Inspection on 18/05/06 for The Green

This inspection was carried out on 18th May 2006.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Green 29/09/05

The Green 14/04/05

The Green 27/09/04

The Green 15/04/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Green Drump Road Redruth Cornwall TR15 1LU Lead Inspector Richard Coates Key Unannounced Inspection 18th May 2006 09:00 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 The Green DS0000009107.V293966.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. The Green DS0000009107.V293966.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Green Address Drump Road Redruth Cornwall TR15 1LU 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) 01209 215250 01209 313375 Cornwall Care Limited Care Home 45 Category(ies) of Dementia - over 65 years of age (45), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (45) The Green DS0000009107.V293966.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. Service users to include up to 45 adults aged over 65 with dementia (DE[E]) Service users to include up to 45 adults aged over 65 with a mental illness (MD[E]) To accommodate one named service user outside the registered categories of the home. To accommodate one named service user outside the registered categories of the home. To accommodate one named service user outside the registered categories of the home To accommodate one named service user outside the registered categories of the home Total number of service users not to exceed a maximum of 45 Date of last inspection 29th September 2005 Brief Description of the Service: The Green is one of eighteen care homes owned by the Registered Provider, Cornwall Care Ltd. It is registered to accommodate forty-five older people with dementia or mental disorder. The Green is situated in a residential area of Redruth close to local amenities and a short distance from the town. The home also provides respite care and day care. The Green is a purpose-built home on two floors in its own grounds. There are seven individually named wings, which comprise residents’ bedrooms, toilet and bathing facilities, a lounge/dining room, and a kitchen area. There are three double bedrooms; the remaining rooms are for single occupancy. The main entrance to the home provides level entry and lifts provide access to both floors. There is a large lounge on the ground floor which is used for day care but is also available to residents and their visitors. A safe courtyard area is accessible to residents. Cornwall Care Ltd provides information about their services and the home in the statement of purpose and service users guide. The range of fees is currently from £290 to £450 weekly at May 2006. The Green DS0000009107.V293966.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a planned key inspection carried out at short notice so as to enable the manager to be present. The purpose of the inspection was to follow up the provider’s compliance with the requirements and recommendations set in the last inspection report dated 25 January 2006, and to focus on the key national minimum standards as identified by the commission. Two inspectors were on the premises over two days. The methods used were discussion with the manager, staff, residents, their relatives and visitors, inspection of records and documents, a postal survey of residents, observation of the daily life of the home and inspection of the premises. The inspectors are grateful to the providers, staff and residents for their assistance in completing the inspection. What the service does well: What has improved since the last inspection? A new registered manager and deputy manager have been appointed. The manager and deputy have begun to provide consistent and informed management and to address the requirements and recommendations set at the last inspection. They have started to review and revise the care plans and risk assessments so that staff have clear directions and information on meeting the care needs of all residents. They have also begun to develop and improve the general organisation and management of the home. Staffing levels for both care and ancillary staff have been improved and now meet or exceed minimum The Green DS0000009107.V293966.R01.S.doc Version 5.1 Page 6 requirements. Cornwall Care Ltd is continuing to recruit to address this matter. The manager and deputy are also improving the support and supervision systems for staff. The home was clean and hygienic – an improvement from the findings of the last inspection. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Green DS0000009107.V293966.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Green DS0000009107.V293966.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. The Green does not provide intermediate care (Standard 6) Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Prospective service users and their families and representatives receive information about the home and services provided. The statement of purpose requires further refinement to provide all required information. The needs of service users are assessed so that they can be assured that the home can provide adequate care, but assessments require more detailed recording of information. EVIDENCE: Cornwall Care Ltd issues a corporate framework for the statement of purpose and each home develops this into an individual document. The current version lacks some information: - the aims and objectives are specified , but there is no information about how the provider meets them; - there is little information about how the provider meets the diversity and cultural needs of residents; The Green DS0000009107.V293966.R01.S.doc Version 5.1 Page 9 - the reference to the complaints procedure is brief and should provide a better summary; - the complaints procedure should give contact details for Cornwall Department of Adult Social Care. The service users guide broadly meets the standard. Managers complete needs assessments for prospective residents and obtain assessments from the commissioning authority. Cornwall Care Ltd has a standard format for assessment and care planning which covers all the issues specified in the standard, if completed in sufficient detail. All the residents’ records case tracked contained written needs assessments. There were copies on file of health and adult social care assessment information provided by the commissioning organisation. However, the assessments case tracked did not state where they had been recorded or identify who was present. This information would provide evidence that the prospective resident and their family were involved in the assessment. Some areas of the assessment record were not consistently completed, for example the areas relating to the person’s preferred routines and family and carer involvement. The records for one resident stated in different places that she was both ‘Mrs’ and ‘Miss’. The Green DS0000009107.V293966.R01.S.doc Version 5.1 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 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Written care plans direct and inform staff about how to meet the residents’ health and personal care needs. The plans need to be more detailed and specific in the direction provided to ensure that each resident’s diverse needs are met. The healthcare needs of residents are monitored and addressed so that their needs are met. The arrangements for the management of medicines protect service users. EVIDENCE: All the residents case tracked had written care plans. Cornwall Care Ltd has a standard single format for assessment and care planning. At The Green staff were also using a ‘Care Profile’. This is a summary of the care plan used as a working document on each wing. However, in those records case tracked, this record omitted parts of the detail on the main care plan. The profile also focussed on personal care needs and did not detail how the resident’s wider social and emotional needs were to be met. Care plans lacked detailed directions and information for staff on meeting the care needs of residents. The Green DS0000009107.V293966.R01.S.doc Version 5.1 Page 11 The plans did not provide consistent individual risk assessments, guidance for staff on responding to the individual care needs of residents related to dementia, sufficient information about the residents’ preferred social and activity needs and did not record their religious beliefs. Daily records were not consistently recorded each day. In some records staff had not signed their full signature and had used red ink. Comments in daily records often lacked adequate or useful detail - for example “food good” rather than a brief summary of what the resident had eaten. Staff retain separate daily records in respect of bathing, and, for some residents, food eaten and bowel activity and urine output. The care plan for one resident who receives respite care had not been reviewed before a recent admission despite there being a detailed revised joint assessment form from health and adult social care on file. Consequently, the plan no longer accurately reflected the resident’s care needs. This contributed to the resident not receiving adequate care during his respite stay. Residents case tracked were all registered with local GP practices. Residents and their representatives felt that their health care needs were well-monitored and appropriate attention obtained. Staff maintain a record of medical contacts for each resident. The community nurses visit the home regularly. Two residents currently have pressure areas currently being treated. An auxiliary nurse felt that the staff obtained prompt attention for residents when required and followed instructions and guidance in the delivery of care. There have been a significant number of falls in the last three months. A high proportion are recorded as not witnessed, where the resident had been found on the floor and was not injured. However, there are no detailed individual falls risk assessments for residents at risk. The provider has not analysed the patterns of recent falls in relation to residents involved, time, place and staff on duty. The provider must record falls risk assessments and provide directions for staff to try to reduce the incidence of falls. Medicines are stored in locked cabinets in a locked room. The room and cabinets were tidy and well organised. The Boots monitored dosage system is in use. No residents are currently assessed as being safe to administer their own medication. Residents sign a medicines agreement, but there was not a copy of this on file for all residents case-tracked. Cornwall Care has a corporate policy and procedure on the handling of medicines. Identified staff, who have completed training, have responsibility for the administration of medicines. The administration records were generally complete and well maintained. On occasions, the code for non-administration did not specify the reason for this. Where a hand written administration record is used, for example for recently admitted residents, a second person should check and countersign the record. A sample of controlled drugs was checked against the record and found to be accurate. The controlled drugs are stored in a small controlled drugs cabinet. This cabinet needs to be properly secured. There is a record of medicines returned to the pharmacist. The Green DS0000009107.V293966.R01.S.doc Version 5.1 Page 12 Residents and their representatives felt that they were well cared for and staff respected their privacy and dignity when assisting with care. Residents reported that they were “well looked after” and the staff were “kind and thoughtful”. Inspectors observed staff providing care in a sensitive manner – for example in support with eating. The older wings have toilet areas containing two adjoining cubicle toilets. This arrangement does not promote the privacy and dignity of residents and should be reviewed. Most residents in these wings use commodes in their rooms, but should have access to individual and private toilets. The bedroom doors in the original wings have glass panels. These reduce privacy and allow light to intrude at night. Many residents have taken individual action to cover this glass. The Green DS0000009107.V293966.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents are supported to follow a lifestyle which accords as far as possible with their own choices and preferences. The diet provided is varied and nutritious with attention to individual preferences. EVIDENCE: Residents and their representatives generally felt that the home offered flexible routines in daily living activities. They provided positive comments on the kindness and sensitivity of staff. Some felt that the activities provided were satisfactory, and others felt that residents should be encouraged more to engage in activities and physical exercises. Residents can join the activities in the day care area in the main lounge. Activities were taking place during both days of the inspection. The care plans need to set out in greater detail the residents’ personal preferences in daily routine, lifestyle and social activities. It would also be good practice for care plans to include the life story of each resident. Relatives were satisfied with the visiting arrangements. Some commented on the pleasant and relaxed atmosphere. Other relatives, however, stated that they did not feel warmly welcomed. The manager is aware of these feelings and is addressing this issue. The Green DS0000009107.V293966.R01.S.doc Version 5.1 Page 14 Residents have arrangements with family and representatives to manage their financial affairs. Residents can bring in to the home furniture, by agreement, and personal possessions when they are admitted. Cornwall Care has made an arrangement with ‘Care Aware’, an advocacy service for residents and Age Concern are available locally. Residents and their representatives were positive about the food and catering arrangements. There is a wide choice at breakfast. The main meal at lunchtime is based on a four week menu, with two choices each day and further individual choices where required. Tea is a range of savoury dishes. The menu details a varied and nutritious diet. The home is currently providing some diabetic diets and a number of residents have their food liquefied. Inspectors enjoyed a well presented and appetising meal with service users. Staff ate with service users and provided sensitive support with eating. The environmental health officer report dated 25 January 2006 reported a ‘good standard’ in relation to food hygiene. The Green DS0000009107.V293966.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. 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 from evidence gathered both during and before the visit to this service. The home has a satisfactory complaints procedure that would ensure that complaints are listened to and acted upon. There are basic arrangements to protect service users from abuse, and these need further development. EVIDENCE: Cornwall Care Ltd has a corporate complaints procedure. The Green has received three complaints in recent months from relatives about care and staffing issues. The provider has investigated these complaints and responded to the complainants. One of these complaints was still being pursued at the time of this inspection. In the main residents and their representatives stated they were satisfied with the services that the Green provides. However, some people reported in the postal questionnaire that they were uncertain about the arrangements for making a complaint. Cornwall Care Ltd has an adult protection procedure. This procedure requires further development to comply fully with the standard. Therefore this is in the process of being revised in line with guidance from CSCI. Staff do not appear to receive any further training in adult protection following their induction. The Green DS0000009107.V293966.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home is generally well maintained and provides a generally safe environment, although the incidence of falls has been high recently. The premises are clean and hygienic providing a pleasant environment and reducing risks to residents. EVIDENCE: The Green is a large building divided into seven separate wings on two floors, with a large communal lounge, and coffee bar and dining areas on the ground floor. Each wing has its own lounge, dining area and kitchen. Wings do not provide accommodation to residents with similar identified needs – for example there is no wing for people with more complex needs. The main entrance provides a level entry and lifts provide access to the first floor. There is a contrast between the newer wings, which are bright, modern and in good repair, and the original wings, which appear rather bleak in places and are in need of redecoration and refurbishment. The original wings still provide three shared rooms. Some bedrooms in the older wings appear to lack basic The Green DS0000009107.V293966.R01.S.doc Version 5.1 Page 17 facilities such as towel rails. All the wings have an assisted bath. The home was clean and hygienic and this has improved since the last inspection. Residents and their representatives were satisfied with the cleanliness of the home. However, odours were noted in some bedrooms. The home lacks imaginative “signposting”, for example putting photographs or recognisable items on doors to support people with dementia in finding their own room. There is a courtyard accessible to residents from the ground floor lounge. The laundry is separate from food preparation areas, well equipped with industrial standard washing machines and dryers, and complies with the standard. Good laundry practice information was on display and hand wash and paper towels provided. There are a number of sluices sited throughout the building. Most bathrooms provided hand wash and paper towels. One downstairs toilet (close to the administration office) has a single tap in the basin and the water from this is excessively hot. This needs to be made safe. The Green DS0000009107.V293966.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The staffing and training arrangements ensure that the needs of residents are met. Recruitment procedures support and protect the service users. EVIDENCE: The last report recorded significant problems in maintaining the minimum staffing levels to ensure the safety and well being of residents. The report set a requirement for improving this. Cornwall Care Ltd has recruited a number of staff for care, domestic and kitchen work, and is continuing to recruit. The roster now details a minimum of eight sometimes nine, care staff during the morning and seven later in the day in addition to domestic staff (general assistants) and management. This allows one staff for each wing with a ‘floating’ worker. There is a full time cook, another cook for four days weekly and a kitchen porter. Three staff and a manager on call cover nights. Some relatives reported concern about the periods of time during which residents were left unattended on wings when staff, for example, had their break or took clothes to the laundry. The manager needs to review the deployment of staff to ensure adequate staff presence at these times. Staff expressed concerns about the availability of staff at busy times to provide care to residents who needed two carers for safe moving and handling, or who had complex needs. Staff are recruited through the Job Centre and local press. Cornwall Care Ltd has standard corporate recruitment procedures. Two managers interview using set questions and keep a record of the interview. Records of recent The Green DS0000009107.V293966.R01.S.doc Version 5.1 Page 19 recruitment contained application forms with health declarations, two references, and Criminal Records Bureau Disclosures. Staff records in general complied with the regulations, although photographs were not on file for all staff. Nineteen out of forty care staff currently are qualified at NVQ level 2 or above. This is just below the 50 stated in the standard. However, this proportion will be improved as staff are registered for and working towards their NVQ level 2. Training records showed that staff were up to date with required training in moving and handling, dementia care, food hygiene and health and safety. Newly appointed staff were beginning their inductions. Cornwall Care Ltd use a ‘Personal Development Plan’ as an individual staff training and development record. Those sampled were completed inconsistently with some containing little information. The Green DS0000009107.V293966.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home has an experienced and qualified registered manager who is determined to ensure that it meets its stated purpose and objectives, and provides the highest quality care. The health and safety of residents and staff are generally promoted and protected, but there has been a lack of attention to detail in some areas. EVIDENCE: There has been a period of instability in the management at The Green since July 2006. The home has had three temporary managers during this time and this has had an impact on the service. Health professionals, relatives and staff have expressed concerns regarding the care provided. Mrs Sue Cain has been in post for four months and is now the registered manager of the home. She has a management qualification and extensive experience of the care of The Green DS0000009107.V293966.R01.S.doc Version 5.1 Page 21 older people. Mrs Cain has a clear view of what needs to be done to improve the quality of service provided at the home. The management team also includes an experienced deputy manager and four assistant managers. There does not appear to have been a formal quality assurance process carried out recently. However, the management team is about to send out the Quality of Service survey for 2006. This will be analysed by independent auditors. The manager discussed the other systems in place – for example the use of a maintenance record to inform the handy person of work required, feedback obtained during care plan reviews with residents and their representatives, and the monthly visits from a Cornwall Care Ltd manager required by regulation. Cornwall Care provides safe keeping facilities for small amounts of personal spending money. Inspectors examined a sample of the records, which detail all payments in and out, and a running balance. The bulk of this money is held in a combined bank account for security and not as cash for each individual. Staff were satisfied with the level of support and supervision that they received. They were positive about the training provided by Cornwall Care Ltd. Records showed that staff had not received regular formal recorded supervision in the past, but the new manager is setting up systems for this, with recent supervisions documented. Staff training in health and safety is up to date. There were no obvious health and safety risks noted in the premises during the inspection. Hoists for transferring residents had records for recent services. Cornwall Care Ltd has a corporate policy on fire safety checks. The records did not evidence that checks on the alarms, automatic-closing doors, emergency lighting and fire-fighting equipment were being carried out at recommended intervals. The records for fire training did not document the attendance of all staff at least every three months. The home’s fire risk assessment could not be located. A daily security check is carried out. A weekly check is carried out for Legionella, but the records should detail what action is taken. The records for the temperatures of the refrigerators on the wings documented that these had been checked, but did not record the temperatures. The Green DS0000009107.V293966.R01.S.doc Version 5.1 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 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 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 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 2 The Green DS0000009107.V293966.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 and Sch 1 Requirement The Green’s statement of purpose must be reviewed to accurately reflect the services that it provides and include the information listed in the report text. This is renotified to you for the third time. Pre-admission assessments must identify service users’ individual needs and preferences in detail. This requirement has been modified following this inspection. Care plans must direct and inform staff how to meet all aspects of each resident’s personal, health and social care needs. Service users’ risk assessments must be reviewed to ensure that the health and safety of all residents is promoted and specific instructions to staff in the moving and handling of service users are clear. This requirement is renotified to DS0000009107.V293966.R01.S.doc Timescale for action 31/08/06 31/08/06 2. OP3 14 3. OP7 15 31/08/06 4. OP8 23 31/08/06 The Green Version 5.1 Page 24 5. OP8 13 you, previous time scale not having been met. The registered person must audit the last three month’s accident records and draw up detailed risk assessments for residents at risk of falling and environmental risk assessments. The registered person must retain a photograph of each staff member. Checks on the fire protection systems must be recorded at the recommended intervals. All staff must receive regular fire training. The temperature of the hot water delivered in the ground floor toilet adjacent to the administrative office must be reduced. 12/06/06 6. OP29 19 and Schedule 2 23 31/08/06 7. OP38 31/05/06 8 9 OP38 OP38 23 13 30/06/06 30/06/06 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 OP18 Good Practice Recommendations The adult protection policy should be expanded to include a timetable of initiating an adult protection referral and explain what procedure should be followed. This is re notified to you. Daily records should be maintained daily, provide usefully detailed information, be in blue or black ink, and have a complete signature. The controlled drugs cupboard should be firmly secured in place. DS0000009107.V293966.R01.S.doc Version 5.1 Page 25 2 OP7 3 OP9 The Green 4 5 6 7 OP9 OP19 OP19 OP19 8 9 OP30 OP38 When medicine administration records are handwritten, a second person should check them and sign to confirm this. The registered person should develop the signposting around the home, for example individualising residents’ bedroom doors. The registered person should ensure that residents’ rooms have basic furniture and fittings – for example towel rails. The registered person should review the fitness for purpose of adjacent cubicle toilets in relation to meeting the diversity needs and privacy and dignity needs of residents. The registered person should review the use of the ‘Personal Development Plan’ record. The temperatures of refrigerators must be recorded when checked. The Green DS0000009107.V293966.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 The Green DS0000009107.V293966.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!