Inspection on 02/01/07 for The Green Home for Older People

This inspection was carried out on 2nd January 2007.

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

The Green Home for Older People 23/03/06

The Green Home for Older People 06/09/05

The Green Home for Older People 11/01/05

The Green Home for Older People 10/08/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE The Green Home for Older People Seacroft Green Leeds LS14 6JL Lead Inspector Ann Stoner Key Unannounced Inspection 2nd January 2007 09:30 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 Home for Older People DS0000033270.V325118.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. The Green Home for Older People DS0000033270.V325118.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Green Home for Older People Address Seacroft Green Leeds LS14 6JL 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) 0113 2144166 Leeds City Council Department of Social Services Miss Michaela Jayne Conoby Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37), Physical disability (1) of places The Green Home for Older People DS0000033270.V325118.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The place for PD is for the named service user only Date of last inspection 23rd March 2006 Brief Description of the Service: The Green Home for Older People provides personal care, without nursing, for 37 residents in a purpose built two storey building in the heart of Seacroft, a suburb of Leeds. There is an adjoining day centre, which is independent of the home and is not regulated, therefore is not included in the inspection process. Accommodation for residents is in single rooms on two floors. There is a lift for those unable to climb stairs. Bedrooms and bathrooms are arranged in small units with communal open-plan sitting and dining areas on both floors. Local facilities including shops, pubs and public transport are within easy reach of the home. Fees that applied at the time of this inspection were stated in the preinspection questionnaire as ranging from £65.50 - £450.15. More up to date information may be obtained from the home. Copies of previous inspection reports are available in the home. The Green Home for Older People DS0000033270.V325118.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk The last inspection was unannounced and took place on the 23rd March 2006. There have been no further visits until this unannounced key inspection, which took place between 9.30am and 6.00pm on the 2nd January 2007. The purpose of this visit was to monitor standards of care in the home and to look at progress in meeting the requirements and recommendations made at the last visit. Before the inspection a pre-inspection questionnaire was sent out to the home, this provided some information for this report. The people who live in the home prefer the term ‘resident’ and this will be used throughout this report. Before the inspection I sent out survey cards to residents, relatives and health care professionals and had a telephone conversation with three relatives. I received eighteen completed survey cards from residents, five from relatives and two from GPs. Comments from the survey cards and telephone conversations can be found throughout this report. During the inspection I spoke to residents, visitors, staff on duty and the manager, I looked at records, made a tour of the building and watched staff working with residents. Feedback at the end of this inspection was given to the manager. I would like to extend my thanks to everyone who contributed to the inspection and for the hospitality during the visit. What the service does well: The home works hard to create a warm, welcoming and relaxed atmosphere whilst still maintaining a high level of professionalism. One resident described the home as being ‘free and easy’ and one relative used terms such as, ‘amazing’, ‘wonderful’ ‘patient and understanding’ and ‘nothing is too much The Green Home for Older People DS0000033270.V325118.R01.S.doc Version 5.2 Page 6 trouble for them’, when describing staff. Another relative said that staff were ‘so friendly’ and ‘absolutely marvellous’. In a letter accompanying a survey card, one relative said, “I cannot praise the staff too highly. They are absolutely wonderful. I speak to two or three members of staff every time I visit my mum, which is two or three times a week, and have never found any one of them too busy to speak to me. There is not one who is unapproachable and I find them all very kind and considerate. Their care of residents is exemplary.” Visitors are made welcome and may stay and have a meal with the resident. Residents surveyed said that staff listen to them and act upon anything that they have to say. Residents’ meetings are held regularly and minutes of these meetings show that people can make suggestions about any changes they think are needed. Menus are being changed in the near future, and so that the views and opinions of residents are taken into consideration, staff have developed an excellent questionnaire for residents to complete. Residents are never rushed. At meal times people sit in small groups and chat at the dining table in a relaxed and informal way. When help or support is needed, staff give this in a discreet way. What has improved since the last inspection? What they could do better: The manager must make sure that the care records consistently provide clear evidence of the care provided to residents. Care plans must also contain instructions for care staff on how to meet the needs of the residents. The Green Home for Older People DS0000033270.V325118.R01.S.doc Version 5.2 Page 7 When bed rails are being considered an assessment must be carried out showing that all other options and the risks associated with the use of bed rails have been considered. There must also be information in the care records about how and when the bed rails must be checked and whose responsibility this is. Residents should be given a statement of terms and conditions before moving to the home. This should be signed and dated by all parties concerned so that residents are aware of the conditions of their stay. The home should have a policy on how to use homely remedies in a safe way. Requirements and recommendations to address these issues can be found at the end of the report. 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. The Green Home for Older People DS0000033270.V325118.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 The Green Home for Older People DS0000033270.V325118.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, 3, 4 & 5. Standard 6 does not apply to this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is sufficient information available to residents and their families to make an informed decision about the home. All residents have their needs assessed before being admitted to the home. EVIDENCE: Telephone conversations with the relatives of three residents admitted to the home since the last inspection confirmed that people have the opportunity to visit the home before any decisions about admission are made. All said that they had visited other homes before choosing The Green. One person said, “It is the nicest home I have seen”, another said that she visited the home unannounced and was made very welcome and was given every opportunity to look round and another said, “I was very happy with what I saw.” One person The Green Home for Older People DS0000033270.V325118.R01.S.doc Version 5.2 Page 10 said that her mother stayed for lunch with other residents as part of the preadmission visit. The Statement of Purpose and Service User Guide were displayed in the entrance of the home; one relative said that during the pre-admission visit she was given time to read both documents. The manager said that every resident has been given a copy of the Service User Guide. The care records of all three residents were looked at and in each there was an assessment completed by a social worker and the home had carried out a preadmission assessment to make sure that the person’s needs could be met. A licence agreement, which forms the statement of terms and conditions, was seen in all of the care records sampled, but these had not been signed and dated by all parties concerned. The manager said that correct information about payment of fees was not available at the point of admission, therefore the licence agreement could not be completed. This should be addressed so that people know the terms and conditions of their stay. A recommendation has been made. The Green Home for Older People DS0000033270.V325118.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 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is good at meeting the care needs of the residents, but this is not always documented in enough detail. Recording in care records has improved, but further work is needed to make sure that staff have precise instructions on how to meet people’s needs. Medication practices are safe and healthcare needs are met. Staff respect the privacy and dignity of residents. EVIDENCE: The level of detail recorded in care plans has improved since the last inspection, but further work is still needed. In the three care records sampled good practice was seen. This included excellent pen pictures giving a description of the person’s life up to the point of admission. There was some good information for staff about the precise level of care that each person The Green Home for Older People DS0000033270.V325118.R01.S.doc Version 5.2 Page 12 needed. For example, ‘is able to brush her own hair, but needs showing where to find her hairbrush’, ‘needs some help taking her nightgown off because she struggles to get it over her head’. However other care plans were less detailed and had instructions for staff such as ‘staff to support’ and ‘to give reassurance’, which are open to interpretation and some care plans lacked detail about the specific strengths of residents, such as the tasks that they could do themselves. Due to a medical condition one resident occasionally uses bed rails. There was no information in this person’s care records about how the assessment for bed rails was carried out, or that all other options and the risks associated with the use of bed rails had been considered. The manager said that an Occupational Therapist had carried out the bed rail assessment, and she made attempts during the inspection to contact this person to obtain a copy of the assessment for the care plan. There was no risk assessment completed and there was no information about how and when the bed rails should be checked and whose responsibility is was to carry this out. Advice about the safe use of bed rails was given. Monthly reviews of care plans were not robust and did not evidence how the care given is still meeting the needs of the resident. During telephone conversations with relatives all were aware of the resident’s care plan, but had not seen or read them. Only one out of the three care plans sampled had been signed and dated by the resident or their representative. Daily records do not show any activity or staff interaction with residents other than at times when personal care is given. Staff also use abbreviations such as ‘TLC’, rather than descriptions of actual care or support given. A requirement and recommendation has been made relating to care records. Telephone conversations with three relatives confirmed that the health care needs of residents are met. One person said that she was always kept informed of her mother’s condition and was pleased with the way that the home managed her mother’s health care needs. Another person said that the home was managing her mother’s needs well and that she was informed and notified about all aspects of her mother’s care. A GP holds a regular weekly surgery in the home, which one relative appreciates because it gives her direct access to the GP if she has any concerns about her mother. The manager said that she is arranging a similar service with other GPs. Returned survey forms from residents indicated that they receive care when needed. There was evidence in care records of residents receiving optical, dental and chiropody treatment. During the inspection staff administered medication safely, but handwritten entries on the Medication Administration Record (MAR) were not checked and The Green Home for Older People DS0000033270.V325118.R01.S.doc Version 5.2 Page 13 countersigned by a second person. The home does not have a homely remedy policy. A recommendation has been made. Residents said that staff always knock on doors before entering and one person said that she appreciates privacy in the visiting room, where she can have a meal and a private conversation with her relatives. Staff described how they protect residents’ privacy and dignity in their everyday work practices. The Green Home for Older People DS0000033270.V325118.R01.S.doc Version 5.2 Page 14 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 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to exercise choice in all aspects of their daily life and are encouraged to give feedback on how the home can improve upon the service it provides. EVIDENCE: Observation and discussion with some of the residents made it clear that residents were able to exercise choice and control over their daily lives as far as possible. Residents spoken with were satisfied with their care and happy living at the home. Minutes of residents’ meetings show that the opinions and views of residents are respected and acted upon. Staff were aware of the importance of respecting resident’s cultural differences and one relative said that staff had been ‘very thoughtful’, in helping her mother display religious pictures in her bedroom. Returned survey cards, completed by residents, suggests that there are mixed feelings about the level of suitable activities provided and during the inspection The Green Home for Older People DS0000033270.V325118.R01.S.doc Version 5.2 Page 15 the only staff interaction with some residents was at times when personal care was being given. However, minutes from residents’ meetings show that outings to Lotherton Hall, Rounday Park and pub lunches have taken place, and future trips to Otley, Wetherby and a local shopping centre are planned. Entertainers visit the home once a fortnight, and one relative said, ‘staff make such an effort to provide parties and entertainment such as a Halloween party and Xmas party’. In a letter one relative said that she was, “quite moved by the commitment of staff in organising an amazing Halloween party”, where residents’ sons, daughters, grandchildren and great grandchildren all attended, many of whom were in fancy dress. One resident takes responsibility for the garden area and his achievement was recognised when he won first prize in a local authority gardening competition. In a returned survey card one relative stated, ‘I feel a dedicated activity person would be of benefit especially in view of the confused ratio of residents who need more stimulation at times’. Another relative said that it was the ‘day to day’ activities that are missing, and that whilst care staff do their best they cannot organise activities whilst carrying out their other caring duties. This was a view echoed by staff and is recognised by the manager, who is trying arrange additional care hours dedicated to providing activities. The manager is considering developing a survey form, similar to the one currently in use relating to menus, so that residents can express their opinions about how the home can improve upon the level and suitability of the recreation and leisure activities it provides. This would be good practice. During telephone conversations with visitors it was clear that they are welcomed into the home. All spoke about being offered refreshments and said that the home is particularly good at welcoming residents’ grandchildren and great grandchildren, who are always offered fruit juice and biscuits. The menus provide a varied, nutritious and balanced choice of food and from the minutes of residents’ meetings it is clear that residents have input into the choice of food offered. The home is in the process of changing the menus and has developed an excellent survey for residents so that they can contribute to any changes that are made. During the inspection the lunchtime meal was relaxed. Residents sat in small groups, which allowed them to chat and support each other. One resident opened a bottle of wine to share with other residents at the dining table. Vegetables were served in tureens and gravy in a gravy boat. This helped residents to have control over portion sizes as well as helping them to maintain a good level of independence. When assistance from staff was needed, this was given discreetly and sensitively. One relative said that her mother particularly enjoyed a cooked breakfast every morning, which is something she never had at home. She was pleased that her mother had gained weight since being in the home. The Green Home for Older People DS0000033270.V325118.R01.S.doc Version 5.2 Page 16 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 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a robust complaints procedure and residents are confident that complaints will be taken seriously. Residents are protected by the existence of a vulnerable adults procedure. EVIDENCE: There is a comprehensive and clear complaints procedure in place that is readily available to residents and relatives and the home has a good system of recording and dealing with complaints. Telephone conversations with three relatives confirmed that they would have no hesitation in making a complaint if necessary. All eighteen residents who returned survey cards said that staff listen to them and act upon what they have to say. There are robust procedures in place to protect residents from abuse and whistle blowing procedures to protect staff. Care staff described the different types of abuse and knew what to do if they suspected someone was at risk of being abused. Some staff have attended training in adult abuse and the manager is trying to arrange for the local authority adult abuse trainer to deliver training in the home so that all staff can attend. The Green Home for Older People DS0000033270.V325118.R01.S.doc Version 5.2 Page 17 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 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe and well-maintained environment. Although there are no en-suite facilities there are excellent communal facilities. EVIDENCE: Bathrooms have been refurbished to a high standard, and since the last inspection some bedrooms and one lounge has been decorated, some commodes have been replaced, a fire door is no longer obstructed, additional clinical waste bins have been provided and there are improved systems for handling soiled linen. The manager said that further decoration and refurbishment is planned. Residents’ rooms are attractively furnished and they are able to bring in personal items to make their rooms more homely. During a telephone The Green Home for Older People DS0000033270.V325118.R01.S.doc Version 5.2 Page 18 conversation with one relative she said, “The home provides a safe and secure environment for people to live in and everyone always looks happy.” There are attractive garden areas, with seating, to the front and rear of the home. Returned survey cards from residents indicated that the home is always clean and fresh, and during the inspection all areas of the home were clean, tidy and fresh smelling. The laundry was well organised and all residents have a personalised basket for their laundry. There are good systems in place for hand washing in all areas of the home where clinical waste or bodily fluids are handled, and good measures to prevent the spread of infection. The Green Home for Older People DS0000033270.V325118.R01.S.doc Version 5.2 Page 19 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 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The increase in staffing levels means that there should be sufficient staff to meet the needs of the residents. Staff are trained and competent to do their jobs. The recruitment procedures protect the residents. EVIDENCE: The manager said that the home has been allocated additional staffing hours, which means that there will be three staff on duty throughout the night, and additional staff during the day. The increased staffing levels during the day will allow dedicated activity time for residents. The recruitment records of two recently appointed staff were looked at and demonstrated that a robust system is in place to make sure that staff are suitable to work with vulnerable people. Mandatory training is well established and staff have access to a range of training to make sure that they have the necessary knowledge to care for the residents effectively. The Green Home for Older People DS0000033270.V325118.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, 33, 35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed. The interests of the residents are seen as very important to the manager and staff, and residents finances are safeguarded at all times. EVIDENCE: There is a clear commitment by the manager and her staff to safeguarding the best interests of the residents. This is evident from discussions with staff and residents. The manager has almost completed a NVQ (National Vocational Qualification) Level 4 in Management and will then complete the Registered Managers’ Award. She is well thought of by residents, relatives and staff. During telephone conversations with relatives one person described the The Green Home for Older People DS0000033270.V325118.R01.S.doc Version 5.2 Page 21 management team as being ‘relaxed and informal’, and said that when she visits she always ‘pops into the office for a chat’. Another said, “The management team always make time for me, everyone is approachable.” Minutes from staff meetings show that the manager is aware of issues in the home that need addressing and is not afraid to challenge staff where necessary. Staff supervision is in place, and staff felt that this was effective as it gave them the opportunity to discuss work, training and development issues on a ‘one to one’ basis. Quality assurance systems are in place with questionnaires being sent out to relatives on an annual basis, and residents’ meetings held regularly. There are arrangements in place for the monthly provider visits, as required, and reports of these visits are forwarded to the CSCI (Commission for Social Care Inspection). Some residents manage their own finances and look after their pocket money. There are lockable facilities in the bedrooms for the safe keeping of valuables. Other residents hand small amounts of money to staff to keep in the safe. There are clear records of all residents’ money and the home is subject to external audit with a system of frequent in-house ‘spot checks’ carried out. All new staff are given fire instruction and regular fire drills are held for all staff, including the night staff. The fire alarm system is checked weekly with a different actuation point tested each time. Records are kept of accidents occurring to residents and the manager keeps a running log of accidents to try to identify any trends. Monthly reports are made to the provider on the number of accidents occurring at the home. The management team carry out monthly health and safety checks and the pre-inspection questionnaire completed by the manager shows that servicing of equipment takes place as required. As previously stated in this report the home does not record when bed rails should be checked and whose responsibility this is. The manager agreed to rectify this during the inspection. The Green Home for Older People DS0000033270.V325118.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 3 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X 3 3 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 3 X 3 3 X 3 The Green Home for Older People DS0000033270.V325118.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. 2 Standard OP7 OP7 OP38 Regulation 15 15, 13 Requirement Care plans must give staff clear and precise instructions about the level of care to be given. Where bed rails are in use the care records must contain an assessment showing that all other options and the risks associated with the use of bed rails have been considered. When bed safety rails are in use the home must follow the guidance stated in the Medical Devices Agency document ‘Advice on the safe use of bed rails’. Timescale for action 31/03/07 31/01/07 The Green Home for Older People DS0000033270.V325118.R01.S.doc 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 2. Refer to Standard OP2 OP7 Good Practice Recommendations All residents should be given a statement of terms and conditions before moving to the home. This should be signed and dated by all parties concerned. Terms such as TLC’ should be replaced with descriptions of actual care and support given. Monthly reviews of care plans should evidence how the care given is still meeting the person’s needs. Wherever possible residents and/or their relatives should be involved in the monthly review of the care plan. Care plans should be signed, agreed and dated by the resident or their representative. Policies and procedures should be revised and updated in line with guidelines from the Royal Pharmaceutical Society. This should include a policy and procedure relating to homely remedies. This is carried forward from two previous inspections. 3. OP9 The Green Home for Older People DS0000033270.V325118.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 The Green Home for Older People DS0000033270.V325118.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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