensure that they know how to safeguard residents from being abused. The home must be properly maintained and kept in good working order. The home must be kept clean. Measures must be followed to prevent the risk of the spread of infection. Arrangements must be made to ensure there all always sufficient staff to meet residents’ needs working at the home. The acting manager must submit an application to be registered to avoid enforcement action and ensure that residents benefit from competent and accountable management. The Annual Quality Assurance Assessment must be fully completed and be a true reflection of services provided in the home. 17/10/07 01/11/07 01/11/07 01/11/07 17/10/07 01/11/07 10/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Greenwood Lodge Care Home DS0000026441.V341886.R03.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Greenwood Lodge Care Home DS0000026441.V341886.R03.S.doc Version 5.2 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. 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