Care Home: Greenhaven Resource Centre

What the care home does well This home provides a safe, well-maintained environment where efforts are made to create homely living spaces. There are enough staff, with relevant training, to meet the diverse needs of the people who live there. There are specialist areas for people with dementia and people who are being helped to redevelop daily living skills. The home assesses people`s needs before they come into the home and uses this information to create care plans which cover their needs and preferences. There are good arrangements to ensure that people`s health needs are met and that medication is handled in a safe way. There home provides a variety of activities so that people have a good choice of what to do. People are encouraged to maintain links with their families and friends and to take part in activities in the community. There are good arrangements so that people are offered healthy meals which suit their preferences and meet their needs.People are provided with good information about how to make a complaint and they are encouraged to express their views. There are very good arrangements for monitoring the quality of care so that the home can continue to develop and improve the service it provides. People living in the home said that they are looked after well. One said, `It`s grand`. What has improved since the last inspection? The home has improved the dining facilities and introduced new menus which reflect the tastes of the people who live there and offers healthier food, using fresh, seasonal ingredients and more dishes created on the premises. There have been many improvements to the building so that flooring is safer, many areas are more contemporary and homely and the dining area is more like a restaurant. There have been improvements to the storage and administration of medication so that people are better protected. Staff have received more training in adult protection issues so that they are more able to recognise the signs of possible abuse and knowledgeable about what action to take. The home keeps better records of staff training so that it is now easier to identify who needs additional or refresher training. There is now a better system for recording and assessing the value of activities in the home. There are better arrangements for consulting the people who live in the home and involving them in planning their care. Some records are now typed up on the computer so that they can be more easily read and there is less opportunity for staff to misinterpret them. What the care home could do better: The home has identified areas in which it could improve and these include changing the use of some parts of the building so that some people have improved access to outside areas.Additional training is planned for staff so that they will have better skills in the specialist areas needed for some people in the home. The home needs to improve the way in which records are kept of the application of creams and bath water temperatures. These improvements should help to protect people who live in the home. The daily contact records and care plans would be more accessible of they were kept together in one place for each person. CARE HOMES FOR OLDER PEOPLE Greenhaven Resource Centre Grout Street West Bromwich West Midlands B70 0HD Lead Inspector Chris Lancashire Unannounced Inspection 4th August 2008 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Greenhaven Resource Centre DS0000035520.V370621.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. Greenhaven Resource Centre DS0000035520.V370621.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greenhaven Resource Centre Address Grout Street West Bromwich West Midlands B70 0HD 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) 0121 557 8088 0121 522 2354 www.sandwell.gov.uk Sandwell Metropolitan Borough Council Vacant Care Home 46 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (31) of places Greenhaven Resource Centre DS0000035520.V370621.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: All requirements contained within the registration report of 6 & 7 December 2002 are met within the timescales contained within the action plan agreed between Sandwell Metropolitan Borough Council and the National Care Standards Commission. A maximum of 31 people in the category of OP to be accommodated on the ground floor, 5 of whom may be aged 57 years and over. A maximum of 15 people in the category DE(E) to be accommodated on the first floor, 2 of whom can be 57 years and over 17th July 2007 2. 3. Date of last inspection Brief Description of the Service: Greenhaven care home is owned and managed by Sandwell Local Authority. It provides residential services to a maximum of 46 older people. Five of the places are allocated for rehabilitation purposes, thirteen to older people who have a diagnosis of dementia. The home is situated in a residential area of Great Bridge West Bromwich. It is in easy reach of Great Bridge centre where bus links are available to neighbouring Dudley and West Bromwich. The home is next to Farley Park. A number of rooms have views over the park. The building is set out on two floors, with a lift providing access to all communal areas of the home. Access for wheelchair users is good. There are dining and lounge facilities on the ground floor with a number of smaller quiet lounges situated throughout the home. Living space includes two conservatories which offer a warm, bright place to sit or use for leisure purposes. The home has generous sized, attractive, safe garden areas which accommodate raised flower beds. Two flats cater for more independent living and represent part of the rehabilitation provision. Greenhaven Resource Centre DS0000035520.V370621.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We visited the home without telling anyone that we would be arriving that day. The purpose of the visit was to find out about the quality of the care and to find out if the requirements in the last report had been met. We asked the manager to fill in a form called an Annual Quality Assurance Assessment before the visit. This tells us how the manager considers the home is running and gives us some information about the staff and the people in the home. The home’s previous manager completed this. On the day of the inspection, the home’s new manager was starting her job. During the visit we looked round the home and spoke to many of the people who live there. We spoke to staff on duty and to the manager and service manager. We also looked at records which are kept on five of the people in the home, the staff, the medication and checks on the safety of the building. We used this information to make judgements about the home and the way it is run. The quality rating for this service is 2 stars. This means that the people who use this service experience good quality outcomes. The fees are available on application to the home. What the service does well: This home provides a safe, well-maintained environment where efforts are made to create homely living spaces. There are enough staff, with relevant training, to meet the diverse needs of the people who live there. There are specialist areas for people with dementia and people who are being helped to redevelop daily living skills. The home assesses people’s needs before they come into the home and uses this information to create care plans which cover their needs and preferences. There are good arrangements to ensure that people’s health needs are met and that medication is handled in a safe way. There home provides a variety of activities so that people have a good choice of what to do. People are encouraged to maintain links with their families and friends and to take part in activities in the community. There are good arrangements so that people are offered healthy meals which suit their preferences and meet their needs. Greenhaven Resource Centre DS0000035520.V370621.R01.S.doc Version 5.2 Page 6 People are provided with good information about how to make a complaint and they are encouraged to express their views. There are very good arrangements for monitoring the quality of care so that the home can continue to develop and improve the service it provides. People living in the home said that they are looked after well. One said, ‘It’s grand’. What has improved since the last inspection? What they could do better: The home has identified areas in which it could improve and these include changing the use of some parts of the building so that some people have improved access to outside areas. Greenhaven Resource Centre DS0000035520.V370621.R01.S.doc Version 5.2 Page 7 Additional training is planned for staff so that they will have better skills in the specialist areas needed for some people in the home. The home needs to improve the way in which records are kept of the application of creams and bath water temperatures. These improvements should help to protect people who live in the home. The daily contact records and care plans would be more accessible of they were kept together in one place for each person. 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. Greenhaven Resource Centre DS0000035520.V370621.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 Greenhaven Resource Centre DS0000035520.V370621.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): Quality in this outcome area is good. 1, 3, 6. People and their representatives have the necessary information they need to make a choice about coming to this home. No-one moves into this home without having their needs assessed and being assured that they will be met. The home tries to help all people living there to keep and develop their independence, particularly those admitted for rehabilitation. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a Statement of Purpose and service user guide which provide people with information about the home and the way it is run. The manager informed us that there are plan to update thee documents so that they reflect the improvements which are planned at the home. They also need to contain the most recent contact details for the CSCI. We saw copies of the Statement Greenhaven Resource Centre DS0000035520.V370621.R01.S.doc Version 5.2 Page 10 of Purpose and guide in the home in shared areas. We sampled people’s care files and found that they contained details of the assessments made on people before they were admitted to the home. This information is used to create the care plans which help staff to know how to look after people. The manager informed us that people’s needs are assessed when they are in their own home wherever possible. People are invited to look round the home and if they decide to move in, they do so on a trial basis, which can be extended if necessary. Staff try to help everyone in the home to keep and develop their skills and to be as independent as possible. There are people who have been admitted for a short stay so that they can regain independence skills before moving back to their home. Staff focus their attention on enabling them to complete basic tasks. People in the rehabilitation unit said that they felt that their stay had been very helpful to them and that staff had been patient. Greenhaven Resource Centre DS0000035520.V370621.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 good. People who live in this home have their health needs met and are protected by the home’s arrangements for the storage and administration of medication. They are treated with respect and their right to privacy is upheld. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We sampled people’s files and found that they contained plans with details of people’s health needs. The care plans are broken down into separate areas for each symptom or condition and have details of how care needs to be provided. The home has started to type records when possible, so that the risks of staff misinterpreting each other’s handwriting are eliminated. Discussions with staff showed that they were aware of people’s particular needs due to health reasons. There were also records of appointments which they had attended and visits to the home by a range of health professionals. The daily contact notes also showed that staff are aware of people’s health needs. However, Greenhaven Resource Centre DS0000035520.V370621.R01.S.doc Version 5.2 Page 12 these notes are not kept with the other records and this makes access to each person’s records more difficult. We discussed this with the new manager, who agreed to consider moving the location of these records. Staff respect people’s privacy at this home. We saw staff knocking on doors and waiting for an answer before entering. Doors to all bathrooms and toilet areas were closed. Staff take good care of people’s clothing so that they can dress in a dignified way. We saw staff being very patient with people who showed signs of confusion. One person who lives in the home told us, ‘The girls are great’. At the last key inspection there were several requirements regarding the medication arrangements. The pharmacist inspector carried out a further inspection on 17th December 2008. Most of these requirements had been met at that inspection. We found that there have been further improvements. These include improved recording of when medicines have been given and better storage arrangements, so that medicines are now at the correct temperature. On the day of this inspection, it was a hot day and the room where the medicines were stored was cool enough because there was a fan in the room. The medicine refrigerator is now defrosted more regularly so that the temperature is more consistent. There are better instructions for staff when medicines need to be given ‘as required’. However, although there are instructions for care staff, there is a need to make sure that all relevant staff are aware when there are specific requirements for people who are taking certain medicines to avoid certain foods and the records of how this information is passed on need to be improved. We discussed this with the new manager, who agreed to put a suitable system in place. The arrangements for recording when creams have been applied have improved. However, records in this area are still not always completed and need to be improved. We saw that this need has already been identified through the home’s quality monitoring system and is being addressed. Greenhaven Resource Centre DS0000035520.V370621.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is good. People who live in this home find that the lifestyle experienced in the home generally matches their expectations and preferences. They are encouraged to maintain contact with family and friends and the visiting times are flexible. They are helped to have control over their lives and to make choices. The people who live in this home are offered nutritious, varied and interesting meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked in people’s records and in the activities book and saw that people had undertalen a range of activities in the home. These included visits from professional and amateur entertainers. People also play games and undertake individual activities such as reading and doing puzzles. Staff told us that they try to tailor activities to the individual as well as group activities. Some people told us that they like to watch television, but there are also several sitting areas where people can sit quietly. The home organises outings where possible and the manager told us that they encourage people to be involved in Greenhaven Resource Centre DS0000035520.V370621.R01.S.doc Version 5.2 Page 14 activities in the local community. The visitors book shows that there are many regular visitors and most people have contact with friends or family. The home also celebrates festivals such as Christmas, Easter, mothers’ day and fathers’ day. There was a successful fun day, earlier in the year, which raised money for further activities. These have all increased the amount of family/carer involvement in the home. There is a new system for monitoring the therapeutic value of the activities which take place and this has been set up to take account of the needs of the specialist units within the home, such as the unit for people with dementia and those who are being preparing for further independence. There are occasional meetings to seek people’s views, but these are not alwayd the most suitable way of helping people to have say in how the home is run as there are so many people and some would to be able to have their views heard. The staff regularly ask people about their preferences, for example their meal choices. There are also annual questionaires and information about how to make comments and make suggestions. We saw from the minutes of reviews that people are involved in discussing their care plans. In order to make sure that staff can meet the needs of all people in the home and have a good understanding of the diversity of need, all staff are provided with training in this area. The records show that during the last three months, 24 care staff and 4 managers within the unit have been enrolled on an accredited course in diversity and equality and the remaining staff are to be enrolled when the first staff have completed the course. The home has introduced a new menu based on the choices and preferences of the people who live there. This makes sure that people are offered at least five portions of fruit and vegetables each day. They have removed 90 of processed products and replaced these with fresh, seasonal products and increased the level of home-made options. The dining room has also been restyled so that it is more like a restaurant and provides a better environment for people to take their meals. When touring the building we saw one person telling the member of staff that she would like a banana. When we passed the room again, she was eating one. The manager said that fruit is available at all times. Several people living in the home told us that the meals are very good and something to look forward to. Greenhaven Resource Centre DS0000035520.V370621.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. People who live in this home are protected by the staff, who follow the policies and procedures. There are good arrangements to make sure that people’s complaints will be listened to. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We saw that there are details of how people can make a complaint on notice boards. They are also in the Statement of Purpose and service user guide. The manager informed us that all staff are provided with guidance during induction to assist in dealing with complaints and further guidance is provided during individual supervision meetings. It is also a standard agenda item within team meetings. The home tries to use all complaints, compliments and suggestions to continually improve the service to people who live in the home. We saw that all staff have recieved training in the protection of vulnerable adults and their responsibilities in relation to this matter to an approprite level dependant on their role within the unit. The manager told us that additional guidance is given to individual staff members during their supervision and general awareness and updates to policy and legislation are provided during team meetings as a standard agenda item. Greenhaven Resource Centre DS0000035520.V370621.R01.S.doc Version 5.2 Page 16 There are records of complaints, comments and suggestions and what has been done about these. The home’s quality monitoring system is used to monitor the number and type of complaints received. Since the key inspection, one complaint and one vulnerable adult investigation have taken place and both were resolved. People who live in the home said that they are very happy with the care provided and they said that they would tell the staff or the manager if they needed to change anything. Greenhaven Resource Centre DS0000035520.V370621.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): 19,21,23 and 26. Quality in this outcome area is good. The home is well maintained so that people live in a comfortable, clean and safe environment. They have sufficient lavatories and washing facilities and their rooms meet their own needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Greenhaven is a large detached home that was purpose built and opened in the late 1970’s. Externally the home is sound. Window frames are all made of UPVC material. The home has attractive outdoor space with raised flower beds and easy access. We saw that the building is well maintained is bright and homely. It has a number of different living spaces including conservatory areas and a choice of lounges in addition to dining rooms on each floor to give choice and privacy. Greenhaven Resource Centre DS0000035520.V370621.R01.S.doc Version 5.2 Page 18 Some areas are used for specialist functions such as the areas for people with dementia or the areas for people who are being assisted to redevelop more independent living skills. Several communal areas, including the reception have been decorated and refurnished so that they are more contemporary and homely. Many of the carpets in corridors and shared areas have been replaced with more practical alternatives which help infection control and reduce the risk of trips. We looked at several bedrooms and found these to be of a good standard in terms of flooring and decoration. They were bright and homely, with personal items to reflect the taste of the person whose bedroom it was. We saw that all areas were very clean. There were good supplies of aprons, gloves and hand sanitizer to prevent the possible spread of infection. Toilets cubicles are all wide enough for staff to be able to offer assistance to the user. Bathrooms have accessible baths and are all provided with waste bins, liquid soap and paper towels. Sluices have been fitted and there are machines for washing commode pots. Greenhaven Resource Centre DS0000035520.V370621.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 and 30. Quality in this outcome area is good. The people who this home have their needs met by adequate numbers of staff who are suitably recruited and who receive training in the necessary areas so that they are competent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The rotas show that there are adequate numbers of staff. The information provided by the manager shows that they receive training so that they can provide suitable care. 55 of staff have NVQ level 2 and a further 7 are in training. The training matrix shows that all staff have been trained in adult protection awareness and, during 2008, several have received training in manual handling, basic health and safety and other relevant areas. Infection control training is not mandatory in Sandwell, but staff have undertaken this as a distance learning package. Records show that some courses run by the local authority are regularly oversubscribed, but the home has negotiated to take up places when there are people who fail to attend as the home is quite close to the training centre. There has been no recent recruitment as Sandwell is implementing its modernisation programme. Some homes have closed and staff have Greenhaven Resource Centre DS0000035520.V370621.R01.S.doc Version 5.2 Page 20 transferred to this home. Recruitment is through the standard local authority procedures and has been found to comply with good practice in the past. Sampled files contained evidence of the necessary checks on people employed. The manager confirmed that she receives notification of checks being complete prior to starting each worker. Greenhaven Resource Centre DS0000035520.V370621.R01.S.doc Version 5.2 Page 21 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 and 38. Quality in this outcome area is good. The people who live in this home benefit from good management and robust systems for monitoring the quality of care. There are systems to adequately safeguard people’s money. The health and safety of people in the home, the staff and visitors is well promoted and managed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is currently no registered manager of this home. However, on the day of the inspection, a new manager had just taken up her role. She has been the registered manager of another home run by Sandwell local authority for Greenhaven Resource Centre DS0000035520.V370621.R01.S.doc Version 5.2 Page 22 several years and plans to apply for registration at Greenhaven. She is well qualified and experienced to undertake this role. We looked at the home’s quality monitoring system. This is thorough and covers all areas of the management and operation of the home. The system includes seeking and analysing feedback from people who live in the home, their relatives and representatives and professional visitors to the home. Accidents, complaints, staff training, and compliance with policies and procedures are monitored. The home has maintained its ISOQUAR registration following an independent inspection earlier this year. This system is used to find areas where the service can be improved and the AQAA contained several areas of planned development. We were informed that managers in the home have recently undertaken financial training. There are monthly checks on the safe and financial handovers at each shift change. We checked the money held by the home on behalf of three people who live there and found that it was correct. We found good records showing how the money had been spent. We were informed, in the AQAA, that all necessary checks have been made on the equipment in the home so that it is a safe environment. We sampled these records and found that checks are up to date. The last check by the environmental health officer on the kitchen was in February 2007 and there are no outstanding areas to address. We also saw risk assessments on the environment and on people in the home and the activities which they undertake. This means that the people in the home, the staff and visitors to the home are kept safe. However, we saw that the forms for recording the temperatures of the baths which people take have not always been completed. We brought this to the attention of the manager. Although the water is regulated, this is an important area to check as people need to be protected from any risk of scalding. Greenhaven Resource Centre DS0000035520.V370621.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 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 X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X 3 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 4 X 3 X X 3 Greenhaven Resource Centre DS0000035520.V370621.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action 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 3 Refer to Standard OP1 OP7 OP9 Good Practice Recommendations The manager should update the Statement of Purpose and service user guide so that they contain the latest contact details for the CSCI The manager should consider keeping care plans and daily contact notes on each person who lives in the home in one place. The manager should make sure that staff record all applications of creams to service users and that all relevant staff are made aware of the specific requirements associated with certain medication. The manager should make sure that bath temperatures are always recorded in the home’s system for this purpose. 4 OP38 Greenhaven Resource Centre DS0000035520.V370621.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Greenhaven Resource Centre DS0000035520.V370621.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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!