Inspection on 31/08/06 for Greys Residential Home Ltd

This inspection was carried out on 31st August 2006.

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

The inspector 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

Greys Residential Home Ltd 16/01/06

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

CARE HOMES FOR OLDER PEOPLE Greys Residential Home Ltd Hook Heath Road Woking Surrey GU22 0JQ Lead Inspector Helen Dickens Key Unannounced Inspection 29th August 2006 08:45 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 Greys Residential Home Ltd DS0000065590.V309950.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. Greys Residential Home Ltd DS0000065590.V309950.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greys Residential Home Ltd Address Hook Heath Road Woking Surrey GU22 0JQ 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) 01483 771523 01483 771523 Greys Residential Home Limited Mr Stephen Phillip Kennedy Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Greys Residential Home Ltd DS0000065590.V309950.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th January 2006 Brief Description of the Service: Greys care home is located in a quiet residential road in Woking. It is family owned and managed and is registered for 20 older people. Accommodation is on two floors and each resident has either en-suite or private facilities adjacent to their rooms. On the ground floor there is a large lounge with a period fireplace, and the main dining room. Upstairs there is also a small lounge/dining area. There is a lift for the convenience of residents. The gardens are very well kept and contain several outdoor seating areas around the home. The main garden has a covered fishpond and rockery, giving a central focus for residents to enjoy. There is car parking space in the drive and on the road. The weekly charges range from £450 to £575 per person. Greys Residential Home Ltd DS0000065590.V309950.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 8.5 hours and was the first full key inspection to be undertaken in the Commission for Social Care Inspection year April 2006 to June 2007. The inspection was carried out by Helen Dickens, Lead Inspector for the service. Stephen Kennedy, proprietor and Registered Manager, and Teresa Kelly, Assistant Manager, represented the establishment. A tour of the premises took place which included all the communal areas and some resident’s bedrooms. Five residents were interviewed during the morning and the remainder spoken to at lunchtime in the dining room. A number of files and records were examined as part of the inspection process including resident’s assessments and care plans, staff recruitment files, and health and safety records. A pre-inspection questionnaire completed by the home, and the proprietor’s recent ‘mock inspection’ file, were also used in writing this report. The inspector would like to thank the residents, staff and the proprietor for their time, assistance and hospitality. What the service does well: What has improved since the last inspection? Greys Residential Home Ltd DS0000065590.V309950.R01.S.doc Version 5.2 Page 6 All the requirements and recommendations made at the last inspection have been met including the home acquiring the latest version of the Surrey multiagency procedures for the protection of vulnerable adults; induction for new staff is now completed within the correct timescales; the electrical wiring safety test had been carried out and a certificate received; and hand washing facilities have reviewed and are now good. Resident’s pre-admission assessment arrangements have improved, and the care planning documentation has been completely renewed. All residents now have a more detailed and regularly reviewed care plan which they have participated in and signed themselves. The medication policy has been up-dated to cover ordering medicines by fax and new arrangements for the disposal of medicines. The storage of medicines has also been reviewed and changes made since the last inspection. Staff have attended a new course on care of the dying and deceased. The home’s policy on dying and death was then up-dated to reflect the latest best practice from the training. Resident’s discussions on activities resulted in the home acquiring a croquet set, which residents have been playing out on the lawn during the summer. All residents took part in a sponsored walk to raise money for the British Heart Foundation. There is an ongoing programme of maintenance and renewal and since the last inspection two residents bathrooms have been completely refurbished; carpets have been replaced in two resident’s bedrooms, and the dining room ceiling has been redecorated. A new washing machine has been purchased for the laundry room and weekly health and safety checks have been introduced. The registered manager has introduced a new quality monitoring system and this is detailed under Standard 33. What they could do better: A number of minor maintenance and safety issues were highlighted and need to be reviewed including the closer on one of the fire doors which wasn’t closing properly; the decorative knob on the bannister which was moving in its socket and could pose a risk to the unsuspecting; a chair placed in front of an exit to the garden which needs reviewing if this is a designated fire door; and a single bracket holding a heavy fire extinguisher was coming loose. The recruitment practices at this home need to be reviewed, and requirements will be made in this regard. The home should also seek advice on the storage and destruction of CRB certificates and the introduction of the Common Induction Standards which will be mandatory for all new care staff from September 2006. Greys Residential Home Ltd DS0000065590.V309950.R01.S.doc Version 5.2 Page 7 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. Greys Residential Home Ltd DS0000065590.V309950.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 Greys Residential Home Ltd DS0000065590.V309950.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 No resident moves into the home without having their needs properly assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A total of six resident’s files were examined. Assessments continue to improve with a new format introduced since the last inspection. Some of the older files showed residents had been assessed under the previous format and this was commented upon at last year’s inspection. The new format is more detailed than the previous version and complies with the items set out in the NMS. The home’s documentation shows that the residents are fully involved in the process and given the opportunity to highlight and discuss their health and personal care needs prior to admission. The home now always seeks input from outside professionals for those residents not admitted with a social services community care assessment. Greys Residential Home Ltd DS0000065590.V309950.R01.S.doc Version 5.2 Page 10 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): 7,8,9 and 10. Resident’s health and social care needs are set out in an individual plan of care and this means their needs are more likely to be met. Medication is well organised at this home and residents are treated with respect. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Resident’s care plans provide a good overview of resident’s needs and residents interviewed confirmed that their care needs were being met by the staff. One resident said the staff were always on hand if he needed help and described them as ‘very good’. Another, when asked if staff gave her the help she needed, said ‘Staff are excellent – they are so nice.’ A new care planning system – a kardex system – has been introduced since the last inspection and is now fully operational. Resident’s ‘short’ care plans are reviewed daily when the daily record is up-dated, and the full care plan reviewed monthly. All six examined were up to date and had been regularly reviewed since the system was introduced in June, and all had been signed by the resident involved. The new system allows for a brief daily report on each resident though the manager was asked to look at whether this was too brief in some instances as staff had written ‘good day’, or ‘slept well’ etc without variation on some Greys Residential Home Ltd DS0000065590.V309950.R01.S.doc Version 5.2 Page 11 resident’s notes. The arrangements for care planning have shown a significant improvement since the use of this new system. The new care planning system includes references to resident’s health needs (for example nutritional screening and any help needed with eating and drinking) and there are separate pockets to keep letters from professionals, and forthcoming hospital appointments etc. There is also a basic mental test which can be carried out and noted for those residents whose mental health may be deteriorating. The staff help residents to access local health facilities and they can either register with the home’s GP or choose another locally. The home has a weekly exercise class which improves resident’s physical health, and they are currently promoting the ‘Thirst for Life’ campaign, as dehydration, especially in the recent hot weather, can be a problem for some older people. The assistant manager is responsible for medication at this home and this includes the ordering, receipt, and managing the overall administration. They use the blister system which is provided by a local pharmacy. The local pharmacist inspected the home’s arrangements in January 06 and made some positive comments about the way medication was being managed. Four staff needed to up-date their medication training and this has since been done. The assistant manager monitors the administration of medication process including monitoring gaps. No unexplained gaps were found on the six medication records examined during the inspection. Currently no residents are selfmedicating and there are no controlled drugs in the home. Staff were observed to treat residents with respect and those residents interviewed confirmed this. Staff were seen to knock on bedroom doors before entering and to have regard to resident’s privacy. The home confirmed that visitors, including visiting health professionals, see residents in private. Greys Residential Home Ltd DS0000065590.V309950.R01.S.doc Version 5.2 Page 12 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 and 15 Social needs are recognised at this home and a variety of activities provided. Contact with family and friends is encouraged and residents given opportunities to exercise some choice and control over their daily lives. Residents are offered a nutritious diet in pleasant surroundings. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As noted at the last inspection a member of staff has been given responsibility to work on activities and recreational opportunities for residents. The home continues to record (now on the new care plan format) what residents enjoy doing and which residents take part in the various activities and how often. Activities were mentioned by residents during interviews; one saying the home put on quite a few activities – this particular resident enjoyed the occasional visiting singers and the regular exercise session, though they also liked watching their own TV. Residents confirmed that activities were discussed at resident’s meetings and the manager said residents put croquet forward as an additional recreation for the summer. A croquet set had therefore been obtained and residents had already had a go in the garden. All 19 residents took part in a sponsored walk in aid of the British heart Foundation (some travelled in their wheelchairs) and family and friends joined in. Both regular Greys Residential Home Ltd DS0000065590.V309950.R01.S.doc Version 5.2 Page 13 and one-off activities for each month are set out in the resident’s newsletter. The newsletter also contains a word puzzle for residents to solve with a prize for the winner. Family and friends are encouraged to visit the home and those residents interviewed who mentioned their family said the staff were always friendly and welcoming – one resident was having visitors on the day of the inspection and staff were heard taking their order for cups of tea. The ‘suggestions box’ is very visible in the front hall and this is available to all visitors to the home. Resident’s spoken to confirmed that residents meetings gave them the opportunity to comment on issues in the home and to make suggestions; changes to the menu or discussions about food were frequently on the agenda. The assistant manager has an ‘advocacy’ session with each resident on a monthly basis where they can raise any concerns and the home are affiliated to the local Age Concern group who may also provide advocacy for residents. There was also evidence in resident’s rooms that personal furniture, as well as other belongings, had been brought in. Previously residents commented to the inspector that the manager made himself available and issues raised were quickly dealt with. Residents at this home manage their own financial affairs, or are assisted by relatives to do so. Meals are served in pleasant surroundings in the main dining room and four residents eat upstairs in a small dining area in preference to going downstairs. Residents have their breakfasts served in their bedrooms. All residents interviewed and all those briefly spoken to in the dining room at lunchtime commented favourably on the main meal of the day. On the day of the inspection residents had lamb chops cooked in gravy with mint sauce, buttered new potatoes, sprouts and butter beans. The lamb was so tender it fell off the bone and everyone said they were enjoying their lunch. For pudding there was an ice-cream sundae with banana, caramel sauce and a chocolate flake. Notes of the resident’s meeting showed there had been some discussion about having cold puddings in the summer in preference to hot sponge puddings and custard. The suppers are not quite as popular as lunches and often one of the topics covered at resident’s meetings. The manager has said these are kept under review and ideas put forward by residents are taken into account when the menus are put together. The menu is posted in the dining room and contains the main meal plus daily alternatives such as fish in parsley sauce, fish in breadcrumbs or a vegetarian option. One of the residents spoken to was not aware there was a choice and this was pointed out. The home, as mentioned above, have been taking part in the ‘Thirst for life’ campaign where the dangers of dehydration for older people are recognised and extra drinks made available, particularly in the hot weather. Greys Residential Home Ltd DS0000065590.V309950.R01.S.doc Version 5.2 Page 14 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 and 18 Complaints are taken seriously at this home and residents protected from abuse. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All residents receive a copy of the complaints procedure with their introductory pack about the home. In addition, it is highlighted on the notice board and there is a suggestions box in the hallway by the front door. The complaints log was examined and no complaints had been received for the last year. Residents have other opportunities for raising concerns including in their oneto-one monthly sessions with the assistant manager, in resident’s meetings, or by putting something in the suggestions box. There have been no protection of vulnerable adults issues raised since the last inspection and the home has up-dated its policy on this subject to fit with the latest Surrey multi-agency procedures for the protection of vulnerable adults. This home does not get involved in resident’s financial affairs and therefore this minimises the possibility of financial abuse. Greys Residential Home Ltd DS0000065590.V309950.R01.S.doc Version 5.2 Page 15 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 and 26 Residents live in a safe and well-maintained environment and the home is clean, pleasant and hygienic. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The location and layout of the home is suitable for its stated purpose and is accessible and well maintained throughout. The home has had regard to the Standards when furnishing and maintaining the home, for example the owner has fitted very tasteful radiator covers to protect residents. He is also continually up grading resident’s individual bathrooms to provide ‘walk in’ shower and bathing facilities and the two latest bathrooms to be refurbished were seen by the inspector. In addition to the new bathing facility, each bathroom had been retiled to a high standard and residents were pleased with the new arrangements. This is part of an ongoing plan of refurbishment for the home. The home also monitors any maintenance work which needs to be done and a written record is kept. The grounds to this home are very pleasant with Greys Residential Home Ltd DS0000065590.V309950.R01.S.doc Version 5.2 Page 16 a rock garden and pond as the central feature. There are tables and chairs for resident’s use and a gardener is employed. There were some minor issues highlighted during the inspection which the manager added to his maintenance log for remedial action; some of these issues are a matter of safety and therefore requirements are made under Standard 38. The decorative knob at the top of the bannister moves in its socket and though this is a ‘feature’, it was felt by the inspector to pose a potential hazard to unsuspecting visitors or residents who tried to use it to steady themselves on the stairs. A resident’s chair blocks her exit to the garden and this needs reviewing with regard to whether this door is used as a fire exit. One fire door needed alteration to the closer as it did not close completely. There is a mobile ramp available to be used as necessary and this was currently placed at the exit from the corridor into the garden. However with no rails, this ramp would not be safe for residents to use on their own. The manager was asked to seek advice on this. Other access was discussed and the manager said that those who have their own door into the garden have a risk assessment with regard to the step and a handrail is fitted to assist them into the garden. The manager was asked to review leaving soap powder out in the laundry as the door is not locked – he suggested that as the door is about to be replaced, the new door would have a lock and it could be kept locked when not in use. The bracket of a fire extinguisher was coming loose and needed attention, and the carpet on the back stairs has become faded with the sun and is getting worn – the manager was asked to keep this under review. White powder had collected on the floor in one bathroom and needed cleaning; the assistant manager arranged for this to be done immediately. This home employs one part time cleaner and is about to take on a second worker to assist with these duties. The halls and communal rooms on the ground floor are clean and fresh smelling, and there were fresh flowers in the hallway, living room and dining room. Night staff hoover the main rooms and day staff clean the bathrooms of residents on a daily basis. The cleaner gives a thorough clean to each resident’s bedroom and bathroom once a week. Laundry facilities were clean and tidy and the floor is impermeable and easy to keep clean. The staff induction covers infection control and the disposal of waste, and staff will be doing an annual up-date on infection control to keep them up to date on this matter. The hand washing facilities in the downstairs toilet (for use by residents and visitors) are now very good. Greys Residential Home Ltd DS0000065590.V309950.R01.S.doc Version 5.2 Page 17 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): 27,28,29 and 30 Resident’s needs are met by the skill mix of staff and residents are in safe hands. Recruitment practices need to be reviewed to meet this Standard in full. Staff are trained and competent to do their jobs. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has four care staff each morning and three in the afternoon. Some residents are fairly independent though others will need help with personal care tasks hence there are more staff on duty in the morning. Residents spoken to confirmed that they were given the help they needed. The home uses the Residential Forum guidance recommended by the Department of Health to work out the staff to resident ratios. There are eleven care staff plus the assistant manager employed t this home (in addition to the registered manager), and six staff have passed NVQ 2 or above, meeting the target of 50 of care staff having NVQ2 or above by December 2005, as set down in the NMS. Three other staff are currently studying for NVQs. Recruitment arrangements were inspected and six staff files including application forms, written references and povafirst and CRB checks were sampled. New staff at this home are allowed to work under supervision as set down in the Care Homes Regulations (2001) as amended, with a satisfactory Greys Residential Home Ltd DS0000065590.V309950.R01.S.doc Version 5.2 Page 18 povafirst check, and whilst awaiting their CRB clearance, and one member of staff was currently working in this way. However, some shortfalls were found and the following were discussed with the manager; all staff must have a full employment history and some files examined had gaps; though some could be explained verbally by the assistant manager e.g. one gap was due to self employment, and another due to time off having children, this must be properly documented. One application form could not be found and may have been archived due to that staff member having worked there for many years. References from previous employers should be from the employer themselves, and not from former colleagues who may not be fully aware of issues such as disciplinary matters in a former employment. The CSCI bulletin ‘ Safe and Sound’ was given to the manager to assist him as he reviews recruitment arrangements. The manager was also asked to look on the CRB website to get up-to-date information on the correct arrangements for storage and destruction of CRB certificates. The induction arrangements at this home are good and the ‘staff achievement file’ contains copies of induction and foundation certificates for staff. Employees who have worked at the home for many years had a different, briefer induction and all but one of these signed checklists were available for inspection. The manager was asked to look on the Skills for Care website and obtain information on the common induction standards which will be compulsory for all new care staff from September 2006. The manager said that staff receive in excess of 4 days paid training per year which exceeds the Standard of 3 days set down in the NMS. Greys Residential Home Ltd DS0000065590.V309950.R01.S.doc Version 5.2 Page 19 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): 31,33,35,36 and 38 Greys is well managed and quality assurance processes are good. Resident’s financial interests are safeguarded. Staff are regularly supervised. Health and safety arrangements are good and resident’s safety promoted. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Provider is also the Registered Manager. He has been managing this home for more than five years, and was in a senior deputising position for two years prior to that. He completed the Registered Managers Award in 2004, and has an NVQ4 in care. Since the last inspection a senior member of staff has been appointed assistant as manager and has now also completed her Registered Managers Award. There are clear lines of accountability within the home with the main responsibilities being divided between the manager and assistant manager. For example the assistant Greys Residential Home Ltd DS0000065590.V309950.R01.S.doc Version 5.2 Page 20 manager is responsible for assessments, care planning, and the administration of medication. The manager is responsible for premises including maintenance and refurbishments, recruitment, and health and safety matters. There are good internal systems in place in this home to measure the quality the service. The manager was commended for one innovation introduced since the last inspection - the ‘Inspectors Folder’. This ring binder file has been put together by the manager setting out how he believes Greys meets each of the NMS. He has carried out a ‘mock inspection’ to consider in detail each of the Standards, and has included evidence such as the results of questionnaires, the pharmacy inspection report, and a copy of the Residential Forum Matrix. The home also periodically distributes questionnaires asking about food, staff, laundry, cleanliness of the home, activities and maintenance. This was last done in June 2006; the responses are collated and printed in the resident’s newsletter. The annual development plan is being finalised using the feedback obtained, and there is also a business plan for the home. Residents meetings are held bi-monthly and staff meet 3-4 times per year. Residents control their own finances at this home, though some do this with the assistance of relatives or friends; the home do not allow staff to get involved in resident’s finances. Staff do not act as Agents or Appointees for welfare benefit purposes, nor do they get involved in distributing resident’s personal allowances. Of the six staff files samples all staff had either received six formal and documented supervision sessions in the last twelve months, or had already had sufficient sessions this year to enable them to reach the this level by the end of 2006. This meets the recommendation set down in Standard 36 and represents a significant improvement. The home have now introduced weekly health and safety checks – the assistant manager goes to all the bedrooms and then the rest the house (including the kitchen), checking fire alarms, emergency lighting, general cleanliness and any hazards. Any risks identified are dealt with and maintenance issues noted in the maintenance log. The home has an annual flush-through of the water system by the plumber as part of their legionella prevention policy – the certificate was not on file but was delivered to the CSCI office the next day. The manager is drawing up a written policy on the steps they at Greys take to minimise the risk of legionella within the home. Other health and safety documents examined included the electrical installation certificate (21/07/06) and the landlords gas safety check (10/06/06). The Environmental Health Officer’s report was examined and noted at the inspection in January 06. Water temperatures were checked in several resident’s rooms and found to be around 43C as set down in this Standard. When the inspection began the hazardous substances cupboard was unlocked but was in use, and no residents were in the vicinity. Staff were reminded that Greys Residential Home Ltd DS0000065590.V309950.R01.S.doc Version 5.2 Page 21 cleaning materials, which are not locked away (e.g. because they are in use), must always be kept within the sight of the person who is using them. The knob on the top of the banister, and the resident’s chair blocking a door into the garden need to be reviewed and risk assessments carried out as necessary. Greys Residential Home Ltd DS0000065590.V309950.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 3 X 2 Greys Residential Home Ltd DS0000065590.V309950.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 OP29 Regulation 19 Requirement The registered person must ensure that recruitment files contain all the information set down in Schedule 2 of the Care Homes Regulations (2001) (as amended), as discussed during the inspection and as set out in this report. The registered person must have a written policy on the prevention of legionella, setting out the steps the home are taking to safeguard residents. . The registered person must review/remedy/risk assess the following minor safety issues; • The decorative knob at the top of the bannister which moves in its socket • The chair in front of one resident’s exit to the garden • One fire door closer which needed adjustment • The mobile ramp with regard to safety rails • The bracket on one fire extinguisher which was loose and may fall. DS0000065590.V309950.R01.S.doc Timescale for action 29/09/06 2. OP38 13(4)(c ) 29/09/06 3. OP38 13(4)(a) (b)(c ) 05/09/06 Greys Residential Home Ltd Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP19 Good Practice Recommendations The home should keep under review the carpet on the back stairs, which is now discoloured, and beginning to show wear. The registered person should seek advice from the CRB website regarding the correct storage and destruction of CRB certificates. The registered person should obtain information on the common induction standards, which will be mandatory for all new care staff from September 2006. 2. OP29 3. OP30 Greys Residential Home Ltd DS0000065590.V309950.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Greys Residential Home Ltd DS0000065590.V309950.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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