Care Home: Green Lane (626)

What the care home does well Widely involve residents in life at the home and wherever possible in the development of the organisation. Engages and encourages residents to live life to full capacity within the confines of their illness. Works well towards improving the quality of services provided to individuals with mental health problems. Enables them to access health care facilities including specialist resources e.g. mental health services. What has improved since the last inspection? Replaced carpets in the bedroom occupied by resident (PD) and on the first floor landing. Reviewed some of the key policies with a commitment to completing those in need of review - in the short term. Improved in the recording of changes made on the medication. Provided training to some staff in managing aggression and violence. What the care home could do better: Ensure that detailed assessments are carried out on residents prior to admitting them to the home. Care plans must accurately reflect the needs of all residents at all times. Ensure that medication charts accurately reflect the activity undertaken to support residents with their medication. Review all outstanding policies as outlined in Standard 40 of this report. Ensure that requirements are fully met within the given timescale set by the Commission. Improve food storage in the home. CARE HOME ADULTS 18-65 Green Lane (626) 626 Green Lane Goodmayes Ilford Essex IG3 9SD Lead Inspector Stanley Phipps Unannounced Inspection 2 to 24 October 2008 15:00 nd th Green Lane (626) DS0000025902.V362849.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Green Lane (626) DS0000025902.V362849.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Green Lane (626) DS0000025902.V362849.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Green Lane (626) Address 626 Green Lane Goodmayes Ilford Essex IG3 9SD 020 8503 8392 020 8503 8392 greenlane.staffteam@rchl.org.uk www.rchl.org.uk Redbridge Community Housing Limited [RCHL] 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) Louise Elizabeth Prendergast Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Green Lane (626) DS0000025902.V362849.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To include one named person over 65 years of age. Date of last inspection 26th October 2006 Brief Description of the Service: 626 Green Lane is a residential home for six adults with a mental health condition and is managed and run by Redbridge Community Housing Limited. The home is situated on a main road on the outskirts of Goodmayes, and has easy access to pubs, shops and other local amenities. There are good transport links both to central London and within the local area. The home was opened in 1991, and is supported by staff on a twenty-four hour basis. Most of the current service users have lived at the home for a considerable period and as such, are growing beyond the original age criteria of the home. However, the registered persons have been employed strategies to enable them to continue to live in the home. They included occupational therapy assessments to determine the suitability of the environment in meeting the needs of individual service users as well as the provision of training for staff in diseases associated with the elderly. A key objective of the service at 626 Green Lane is working with all service users to maintain their independence whilst living in the home. Staff work closely with them in ensuring that their personal, social, spiritual, psychological, mental health and general healthcare needs are met. An on-call system is in place to support staff beyond the normal working hours, including the weekends. There are bedrooms on both floors of the building, with a set of stairs allowing access to them. There is no lift facility in the building and this would have implications for service users as they grow older and become frailer. Toilets and bathrooms are located on both floors and, the building contains separate dining and lounging facilities. There is also a kitchen adequately sized and equipped to allow service users opportunities to maintain their culinary skills. A well-maintained rear garden is easily accessible to all individuals living at 626 Green Lane. A statement of purpose is made available to all service users and/or their relatives and a copy of the service user guide is given to each service user. Fees are charged between £94.45 £98.65 pence per week. Green Lane (626) DS0000025902.V362849.R01.S.doc Version 5.2 Page 5 Service users pay additional for toiletries, holidays and hairdressing - the prices of which are all variable. Green Lane (626) DS0000025902.V362849.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was carried out between the 2nd and 24th October 2008 to ensure that all key standards in the key outcome areas were assessed. There were five residents in the home, most of whom looked settled and comfortable in their environment. They all contributed to the inspection process giving individual and various accounts of their experiences of the service. On the first day of the inspection contributions were also made to the inspection process by; the senior staff on duty and the support staff working with him. The registered manager was coming towards the end of her maternity leave and the acting manager had worked her last day on the 1/10/08. An assessment of medication practice, menus, policies and procedures, records required by regulation, residents’ care plans and the environment was undertaken. Discussions were held with the registered manager on day two of the inspection and several members of staff. The inspection also considered: information provided in the Annual Quality Assurance Assessment (AQAA) provided by the registered manager, and verbal feedback from external professionals. The outcomes for residents remained positive, as the management and staff at Green Lane continued to make improvements to the service as a whole. To this end the registered persons complied with the three previously set requirements, while progressing work on two others. What the service does well: What has improved since the last inspection? Replaced carpets in the bedroom occupied by resident (PD) and on the first floor landing. Green Lane (626) DS0000025902.V362849.R01.S.doc Version 5.2 Page 7 Reviewed some of the key policies with a commitment to completing those in need of review - in the short term. Improved in the recording of changes made on the medication. Provided training to some staff in managing aggression and violence. 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 summary of this inspection report can be made available in other formats on request. Green Lane (626) DS0000025902.V362849.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Green Lane (626) DS0000025902.V362849.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (2) People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The needs of most residents have been assessed in a detailed manner. However, this must be carried out in every case and on every occasion to ensure that the home is able to meet the specific needs of the residents they wish to admit. EVIDENCE: From past inspection visits there is evidence to confirm that residents as part of the admissions process, are subject to a detailed assessment that they are a part of. They, as a matter of course get to see the home and have access to information about the service, which enables them to make an informed choice about deciding to live at 626 Green Lane. However, on examining the case file of the most recently admitted resident it was observed that this process had not been undertaken. There was a basic assessment on file that failed to identify or address the mental health needs of the individual concerned. This did not meet the minimum standard required, although the process had been carried out for other residents. To make matters worse the home failed to acquire a summary of the resident’s needs as required by this standard. Green Lane (626) DS0000025902.V362849.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (6,7,9) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. From a care planning perspective, improvement is required in recording of how the specialist needs of all residents are met. This is to ensure that residents receive consistent standards of care at all times. There was evidence that residents take decisions with support, and maintain their safety and independence within a risk management framework. EVIDENCE: There were care plans in place for each of the residents living in the home, most of which were updated. They were developed from assessments carried out with residents and as such, were individualised. Care planning is carried out in conjunction with the residents’ key workers – an individual that generally leads on coordinating the care and support provided to each resident. Residents spoken to were aware of their key workers and confirmed that they participate in what goes into their care plan. One good example noted was – having a support plan and risk assessment for the benefit of someone who smokes. On the day of the visit, a random sample of two care plans including that of the most recently admitted resident. While one of the care plans viewed was of Green Lane (626) DS0000025902.V362849.R01.S.doc Version 5.2 Page 11 a good standard, the other was significantly lacking in its ability to address – particularly the specialist needs of the individual concerned. This individual had both physical and psychological support needs, and the actions to support those needs were not reflected in the care plan or any like document. There was an absence of: former history/summary to include the individual’s psychiatric history, a mental health diagnosis, and a mental state assessment. The risk of this individual receiving a compromised standard of care is quite high as a result. To make matters worse the individual had been in the home for over five months. The registered persons need to ensure that this failing is addressed, but more importantly through their monitoring ensure that it is not repeated. The needs of the resident group are complex and though they are fairly settled in the home, as most needed some level of support to influence and communicate their needs. Staff play a major role in enabling them to make decisions about their goals and objectives, which is done through the key worker system. Staff along with the resident/s detail what goes into their care plan, which is again, positive. Residents’ meetings are held regularly and they are enabled to participate and contribute to the home’s operations. Information for e.g. complaints and activities are available to them in suitable formats, throughout the home. Residents spoken to informed that they feel supported to decide what is best for them – which is positive. A system for risk assessment and risk management is in place at 626 Green Lane. In most cases they were linked to the resident’s care plan. Staff spoken to understood the importance of risk assessments in ensuring that both the independence and safety of service users are promoted. Linking the risk assessments to their care plans ensure that staff are knowledgeable about the needs, risks and safe management of each individual resident. Most of the care plans and risk assessments were updated as a result of being regularly monitored and reviewed. Residents have the opportunity to retain in their possession - keys to their bedrooms. A missing person’s procedure is in place to ensure that prompt action is taken to secure residents safety should they go missing. Green Lane (626) DS0000025902.V362849.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (12,13,15,16,17) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Residents are encouraged to participate in: their community, in appropriate activities and are able to maintain and develop social and personal networks of their choosing. They are also supported to exercise their rights, which are respected and promoted by staff in the home. At 626 Green Lane meals are reflective of the residents’ choice and nutritional requirements. EVIDENCE: There was evidence that residents are supported to develop and maintain their living skills, however restricted they might be. This is true despite having varied levels of needs and motivation. Staff at the home recognise that motivating residents may present a challenge for them and from observation they were aware of the challenges in providing care and support to the resident group. Residents have an individual programme of activity, which is specific to their choice and interests and all staff are supported to work in accordance with this. Some residents enjoy shopping and most are able to get out with support and about to attend to their personal matters e.g. their finances. A smaller number enjoys religious worship and opportunities are provided for all to participate in: day trips, menu-planning, staffing recruitment Green Lane (626) DS0000025902.V362849.R01.S.doc Version 5.2 Page 13 and quality assurance committee meetings, run by the organisation. It was also noted that a computer is now available to residents with internet access and games. From conversations held with residents and from records seen, there was evidence to support the view that most of the residents are familiar with, and use their community facilities regularly and to maximum effect. One resident commented ‘I enjoy going to the shops where I get good value for my money’. This was an activity that she clearly enjoyed and the staff provided flexible support to enable her to have the experience. All residents have the support available to them should they wish to vote and the same is true for access to advocacy services. Residents get good support to participate in their community, which is positive. A visitor’s policy is in place to ensure that families and friends maintain contact with their loved ones. Residents also have access to a phone, which they can use to maintain contacts in their own time and with privacy. Where relatives are accessible they are kept informed of key events regarding the welfare of respective residents, as and when required. Relatives are also invited to and in some cases attend social events in the home such as birthday events. At 626 Green Lane staff were observed addressing residents by their preferred names. Residents spoken to confirmed that they are able to choose what they wear and the times they wakeup, and go to bed. Staff were observed checking with a resident in the home on the day, about her preferences regarding meals and it was positive to see that the resident’s choice was respected. Advocacy information is made available to residents and the key worker system is used as a means of ensuring that their rights and needs are respected and provided for. From the feedback provided by residents, it was clear, that their rights are maintained through the level of involvement e.g. regular resident meetings, that they have in deciding what is best for them. Meals were not witnessed during the course of the inspection, however discussions held residents informed that they were quite pleased with the meals provided at 626 Green Lane. Menus were in place and were chosen by residents in their regular meetings. They were varied and looked nutritionally sound in respect of meeting the individual needs of residents. More importantly staff were adept to having a flexible way of engaging with the residents to ensure that their nutritional needs are met. A good supply of food and drink was accessible to all residents in the home. Green Lane (626) DS0000025902.V362849.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (18,19,20) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Residents enjoy personal support in a manner that is generally suited to them. Arrangements are in place to provide for their physical and emotional health needs, as staff continued to maintain effective links with external professionals in achieving this outcome. Although good improvements were made to enhance the quality of support residents receive with their medication, care must be taken in ensuring that drug charts are appropriately recorded during the course of administering medication in the home. EVIDENCE: Feedback received from residents strongly informed that they were pleased with the way in which personal support is provided to them, which is coordinated through the key-worker system used in the home. Staff were observed throughout the course of the inspection offering personal support to individuals that needed it. Their interactions were carried out in a respectable and dignified manner. It was also clear that the staff had a system for determining individuals’ preferences and dislikes, which made the relationship between them – a positive one. Residents have their individual style of dress, which is consistent with their choice, culture and personality. Importantly, the staffing mix in the home ensures that same gender care is available to all residents in the home. Green Lane (626) DS0000025902.V362849.R01.S.doc Version 5.2 Page 15 Residents are generally given good support to ensure that their health needs including their mental health needs are provided for, e.g. dentist, chiropodist, psychiatrist and opticians. From looking at the records and discussions with staff it was clear that they (staff) were capable of making interventions to promote the health and welfare of most of the residents in their care. Residents also have the benefit of getting support as and when required to attend their outpatients’ appointment. Feedback received from external professionals was positive about the staffing awareness of residents’ needs. Records bore evidence that all community appointments were documented as they occurred. Good support is provided in relation to the healthcare needs of residents at 626 Green Lane. There were improvements in how residents were supported with their medication, when compared to the previous inspection. It was noted that changes to medication were appropriately recorded and dated and that staff were using the drug charts when administering medication. However, on checking the medication charts, a missing signature was observed in the lunchtime medication for one of the residents. On checking the relevant drugs, it was not where it would have been – had it not been administered. The most recent pharmacist visit also reported two gaps in the signature columns of the MARS sheet. This needs to improve. At the time of the visit, none of the residents were managing their medication, for which a clear policy is in place. Medication storage was good and all staff responsible for supporting residents with their medication did have training prior to undertaking the responsibility of supporting residents with their medication. Residents spoken to were happy with the level of support they received with their medication. A satisfactory medication policy is in place for the benefit of staff and residents. Green Lane (626) DS0000025902.V362849.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (22,23) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. A satisfactory complaints procedure is in place and widely available to all residents and staff. Safeguarding adults’ practices within the home generally protects residents from the risk of abuse, EVIDENCE: A satisfactory complaints procedure is in place at the home and is made widely available in appropriate formats to all residents. In discussion with a sample of residents, they were well aware as to whom they could complain. There was evidence that the complaints procedure is made widely available to all and it was noted that there had been two complaints since 2006 i.e. 6/7/07 and the 1/2/08. At the time of the visit the latter of the two had not been concluded in terms of outcomes, however, one of the senior managers was dealing with it and an audit trail was available. Staff spoken to were aware of their role in supporting residents to raise concerns and/or complaints, should they be unhappy with any aspect of the service. There was evidence that staff had safeguarding training and that a policy was in place to direct them on safeguarding issues. There were no safeguarding issues in the home and other aspects of the home’s operations e.g. recruitment, ensures that residents are protected from abuse. Staff spoken to demonstrated a good understanding of how they would deal with abuse or allegations of abuse. They also showed an awareness of how and when they would invoke the whistle blowing procedure. Residents are therefore are assured that they are protected from abuse while living at 626 Green Lane. Green Lane (626) DS0000025902.V362849.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (24,25,30) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Improvements have been made both to the communal and private areas of the environment. The home is maintained to a good standard of hygiene and cleanliness, which ensures the physical safety of all residents living there. EVIDENCE: During both visits to the 626 Green Lane the environment felt homely, as residents were quite relaxed carrying on with their individual activities. Action had been taken by the registered persons making improvements to both the communal area i.e. the upstairs landing and one of the bedrooms that was identified for improvement at the last inspection. Residents spoken to were happy with both the communal and private spaces throughout the home. They were able to access all areas of the home, including the rear garden, which itself has had some improvement works carried out to a fishpond located there. There was also a newly laid patio with new chairs and a Gazebo. It was clear that the registered persons have taken steps to ensure that the home remains not only fit for purpose, but also in line with the wishes of the residents that live there. Green Lane (626) DS0000025902.V362849.R01.S.doc Version 5.2 Page 18 The laundry facilities were examined and found to be in good order. Most of the residents are supported to do their laundry and they remain pleased with this. An infection control policy is in place and residents and staff are encouraged to work within this e.g. hand-washing. The laundry equipment is designed to cater for soiled linen and appropriate arrangements were in place for maintaining them. The layout of the home is such that foul linen is well away from food preparation and so the risk of the spread of infection is minimised. Services and facilities do comply with the Water Supply Regulations 1999. It must be noted that the feedback received from two residents informed that they were satisfied with the cleanliness of the environment as a whole. Green Lane (626) DS0000025902.V362849.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (32,34,35) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Residents receive care and support from a staff team that is motivated to work with them. Their welfare and best interests are promoted by ensuring that generally staffing levels are based on the needs of the residents. Good training arrangements are in place to equip staff with the knowledge and skills to carry out their roles in providing a quality service at 626 Green Lane. EVIDENCE: The staffing roster was assessed and importantly it was accurate in that it reflected the staff that were on duty for both days of the inspection. There was a sense of calm throughout the inspection process and the staffing interactions and interventions with residents were professional and reassuring. From the records viewed, staff were able to make appropriate referrals to external professionals e.g. the GP and generally able to act when emergencies occur. In discussion with individual members of staff, apart from knowing most of the residents well, they also demonstrated a good understanding of their roles and responsibilities in caring and supporting all residents. The recruitment files of the most recently recruited staff was examined and there was good evidence of the robustness in the recruitment practices undertaken by the organisation. All checks required by regulation were undertaken prior to staff taking up duty at 626 Green Lane. More importantly Green Lane (626) DS0000025902.V362849.R01.S.doc Version 5.2 Page 20 residents have opportunities to take part in the staffing recruitment process Residents are therefore assured that all staff are thoroughly screened prior to engaging with them. They are therefore more protected from the risk of coming to harm, from staff that may be unsuitable to provide care and support to them, which is a positive. A training and development plan is in place for the staff, which generally is line with the aims and objectives of the service. The training records of the most recently recruited staff was assessed and it was observed that she was provided with an appropriate induction one that was in line with the requirements of this standard. Other training that was provided included Fire safety, general health and safety, challenging behaviour, mental health and medication. Given the mix of the resident group plans were in place for the individual to undertake training in the care of the elderly. Interestingly, some residents have joined in the care of the elderly training with some, having already done health and safety. One off the key pieces of training that was planned for December 2008 was – safeguarding through dignity and care. This is positive and a strong area of the home’s operations. Green Lane (626) DS0000025902.V362849.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (37,39,40,42) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Management systems are in place to provide a quality service at 626 Green Lane. Good quality assurance systems are implemented to enhance this, although there is still outstanding work to be carried out on reviewing policies. Health and safety practices within the home generally protect the residents living there, but food storage needs to improve to ensure the safety of all residents and staff. EVIDENCE: During the second site visit the registered manager was on duty had recently returned from a long period of leave. An acting manager was put in place to cover this absence – supported by an experienced senior manager. Feedback received from the staff and residents indicated that the home was generally Green Lane (626) DS0000025902.V362849.R01.S.doc Version 5.2 Page 22 run to a good standard. The registered manager is experienced and has acquired her Registered Managers Award along with a VRQ – Level 2 in Mental Health. She has the support of her staff team and all residents spoken to were happy to have her back. In discussion with he registered manager she was looking forward to leading the team once again to providing good quality outcomes for the residents living there. There was evidence that quality assurance systems were implemented with the view to improving the service. This included; an internal audit of the service, regular monthly monitoring visits as required by Regulation 26 of the Care Homes Regulations 2001,regular resident meetings and opportunities for all residents to influence how the service is shaped. They also receive quite a bit of information about the organisational development and are invited to most events. Residents are therefore assured that the registered persons would take steps to monitor and develop the service in their best interests. This is a strong area of the homes operations. There were some improvements in the review of policies and procedures, in line with the requirements of the last inspection report. However, there is a bit more to be done and the registered manager informed that plans were in place to carry them out. It is imperative that they are reviewed as a matter of urgency s some e.g. the induction policy is way outdated i.e. issued in 2000 – some eight years old. Other examples included: Supervision, Safeguarding Adults and Equal Opportunities (2001). One of the worst examples is that of the one on Personal and General Health – Administration procedure on Controlled Drugs, which has been out in 1999. This is an area that must be completed to ensure that staff have access to updated policies and procedures to carry out their roles more effectively. The health and safety file was assessed and all records on; appliance safety, fire safety and electrical safety were in order. There was evidence that staff have as part of their induction, appropriate training in health and safety. Safety signs were also appropriately displayed throughout the home and all areas of the home were safely accessible to the residents. Risk assessments were in place for all residents to ensure their safety and independence. Health and safety policies were updated and available to all staff. However, food storage in the home was of an adequate standard as up to ten items of food were inappropriately stored. Improvement is needed in this area. Green Lane (626) DS0000025902.V362849.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 2 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 x 27 x 28 x 29 X 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 4 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 4 2 x 2 x Green Lane (626) DS0000025902.V362849.R01.S.doc Version 5.2 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14(a)(b) Requirement Timescale for action 30/05/09 2. YA6 15(1) 3. YA20 12,13 4. YA40 12 The registered persons are required to ensure that a summary of needs is obtained on residents and a detailed assessment - carried out prior to admitting them to the home. This would ensure that residents’ needs are identified and planned for, prior to agreeing their admission. The registered persons are 30/05/09 required to ensure that care plans accurately reflect the needs of all residents at all times. This is to promote the health and welfare of all residents. The registered persons are 30/05/09 required to ensure that staff accurately keep a record of drugs administered in the home. This is to promote the health and welfare of residents receiving support with medication. The registered persons are 30/05/09 required to complete the review update of the policies identified in Standard 40 of this report. This is to ensure that staff have updated guidance to carry out DS0000025902.V362849.R01.S.doc Version 5.2 Green Lane (626) Page 25 their roles more effectively. 5. YA42 13 The registered persons are 30/05/09 required to ensure that a system is in place to monitor and promote the safe storage of food in the home. This would preserve and promote the safety of residents and staff in the home. . RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Green Lane (626) DS0000025902.V362849.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Green Lane (626) DS0000025902.V362849.R01.S.doc Version 5.2 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. 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