Inspection on 21/02/07 for Greycroft Residential Care Home

This inspection was carried out on 21st February 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 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

Greycroft Residential Care Home 07/11/07

Greycroft Residential Care Home 19/01/06

Greycroft Residential Care Home 12/07/05

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

CARE HOMES FOR OLDER PEOPLE Greycroft Residential Care Home 15 Queens Road Accrington Lancashire BB5 6AR Lead Inspector Mrs Julie Playfer Unannounced Inspection 09:15 21 February 2007 st 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 Greycroft Residential Care Home DS0000063677.V326157.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Greycroft Residential Care Home DS0000063677.V326157.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greycroft Residential Care Home Address 15 Queens Road Accrington Lancashire BB5 6AR 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) 01254 234766 Mrs Helen Elizabeth Crickmore Mr John Crickmore Mrs Ann Bernadette Williams Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places Greycroft Residential Care Home DS0000063677.V326157.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service should employ a suitably qualified and experienced person who is registered with the Commission for Social Care Inspection The care home is registered to provide personal care to a maximum of 14 service users who fall into the category of Older People (OP) 19th January 2006 Date of last inspection Brief Description of the Service: Greycroft Residential Care Home is registered to provide accommodation and personal care for 14 Older People. The home is detached and is situated on a main road opposite to Accrington Victoria Hospital. There is a garden/patio area at the front of the home, which can be used by the residents in fine weather. There is a small car park to the rear. Accrington Town Centre is nearby and the home is on a local bus route. The home has 2 lounges, a large conservatory which is used as the dining room, 12 single bedrooms and one double bedroom, which has an en-suite. A stair lift is fitted in two sections to the main staircase. According to information provided by the home the scale of charges was £315 to £355.00. Additional charges were made for personal newspapers and hairdressing. The registered person made information available to prospective residents by means of an information leaflet and statement of purpose. The information leaflet was usually given to relatives and/or prospective residents on viewing the home or at the point of assessment. Greycroft Residential Care Home DS0000063677.V326157.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Greycroft Residential Care Home on 21st February 2007. At the time of the inspection, there were 13 residents accommodated in the home. The inspection comprised of spending time with the residents, looking round the home, looking at the residents’ care records and other documents and discussion with the staff and the registered manager. As part of the inspection process the inspector used “case tracking”, as means of gathering information. This method enabled the inspector to focus on a small representative group of residents. Prior to the inspection, the registered provider completed a questionnaire, which provided useful evidence for the inspection. Comment cards were also sent to the home for the residents and their relatives. Four cards were received back from the relatives and four questionnaires were received from the residents. What the service does well: The admission procedures involved an assessment of peoples’ needs. This enabled the registered manager and prospective residents to determine whether or not the home could meet their needs. Each resident had a plan of care. This document provided details about the residents’ personal and social needs, which meant the staff had clear guidance on how best to meet the residents’ needs. Residents spoken to felt they received a good standard of care and the staff respected their rights to privacy and dignity. The residents described the staff as “very caring” and one person said, “I think it’s a very nice place to live - the staff are very good”. The residents thought the routines were flexible and they were able to make individual choices about how they wished to spend their day. One resident who completed a comment card said “you can’t get better”. The residents were provided with varied, nutritious and well-presented meals. All the residents spoken to said the meals were “very good”. The residents also confirmed there was always plenty to eat and the food was always of a good quality. Visitors were welcome in the home at any time and residents were supported to maintain good contact with their family and friends. All the relatives and visitors who completed a comment card expressed satisfaction with the overall care provided. One person commented, “my friend is very happy here and it is a very good service”. Greycroft Residential Care Home DS0000063677.V326157.R01.S.doc Version 5.2 Page 6 Good systems had been established to consult the residents, which enabled them to voice their opinions about life in the home. All the residents spoken to said they felt comfortable expressing their views and were confident that they would be listened to. What has improved since the last inspection? What they could do better: Suitable written information must be provided to the residents to ensure they are well informed about the current services and facilities available in the home. All residents should also be supplied with contract with the current owners, which provides clear information about the level of charges for any additional services. Whilst each resident had a plan of care the registered manager must ensure that the residents’ healthcare needs are more clearly identified in the plan. This is to ensure that staff are aware of the healthcare needs and they have up to date guidance on how best to meet the needs. The residents must also be more involved in the care planning process, so they can express their opinions on how their care is provided. Some records pertaining to medication, must be more detailed to ensure staff have accurate information and an audit trail can be traced of all medication handled in the home. Safe systems of assisting residents move round the home must be established, in order to protect the well-being and safety of the residents. Some repairs must be undertaken round the home to ensure the residents are provided with a safe and pleasant environment. The ambient temperature of the home must be carefully monitored and the heating adjusted accordingly to Greycroft Residential Care Home DS0000063677.V326157.R01.S.doc Version 5.2 Page 7 ensure the residents feel warm and comfortable at all times in all areas of the home. Suitable arrangements must be made to ensure residents are not at placed at a potential risk from uncovered radiators in the toilets. The registered person must review the level of staffing during the night, to ensure the residents’ needs continue to be met. When recruiting new staff all records and documentation must be collated in line with legal requirements, to ensure all staff are thoroughly checked before working with the residents. An annual development plan based on the findings and outcomes of the quality monitoring systems must be produced to demonstrate the service is responsive and run in the best interests of the residents. 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. Greycroft Residential Care Home DS0000063677.V326157.R01.S.doc Version 5.2 Page 8 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 Greycroft Residential Care Home DS0000063677.V326157.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the residents’ needs were suitably assessed, the residents were not provided with appropriate written information about the services and facilities available in the home. EVIDENCE: Written information was available for current and prospective residents in the form of a statement of purpose and information leaflet, which provided an overview of the services and facilities available at the home. However, the leaflet did not cover the elements listed under the Regulations or National Minimum Standards to constitute a service users guide. The statement of purpose seen was incomplete. The case tracking process demonstrated that each resident had been given a contract. However, one resident had not been issued with a contract with the Greycroft Residential Care Home DS0000063677.V326157.R01.S.doc Version 5.2 Page 10 current registered providers. The contracts included details about the level of fees, however, it was noted that whilst the contract stated additional charges would be made if a member of staff had to accompany a resident to hospital, there were no details about the charging and paying for this service. From inspection of the residents’ personal files, it was noted that the residents’ needs were assessed prior to admission to the home by a social worker and/or the registered persons. The assessments were kept under regular review in the home. Greycroft Residential Care Home DS0000063677.V326157.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The personal care received by the residents was based on their individual needs. However, the care planning process could be improved with more detailed information about the residents’ healthcare needs and ongoing consultation with the residents. EVIDENCE: From the case files seen, it was evident each resident had a plan of care, based on an assessment of needs. The plans were supported by records of personal care, which provided information on changing needs and any recurring difficulties. All records seen were detailed and the residents’ needs had been described in respectful terms. There was evidence to indicate the care plans had been reviewed on a monthly basis. However, none of the residents spoken to could recall discussing their care needs with a member of staff and there was no documentary to indicate the residents had been involved in the care planning process. Greycroft Residential Care Home DS0000063677.V326157.R01.S.doc Version 5.2 Page 12 General risk assessments had been incorporated into the care plan documentation, however, risk management strategies were not always identified to manage, reduce or eliminate an identified hazard. The residents’ healthcare needs were not fully detailed in the care plan. For instance, the details about one resident’s medical condition were not clearly identified, to enable the staff to monitor the resident’s condition consistently. There were no nutritional risk assessments seen, although, a separate weight chart had been maintained for each person. All residents were registered with a local Doctor and there was evidence to indicate the residents had access to NHS services. Advice from specialist services had been sought as necessary, for example the District Nursing Team. The residents spoken to felt the staff respected their right to privacy and all made complimentary remarks about the staff, for instance one resident said the staff were “all very nice” and added “I’m as happy as I can be”. The staff were observed to interact with the residents in a positive manner and they referred to the residents in their preferred term of address. The home operated a monitored dosage system for the administration of medication, which was dispensed into blister packs. Policies and procedures were available to cover all aspects of managing medication in the home. Appropriate records were in place to record the administration and disposal of medication. However, there was no record of medication received into the home. It was also noted that handwritten entries on the medication administration record (MAR) did not always include all the information from the prescription label and there were no specific protocols seen for the administration of medication prescribed “as necessary”. Systems were in place for the management of controlled drugs and all staff designated to administer medication had completed accredited training. Greycroft Residential Care Home DS0000063677.V326157.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were able to exercise choice and control over their lives and maintained good contact with their family and friends. The residents were provided with a nutritious varied diet according to their assessed requirement and choice. EVIDENCE: The residents’ preferences in respect of social activities had been recorded as part of the assessment. The residents were encouraged to pursue a range of activities, which included tabletop games, manicures, bingo and various social events for example the celebration of birthdays. A professional entertainer visited the home once a fortnight and two clothes parties were planned in the near future. Since the last inspection, the residents had enjoyed trips out to the Blackpool illuminations, lunches at the local pub and a party in a nearby town. Four residents were observed to be playing dominoes on the day of inspection. The residents spoken to were satisfied with the type and frequency of the activities provided. Information about forthcoming activities was displayed on an information board in the hallway. Greycroft Residential Care Home DS0000063677.V326157.R01.S.doc Version 5.2 Page 14 Since the last inspection SKY television had been installed, which was particularly enjoyed by the residents who had an interest in football. The residents were supported to continue with their chosen religion and representatives from the local churches visited the home on a regular basis for prayers and communion. In addition two residents attended a church in the local area each Sunday. The routines in the home were well established and residents had a choice in the times they went to bed and got up in the morning. One resident said “it doesn’t matter when I go to bed, it’s whenever it’s right for me”. The staff were observed to seek the views of residents throughout the inspection and residents said they felt comfortable to comment on life in the home. There were no restrictions placed on visitors and residents were able to entertain their guests in the privacy of their bedrooms. All the relatives and visitors who returned comment cards indicated they all were satisfied with the level of care provided. One person commented, “my mother has benefited from the care given at Greycroft and she is happy where she is”. Residents spoken to described the meals as “very good” and “all very nice”. They also said there was always plenty to eat and the food was a good quality. On the day of inspection, the meal looked appetising and was well presented. Special diets such as vegetarian and diabetic were catered for as necessary. Drinks and snacks were served at set times throughout the day and other times on request. Residents were observed asking for drinks during the inspection and were promptly served by the staff. The registered manager maintained an up to date record of all meals served to residents. Greycroft Residential Care Home DS0000063677.V326157.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems were in place to ensure any concerns of residents would be acted upon. However, in order to fully protect the best interests of the residents, improvements must be made to the vulnerable adults procedures. EVIDENCE: The complaints procedure was displayed in hallway and had been distributed to the residents and staff. The procedure contained the necessary information should a resident wish to raise a concern with the home or direct to the Commission. The home had not received any complaints since the last inspection. The residents were aware of the procedure and knew who to speak to if they had a concern. There was a copy of “No Secrets in Lancashire” (The Joint Strategy for the Protection of Vulnerable Adults) and an adult protection procedure specific to the home. However, the internal procedure seen was very brief and did not include the role of Social Services or include the contact details of the relevant agencies. The staff had access to a whistle blowing procedure and had received training on safeguarding vulnerable people. All staff spoken to had an awareness of the vulnerable adults procedure. Greycroft Residential Care Home DS0000063677.V326157.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Whilst the residents were provided with homely surroundings, some aspects of the environment were not safe and presented a potential risk to the residents. EVIDENCE: Greycroft is a detached property, set in it’s own grounds. Accommodation is provided in 12 single bedrooms and one double bedroom, which has an ensuite facility. Communal space is provided in 2 lounges and a conservatory, which is used as a ding area. Since the last inspection, two bay windows had been replaced, five bedrooms, the conservatory, the stairs and the hallway had been repainted, new curtains had been fitted in the conservatory and new blinds had been fitted to the lounge. However, it was noted that several areas of the home still required Greycroft Residential Care Home DS0000063677.V326157.R01.S.doc Version 5.2 Page 17 some attention. These included screw holes in the wall of one bedroom, a broken tile in the small toilet on the ground floor, missing handles on some bedside units, cracked plaster worker around the back door and wallpaper coming off the wall in one bedroom. It was also noted the veneer was damaged on one cupboard door in the kitchen and debris from the door was falling onto the work surface. Wooden beading had been fitted behind the kitchen sink, which made this area difficult to clean and there was a broken tile behind the cooker. Whilst improvements had been made to the environment, a programme of future maintenance and renewal of fabric and decoration of the building was not seen. The majority of the residents spoken to said that they liked their bedrooms and two people said they enjoyed helping to keep their room clean and tidy. However, three residents said their bedrooms were not always maintained at a suitable temperature. One person said, “I like my room, but it’s very draughty” another person said “I don’t feel right in my room, it always cold and chilly”. This person added “it’s not right having to wear a cardigan in bed”. Many of the radiators had been covered. However, it was noted that the radiators in the small toilets on the ground and first floor were not covered and since they were situated in very close proximity to the toilets, the hot surfaces of these radiators presented a risk to the residents. All bedroom doors were fitted with locks and keys had been distributed to the residents. However, an inappropriate lock was fitted to one bedroom door. This lock had a deadlock facility and if operated would not allow staff access into the room in an emergency. It was observed the wheelchair would not pass through a corridor door, when it was fitted with footrests. This meant the residents using this chair had no support for their feet and legs, when transported round the home. One resident who used the wheelchair said, “I don’t like that chair”. There was no hoist available to assist the mobility of residents, who had difficultly bearing their own weight and staff were observed using a handling belt and underarm support. A resident commented that she did not like wearing the belt. There were no occupational therapy assessments seen in relation to the type of equipment the residents required to meet their needs. One lounge was used as a sleeping area for staff during the night. This meant this room was not available for use during the night for residents, who liked to get up. The home had a good level of cleanliness in all areas seen and the home was free of offensive odours. There was a designated laundry room on the ground floor, however, this room did not include a sluicing facility and soiled laundry was being soaked in a bucket with a lid. Greycroft Residential Care Home DS0000063677.V326157.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents’ benefited from well-trained and competent staff. However, in order to fully protect the residents the recruitment process must be improved. EVIDENCE: The registered manager maintained a staff rota, which indicated which staff were on duty at any time on a particular day. All staff providing personal care were aged over 18 and all staff left in charge of the building were aged over 21. The number of staff on duty at the time of the inspection was sufficient for the number of residents living in the home. It was noted one waking person and one sleeping person carried out the night duties. However, it was apparent from viewing the residents’ case files that two people required assistance and support during the night from two carers and one person liked to get up at various times throughout the night. There was no review seen of the staffing arrangements in light of the residents’ dependency needs during the night. The files of three members of staff, who had commenced work in the home since the last inspection, were examined. All staff had completed an application form and appropriate police checks had been received prior to the staff Greycroft Residential Care Home DS0000063677.V326157.R01.S.doc Version 5.2 Page 19 commencing work in the home. However, it was noted that one applicant had not provided a full working history and a reference had not been sought from previous employment, which involved working with vulnerable adults. Documentation seen during the inspection demonstrated all new employees undertook an in house induction programme and competed a “Skills for Care” induction. The latter provided underpinning knowledge for NVQ level 2. At the time of inspection the equivalent of 84 of the care staff were trained to NVQ level 2 or above. Staff also attended both internal and external training courses and had at least three paid days training a year. The staff spoken to said, there were good training opportunities in the home and felt the knowledge they had obtained through training could be readily applied to their every day practice in the home. Greycroft Residential Care Home DS0000063677.V326157.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management approach promoted positive relationships between the staff and the residents and the overall atmosphere was open and friendly. Systems were in place to monitor the quality of the service and staff had a good awareness of relevant health and safety issues. EVIDENCE: The registered manager had responsibility for the day-to-day management of the home and had completed the NVQ level 4 in Care. At the time of the inspection the manager had also completed the Registered Manager’s Award and was waiting for verification. The manager had several years experience working in various residential and nursing settings. Greycroft Residential Care Home DS0000063677.V326157.R01.S.doc Version 5.2 Page 21 Relationships within the home were good and staff spoke about the residents with respect. The residents valued the help and support they received from the staff, who they described as “very nice” and “good”. There was a programme in place for staff supervision and the topics discussed during supervision were recorded on a suitable format. The staff also received an annual appraisal of their overall work performance and were given the opportunity to participate in regular staff meetings. The home achieved an Investor’s in People Award in June 2004. Satisfaction questionnaires had been distributed to the residents and their relatives in September 2006. The results had been collated into graph formats, which were available in the home for reference. The residents were consulted informally as part of daily practice in the home and formally at regular residents’ meetings. Systems were also in place to receive feedback from the staff team. However, an annual development plan based on the outcomes of the quality monitoring processes had not yet been produced. Appropriate records were maintained to assist residents with their financial affairs. There was no money deposited on the premises by or on behalf of a resident at the time of the inspection. Since the last inspection the registered manager had reviewed and updated the policies and procedures in line with current good practice and legal requirements. There was a set of health and safety procedures available, which included the safe storage of hazardous substances. Staff received health and safety training, which included moving and handling, food hygiene, first aid and fire safety. However, as mentioned under the Environment section, the home had limited equipment to assist with moving and handling the residents. The registered manager and the staff had also completed an infection control course. All the staff spoken to had an awareness of health and safety issues in the home and the importance of maintaining a safe working environment. Information contained in the pre inspection questionnaire indicated the gas and fire systems were serviced at regular intervals. The fire log demonstrated that staff had received instructions about the fire system and fire equipment was tested on a regular basis. The registered manager had carried out environmental risk assessments in relation to safe working practice topics. Greycroft Residential Care Home DS0000063677.V326157.R01.S.doc Version 5.2 Page 22 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 2 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 2 1 X 2 1 2 STAFFING Standard No Score 27 2 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 4 X 3 Greycroft Residential Care Home DS0000063677.V326157.R01.S.doc Version 5.2 Page 23 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 OP1 Regulation 5 (1) (2) (3) (4) Requirement The registered person must produce a service users guide, which covers all the elements listed under Standard 1 and Regulation 5. On completion a copy of the guide must be supplied to each resident. The contract must include the arrangements in place for charging and paying for any services additional to the fees. The residents must be involved in the care planning process and the plans must be agreed and wherever possible signed by the resident. The care plans must clearly identify the residents’ healthcare needs and detailed guidance must be provided for staff on how to monitor the resident’s medical conditions. The risk assessments must incorporate control measures to manage, reduce or eliminate the risk. Nutritional risk assessments must be undertaken as necessary. Timescale for action 15/04/07 2. OP2 5 (1) (bc) 01/04/07 3. OP7 15 (1) (2) 15/04/07 4. OP8 15 (1) 17 (1) Sch 3 (m) 15/04/07 Greycroft Residential Care Home DS0000063677.V326157.R01.S.doc Version 5.2 Page 24 5. OP9 13 (2) 6. OP18 13 (6) 7. OP19 23 (2) (d) (5) 8. 9. OP21 OP22 23 (2) (d) 13 (5) 23 (2) (a) (n) A record must be made of all medication received into the home. Handwritten entries on the MAR sheet must include all the relevant details from the prescription label and be signed and witnessed by two staff. The safeguarding adults procedure must be revised and updated to set out the response to be taken in the event of any allegation, suspicion or evidence of abuse. The role of Social Services as the lead agency must be clearly stated and contact details of the relevant agencies should be included. The registered persons must produce a programme of maintenance of the building and renewal of fabric and decoration along with timescales in order to address the issues relating to the environment as part of the inspection. The broken tile in the small toilet on the ground floor must be replaced. A safe system of moving and handling must be established for all residents who require assistance with their mobility. Therefore following an assessment by a suitably qualified person e.g. an occupational therapist, appropriate equipment must be obtained or purchased to meet the mobility needs of the residents. The wheelchair must be fitted with footrests and arrangements must be made to allow the free passage of the chair down all corridors. 21/02/07 01/04/07 30/04/07 15/04/07 30/04/07 Greycroft Residential Care Home DS0000063677.V326157.R01.S.doc Version 5.2 Page 25 10. OP24 23 (2) (b) (d) The inappropriate lock on one bedroom door must be removed. The broken drawer handles on bedside units must be appropriately repaired. The wallpaper coming off the wall in one bedroom must be repaired. All areas of the home must be maintained at a suitable temperature, in line with the needs and preferences of the residents. The ambient temperature must therefore be monitored by means of a thermometer in every room. Suitable arrangements must be made to ensure the hot surface of the radiators in the toilets do not pose a risk to the residents. The registered person must review the night time staffing level, with consideration being given to increasing the staffing to two wake and watch, given the dependency levels of the residents during the night. All records and documentation relating to the recruitment of new staff must be collated in line with regulatory requirements. An annual development plan must be produced for the home based on a systematic cycle of planning, action and review, which reflects the outcomes for the residents. 15/04/07 11. OP25 23 (2) (p) 01/04/07 13 (4) (c) 12 OP27 18 (1) (a) 01/04/07 13 OP29 14 OP33 19, Schedule 2 (as amended) 24 (1) (2) (4) (5) 21/02/07 01/05/07 Greycroft Residential Care Home DS0000063677.V326157.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3 4 Refer to Standard OP2 OP9 OP20 OP26 Good Practice Recommendations All residents should be issued with a contract with the current registered providers. Written protocols should be devised for the administration of all medication prescribed “as necessary”. The residents should have free access to the communal rooms including the lounges at all times. A sluice should be fitted in the laundry room. Greycroft Residential Care Home DS0000063677.V326157.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Greycroft Residential Care Home DS0000063677.V326157.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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