Care Home: Green Trees

What the care home does well The staff at Green Trees are knowledgeable with regards to the needs of the people living in the home. There is an established manager leading the staff team. People’s needs are assessed prior to them moving into the home. This ensures that people’s individual needs can be met. The home is clean and tidy and residents are encouraged to bring personal items to the home so they have familiar things around them. This assists to make them feel secure and at home. People are encouraged to have appropriate relationships and maintain contact with family and friends, which promotes their emotional wellbeing. People are offered a healthy varied diet and their cultural wishes and preferences are respected. The home quickly identifies when people are not well and keeps relatives informed about what is happening. What has improved since the last inspection? When we last inspected the home on the 28th of October 2008 we made one requirement, asking the provider to make sure that guidelines were in place stating when `as required` medication should be administered. We saw during this visit that this guidance had been provided and staff were able to tell us Green Trees DS0000010646.V378046.R01.S.doc Version 5.2 how they made sure people living in the home got the medication they needed at the correct time. We also made 11 recommendations to improve outcomes for people living in the home. During this visit we found that the registered person had archived the old care plans and risk assessments. This avoids confusion about what is the most current guidance on support and care for the residents. The registered manager confirmed she has started her management training course. The deputy manager has identified a different work environment which will further develop his knowledge and skills and has told us that he will take up the opportunity to develop his skills further. The remaining recommendations noted on the previous report were discussed with the management team on the day of the inspection. What the care home could do better: One identified risk assessment in relation to the use of cot sides needs to be completed and reviewed. There needs to be a record of the opening date on an identified person’s eye drops to ensure that medication is disposed of within timescale. The safeguarding alerts procedure needs to be followed in all cases to ensure that people are cared for safely. Key inspection report CARE HOMES FOR OLDER PEOPLE Green Trees 21 Crescent East Hadley Wood Hertfordshire EN4 0EY Lead Inspector Wendy Heal Key Unannounced Inspection 15th October 2009 11:30 DS0000010646.V378046.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Green Trees DS0000010646.V378046.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Green Trees DS0000010646.V378046.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Green Trees Address 21 Crescent East Hadley Wood Hertfordshire EN4 0EY 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) 020 8449 6381 020 8449 2008 admin@greentreescarehome.co.uk www.greentreescarehome.co.uk Mr Brian Colin Haydon Ms L June Haydon, Mr Simon John Kidsley Ms L June Haydon Care Home 16 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0) of places Green Trees DS0000010646.V378046.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th October 2008 Brief Description of the Service: Green Trees is a small family owned residential care home specialising in the holistic care of the frail elderly and those who suffer from dementia. Green Trees home is a detached Edwardian property located in a residential area of Hadley Wood registered to provide care and support for 16 older people. The home is near to local shops. The home has 12 single and 2 double rooms available on two floors. Ten of the single bedrooms have en-suite toilets and wash basins. There are two bathrooms, both with hoists, a shower room with toilet and a ground floor toilet. The home has a lift. The home has a spacious lounge and dining room. The attractive rear garden is designed to be accessible for the residents. Mrs Haydon is one of three providers and she has managed the home for approximately fourteen years. The other two registered providers are Mr Haydon and Mr Kidsley. We would like to thank all three providers, people living in the home and staff working with them for their help with this inspection. The home’s stated aims and objectives are to make the resident’s stay as happy and as comfortable as possible, giving high quality care to enable the highest level of independence, choice, privacy, dignity and fulfilment that individual abilities will allow. Inspection reports produced by the previous regulator, the Commission of Social Care Inspection (CSCI), are available upon request from the registered manager/provider. The current scales of charges range from £500 to £575 per week. Green Trees DS0000010646.V378046.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This unannounced key inspection took place on Thursday 15th and Monday 19th October 2009. Wendy Heal, Regulation Inspector and Tony Lawrence, Local Area Manager, carried out the inspection. We spent a total of eight hours in the home assessing outcomes for residents against the National Minimum Standards for care homes for older people. We did this by talking to residents, their relatives, staff working in the home and the providers. We also checked care records and saw all parts of the home, including residents’ bedrooms and shared areas. We also received confidential surveys from people that live in the home, staff that work in the home and social and health care professionals and we have included their comments in this report. What the service does well: The staff at Green Trees are knowledgeable with regards to the needs of the people living in the home. There is an established manager leading the staff team. People’s needs are assessed prior to them moving into the home. This ensures that people’s individual needs can be met. The home is clean and tidy and residents are encouraged to bring personal items to the home so they have familiar things around them. This assists to make them feel secure and at home. People are encouraged to have appropriate relationships and maintain contact with family and friends, which promotes their emotional wellbeing. People are offered a healthy varied diet and their cultural wishes and preferences are respected. The home quickly identifies when people are not well and keeps relatives informed about what is happening. What has improved since the last inspection? When we last inspected the home on the 28th of October 2008 we made one requirement, asking the provider to make sure that guidelines were in place stating when as required medication should be administered. We saw during this visit that this guidance had been provided and staff were able to tell us Green Trees DS0000010646.V378046.R01.S.doc Version 5.2 Page 6 how they made sure people living in the home got the medication they needed at the correct time. We also made 11 recommendations to improve outcomes for people living in the home. During this visit we found that the registered person had archived the old care plans and risk assessments. This avoids confusion about what is the most current guidance on support and care for the residents. The registered manager confirmed she has started her management training course. The deputy manager has identified a different work environment which will further develop his knowledge and skills and has told us that he will take up the opportunity to develop his skills further. The remaining recommendations noted on the previous report were discussed with the management team on the day of the inspection. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Green Trees DS0000010646.V378046.R01.S.doc Version 5.2 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 Green Trees DS0000010646.V378046.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3, 5 and 6. People using 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. Admissions are not made to the home until a full care needs assessment has been completed. Prospective residents are given the opportunity to spend time in the home. EVIDENCE: During a discussion with the registered manager it was confirmed that prospective residents are given the home’s brochure along with the home’s Statement of Purpose and residents’ handbook, which contains a copy of the home’s contract of terms and conditions. The home also has a website. This ensures that accurate information is available about the home for those people that are making a decision as to whether they wish to live in the home. This information is also recorded in the Annual Quality Assurance Assessment prepared by the home. We were also informed that prospective residents can visit the home when they wish without making an appointment. Those people that may wish to live Green Trees DS0000010646.V378046.R01.S.doc Version 5.3 Page 9 at the home have a free trial period of seventy two hours as part of their referral admission procedure which allows people more opportunity to decide if the home can meet their individual needs. The inspector noted that within the home’s brochure services such as hairdressing, chiropody and the supply of toiletries are included the home’s fees. Residents can also invite friends or relatives for lunch by prior arrangement at no additional cost. One resident told us ‘My daughter visited before I moved in and I’ve been very happy here’. During this visit we checked the care plan files for five people living in the home. We saw that the provider had completed the home’s own care needs assessment or had obtained copies of assessments completed by health or social care professionals. This showed us that the provider made sure that each person’s identified care needs could be met at the time they moved into the home. We also saw evidence that the provider involved local authority staff in the review of people’s care needs after they had moved in. The provider told us that the home does not provide intermediate care and therefore Standard 6 does not apply. Green Trees DS0000010646.V378046.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People using 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. The delivery of personal care is individual and is flexible, consistent and reliable. Residents have access to healthcare and remedial services. The home has an efficient medication policy and procedures and practice guidance which staff understand and follow. EVIDENCE: During discussions with people living at the home the following comments were made: ‘I get up and go to bed when I’m ready. If I want to lie in bed in the morning, I just tell the staff’. ‘I can see the doctor whenever I want to and the staff make sure I take my tablets’. Green Trees DS0000010646.V378046.R01.S.doc Version 5.3 Page 11 During this visit we checked the care plans for five people who live in the home. We found that the care plans covered each person’s personal and health care needs and there was evidence that these were reviewed each month. This ensures that people’s changing needs are met. We also saw that staff completed nutritional, moving and handling and pressure care risk assessments and these were also regularly reviewed which assists to ensure that identified risks are minimised. The home also keeps a record of each person’s weight on a monthly basis. The daily care notes completed by staff showed us that people’s personal care needs were met and staff recorded what people ate at mealtimes, when people had a bath or shower, how they were involved in choosing what to wear and when to get up in the mornings or go to bed at night. This helps to make sure that people’s individual choices are respected. The care plan files we checked included a good record of any health care appointments and visits by the general practitioner, dentist, optician and chiropodist. The health care records we saw showed us that the provider asked for support from relevant professionals whenever a person’s health care needs changed. Staff had completed risk assessments for each resident’s mobility, nutrition, pressure care and risk of falling and we saw that these were regularly reviewed and updated. We did see that for one person, the use of cot sides at night had been agreed with the resident’s family, but no risk assessment had been completed. We pointed this out to the providers and they said that they would make sure this was done. One person wrote on their returned questionnaire ‘very good care, nothing is too much trouble’. Another person wrote ‘my honest opinion is that they do everything perfect. I have not got any complaints at all. The home is exceptional in the way that it gives each person individual care and attention’. This person also told us that their relative ‘is very settled and happy and looks upon it as their special home’. As part of this inspection we checked the medication for eight people living in the home. We saw that all prescribed medication was securely stored in a lockable trolley. Medication was administered from the pharmacist’s original containers and recorded on the administration record sheet for each person. The records we checked were very well completed and showed us that people living in the home got the medication they needed at the right time. We have made one requirement following this visit to make sure that staff record the opening date on bottles of residents’ eye drops. This will make sure that they are disposed of within agreed time scales. Green Trees DS0000010646.V378046.R01.S.doc Version 5.3 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People using 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 supported to make choices in all areas of their daily lives. People take part in activities in the home. People are actively encouraged to maintain their relationships. This promotes their emotional wellbeing. People are supported to choose healthy nutritious meals, which benefit their health and wellbeing. EVIDENCE: ‘We had a lovely party yesterday, with lovely food and lots of singing’. Comment from a resident. ‘I always enjoy the food, it is very, very good’. Comment from a resident. During this visit we saw that people’s care plans included some information about their social, cultural and religious needs and leisure interests. Residents and staff told us that a local minister visited the home regularly to meet with residents. This ensures that people’s individual rights are respected. Green Trees DS0000010646.V378046.R01.S.doc Version 5.3 Page 13 We also saw that staff kept a record of social activities and the people living in the home who took part in these. The daily care notes we saw did concentrate on the personal and health care needs of individuals and we recommend that staff also include more details about family visits and social activities in the home. For example, residents, relatives and staff told us that everybody had greatly enjoyed a birthday party held the day before we visited, but we saw that this was mentioned only briefly in a small number of daily care notes. The care plans we looked at included information about each resident’s family, friends and other significant people, together with details about how and when people should be contacted. Staff we spoke with had a good knowledge of residents’ life histories and significant people in their lives. When we last inspected the home, we recommended that staff should support people to take part in more activities in the local community. During this visit we saw evidence that social and leisure activities took place within the home, which include art and craft, bingo, quizzes, fortnightly visits from the hairdresser and beautician, on the day of the inspection the physiotherapist was holding a gentle exercise class. The home also has two cats and people were observed spending private time in their rooms. However the community activities happened less often. This is an area that the providers could improve in order to improve their overall quality rating. One person informed us in their questionnaire that ‘the home could increase the activity for residents including those individuals who cannot be cared for in communal areas’. During the two days we visited the home we talked with the home’s chef and saw the food prepared for lunch each day. We also checked the home’s menus. These showed us that the chef provided a good variety of nutritious food. The residents we spoke with were very positive about the food they ate at mealtimes. The meals we saw used fresh vegetables and were enjoyed by residents, with very little food wasted. Most people ate their meals in the home’s dining room which was a comfortable area, with people eating in small groups. Staff told us that they also supported some people to eat their meals in their bedrooms, if this was their choice or if they were unable to come to the dining room. ‘Family and friends are encouraged to visit and maintain contact by having no fixed visiting hours, and they are welcome to staff for meals if they wish and many do’. Extract from AQQA prepared by the home’. One health care professional told us that ‘the food looks appetising and residents enjoy meal times’. Green Trees DS0000010646.V378046.R01.S.doc Version 5.3 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People using 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. The home keeps a full record of complaints and this includes details of the investigation and any actions taken. The policies and procedures for safeguarding adults are available and give specific guidance for staff. Training of staff in safeguarding is regularly arranged by the home. EVIDENCE: ‘If I was worried about anything, I would talk to the staff or my daughter’. Comment from a resident. ‘It’s my job to make sure people are safe. I would talk to the manager if I had any concerns’. Comment from a member of staff. During this visit the provider told us that the home and the local authority’s safeguarding policies and procedures were available on the home’s computer. Staff told us that they knew where the policies were available for reference, but we would recommend that the procedure for reporting concerns is printed off and displayed in the office to make it easier for staff to refer to. The staff files we checked included copies of safeguarding adults training certificates for each member of staff. This assists to ensure that staff have the relevant knowledge and skills to protect residents living in the home from potential abuse. Green Trees DS0000010646.V378046.R01.S.doc Version 5.3 Page 15 We also saw that the provider kept a good record of any complaints received. Two formal complaints had been received since January 2009. One complaint involved medication found in a resident’s room. We saw that this was well investigated by the home’s manager and the complainant was satisfied with the outcome of the investigation and the action taken by the provider. The second complaint was from a relative and concerned injuries sustained by a resident who may have fallen out of bed. While we felt that the complaint had been well investigated by the manager, this should have been referred to the local authority as a safeguarding adults’ referral. This would have enabled a multi-agency investigation to make sure that the person was cared for safely in the home and agreed action was taken to prevent further incidents. The registered manager told us that the home does not retain any money or valuables on behalf of residents and relatives assist people living in the home with their finances. Green Trees DS0000010646.V378046.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,26, People using 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. People live in a spacious environment that is clean and comfortable. EVIDENCE: We undertook a tour of the home with the assistance of the manager. There are fourteen single and two double bedrooms available on two floors. Ten of the bedrooms have en-suite toilets and wash basins. There are two bathrooms, both equipped with hoists, a shower room with a toilet and a ground floor toilet. The home has a lift. There is also a spacious lounge and dining room. At the time of the previous inspection it was observed that the chairs in the lounge were in a line and this was still the case at the time of this inspection. However, the inspectors were informed that attempts had been made to position the chairs differently but the residents had re-positioned the chairs back to the original lay out. The management team expressed the view that they would try to change the layout of the lounge which was acknowledged by the inspectors. Green Trees DS0000010646.V378046.R01.S.doc Version 5.3 Page 17 There is an attractive garden accessible to residents, which also has a pond well stocked with different types of fish. The home has a well equipped kitchen. All of the equipment in the home was in working order on the day of the inspection. There were no unpleasant odours in the home. The home has a cleaner who was working on the day of the inspection and the home was clean. This safeguards the health and wellbeing of the people living in the home. Green Trees DS0000010646.V378046.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30, People using 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. People have confidence in the staff who care for them. All staff receive relevant training that is focussed on delivering improved outcomes for residents. All elements of recruitment are accurately recorded and the required documentation is always received prior to the employee starting work. EVIDENCE: ‘The staff are very good, they would do anything for me’. Comment from a resident. ‘I like all of the people here, they look after me very well thank you’. During this visit we saw that the home had enough staff on duty to meet the residents’ care needs and all staff worked well together to make sure that individuals were supported appropriately. We looked at the home’s rota and this showed us that there were always enough staff on duty. We did note that the home’s assistant manager sometimes worked for extended periods without a day off and the manager’s working hours were not recorded on the rota. We recommend that the manager records the hours she works on the rota and that the assistant manager reviews his shift pattern to make sure that he has sufficient breaks and days off. Green Trees DS0000010646.V378046.R01.S.doc Version 5.3 Page 19 We also checked the staff files for three care staff, one volunteer and the home’s chef. We saw that all of the required checks had been completed before people started work in the home. Staff files included proof of identity, two written references and a Criminal Records Bureau check. This showed us that the home made sure staff were suitable to work with older and vulnerable people. All of the staff files we checked included copies of training certificates showing us that all staff had completed the training they needed to work effectively and safely with people living in the home. This training included food hygiene, infection control, protection of vulnerable adults, health and safety, first aid for carers, dementia awareness, medication training and fire safety training. Green Trees DS0000010646.V378046.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38, People using 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. The manager has experience and qualifications and is competent to run the home. All staff are trained to follow the home’s health and safety policy and procedures. EVIDENCE: Mrs Haydon, the registered manager of the home, has been in post for many years. She has appropriate care qualifications and is currently undertaking a management qualification. ‘The manager has very good knowledge in relation to the residents’ needs. One health care professional noted in their questionnaire that ‘The manager knows her residents well’. The assistant manager is Mrs Haydon’s son and he wishes to become the manager when his mother makes the decision that she wishes to retire. A Green Trees DS0000010646.V378046.R01.S.doc Version 5.3 Page 21 discussion took place with Mr Haydon as at the time of the last inspection it was recommended that it would be helpful if he further developed his skills by having some experience of working in another service. Mr Haydon confirmed that he has approached another service provider that he knows and did acknowledge that he is planning to explore this further as part of his personal development. During this visit we checked the home’s arrangements for implementing the Mental Capacity Act and Deprivation of Liberty safeguards (DOLs) introduced this year. We saw that the home’s manager had completed a Dols checklist for each person living in the home. This had been used to identify any restrictions placed on residents. The Manager told us that the local authority social services departments responsible for placing people in the home had been told about the outcome of each person’s assessment. The home completes quality assurance surveys ‘completed by residents, relatives, general practitioners and hospital consultants’. (extract from an AQQA prepared by the home.) The manager and staff told us that staff had formal supervision with the manager or assistant manager every two months. The manager told us that the supervision records were kept on the homes computer system. The current certificates were available to confirm the maintenance for the portable electrical appliances, gas appliances, the electrical certificate, maintenance of the lift, bath, Aid call, fire alarm and extinguishers and emergency lighting. The weekly fire alarm checks and quarterly fire drills are taking place according to the fire safety records. This promotes the health and safety of the people living in the home. Green Trees DS0000010646.V378046.R01.S.doc Version 5.3 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 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 X X 3 3 X 3 Green Trees DS0000010646.V378046.R01.S.doc Version 5.3 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP8 Regulation 13 (8) Timescale for action Where cot sides are used on a 31/12/09 resident’s bed, the provider must make sure that a risk assessment is completed and regularly reviewed. This will help to make sure that residents are cared for safely. Staff must record the opening 31/12/09 date on bottles of residents’ eye drops. This will make sure that they are disposed of within agreed time scales. The provider must make sure 31/12/09 that the home’s safeguarding adults procedures are followed in all cases. This will help to make sure that residents are cared for safely. Requirement 2. OP9 13(2) 3. OP18 13 6 s3 reg 171a 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 Trees DS0000010646.V378046.R01.S.doc Version 5.3 Page 24 1. 2. OP18 OP27 The registered person should ensure that the procedure for reporting concerns is displayed in the office to make it easier for staff to refer to. The registered person should ensure that the hours they work are identified on the rota and the assistant manager reviews his shift pattern to make sure that he has sufficient days off and breaks. Green Trees DS0000010646.V378046.R01.S.doc Version 5.3 Page 25 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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