Care Home: Greenway House

What the care home does well A small home providing individualistic care for a small group of older people. Relationships between residents and staff are close and easily established in what resembles a small family group. Good engagement was noted between staff and residents and a relaxed, informal, family atmosphere prevailed. The Registered Managers are also owners and have a daily presence in the home, closely monitoring high standards of care provided. Owners arereceptive to advice and input. They have a good record of compliance with CSCI requirements and recommendations. This home has a good record of a sustained high quality environment with high standards of care maintained. Visiting is encouraged. Visitors received either in the lounge areas or privacy of bedrooms if residents prefer. There is a pro-active approach to health care needs with early referrals to healthcare professionals where indicated. Good relationships are evident between health care professionals and the homes staff. The care of a 102 yr old resident with very high dependency needs was excellent. Her physical needs assessed in detail with a care plan to ensure those needs were met. This is a good example of person-centred care where the quality of life issues, in addition to just the physical needs of the person were known and met. Chosen lifestyles are met. Residents wishing to socialise have good opportunities with a range of activities available if needed. Those residents wishing to have greater privacy with perhaps a larger part of their time spent in their bedrooms are allowed to do so. What has improved since the last inspection? Ongoing refurbishment/improvements continue: The main lounge area has been redecorated, re-carpeted and matching softfurnishings replaced. Residents have been consulted and have made choices about colour/type etc. New skylights have been replaced in the conservatory and kitchen area. Hall/corridor areas have been redecorated. A small kitchenette where residents and visitors can make drinks etc has been completely refurbished to a high standard. New carpets, furniture and redecoration of two bedrooms has taken place. IT is the homes policy as bedrooms become vacant to redecorate and refurbish as necessary. Lounge and dining chairs have been renewed/re-upholstered. The external parts of the building have been repainted and flat-roofs refinished. All activities are now recorded including those provided on a 1:1 basis with individuals, including those with dementia care needs and unable to engage in small group activity. What the care home could do better: CARE HOMES FOR OLDER PEOPLE Greenway House 103 Springhill Lane Lower Penn Wolverhampton Staffordshire WV4 4TW Lead Inspector Peter Dawson Unannounced Inspection 31st January 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Greenway House DS0000004948.V358579.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. Greenway House DS0000004948.V358579.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greenway House Address 103 Springhill Lane Lower Penn Wolverhampton Staffordshire WV4 4TW 01902 330444 01902 335849 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) Mrs Deborah Roberts Mrs Jacqueline Edwards, Mrs Christine Munslow Mrs Deborah Roberts Mrs Christine Munslow Care Home 12 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (12), of places Physical disability over 65 years of age (7) Greenway House DS0000004948.V358579.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th June 2006 Brief Description of the Service: Greenway House is a twelve-bedded residential care home for elderly people. The home is located in Lower Penn near to the city of Wolverhampton. Originally a private family home tastefully converted to a residential care home. Accommodation is to a very high standard. Residents’ bedrooms are located on the ground and first floor; the first floor being accessed via the shaft lift or staircase. All bedrooms have en-suite facility and are tastefully decorated. They have views from the windows over the extensive gardens and countryside. The larger lounge with a conservatory provide easy access to the wellmaintained, private garden area. The home is tastefully decorated and is maintained to very high standard by its owners. Greenway House DS0000004948.V358579.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 star. This means the people who use this service experience good quality outcomes. This unannounced key inspection was carried out by one inspector on one day from 9 am – 5.00 pm. The National Minimum Standards for Older People were used to assess the service. The home provided an Annual Quality Assurance Assessment (AQAA) prior to the inspection providing pertinent information about the service, some information being used in this report. There were 12 people in residence at the time of the inspection (no vacancies) all were seen and the majority spoken with together/separately and many in private. One visitor was seen privately during the visit. All residents spoke highly of the care provided at Greenway House and said that staff supported them well. Comments included “staff are wonderful” “this home is the best I have seen” and “we can have anything we ask for”. Two recently admitted residents said that they had settled quickly and well into the home, assisted greatly by staff. A visitor of a recently admitted person confirmed this and felt that his mother had “settled better than they thought she would”. Her particular social needs had been listened to and acted upon and her individual needs met. What the service does well: A small home providing individualistic care for a small group of older people. Relationships between residents and staff are close and easily established in what resembles a small family group. Good engagement was noted between staff and residents and a relaxed, informal, family atmosphere prevailed. The Registered Managers are also owners and have a daily presence in the home, closely monitoring high standards of care provided. Owners are Greenway House DS0000004948.V358579.R01.S.doc Version 5.2 Page 6 receptive to advice and input. They have a good record of compliance with CSCI requirements and recommendations. This home has a good record of a sustained high quality environment with high standards of care maintained. Visiting is encouraged. Visitors received either in the lounge areas or privacy of bedrooms if residents prefer. There is a pro-active approach to health care needs with early referrals to healthcare professionals where indicated. Good relationships are evident between health care professionals and the homes staff. The care of a 102 yr old resident with very high dependency needs was excellent. Her physical needs assessed in detail with a care plan to ensure those needs were met. This is a good example of person-centred care where the quality of life issues, in addition to just the physical needs of the person were known and met. Chosen lifestyles are met. Residents wishing to socialise have good opportunities with a range of activities available if needed. Those residents wishing to have greater privacy with perhaps a larger part of their time spent in their bedrooms are allowed to do so. What has improved since the last inspection? Ongoing refurbishment/improvements continue: The main lounge area has been redecorated, re-carpeted and matching softfurnishings replaced. Residents have been consulted and have made choices about colour/type etc. New skylights have been replaced in the conservatory and kitchen area. Hall/corridor areas have been redecorated. A small kitchenette where residents and visitors can make drinks etc has been completely refurbished to a high standard. New carpets, furniture and redecoration of two bedrooms has taken place. IT is the homes policy as bedrooms become vacant to redecorate and refurbish as necessary. Greenway House DS0000004948.V358579.R01.S.doc Version 5.2 Page 7 Lounge and dining chairs have been renewed/re-upholstered. The external parts of the building have been repainted and flat-roofs refinished. All activities are now recorded including those provided on a 1:1 basis with individuals, including those with dementia care needs and unable to engage in small group activity. 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. Greenway House DS0000004948.V358579.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 Greenway House DS0000004948.V358579.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. Standards 1 –5 were assessed on this visit. There was adequate information provided about the services offered. Preadmission procedures were good enabling people to make an informed judgement about the home prior to admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose/Service Users Guide have been updated. All residents have a copy and there is a copy readily available in the home for visitors or prospective residents and their families. Written contracts/statement of purpose were seen on individual files sampled. Greenway House DS0000004948.V358579.R01.S.doc Version 5.2 Page 10 The home carries out pre-admission assessments for all prospective residents in their current environment. The assessment document seen was comprehensive and adequate – several seen on sample of care plan files. The majority of residents are self-funding and therefore do not generally have Care Management Assessments. The homes own assessment is therefore crucial. Prospective residents are invited to the home prior to admission to make a judgement about suitability of the home. A recently admitted resident said she had visited twice prior to admission and offered an overnight stay which she had declined. Greenway House DS0000004948.V358579.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): Quality in this outcome area is good. Standards 7 – 10 were inspected on this visit. Care plans contain good health and personal care information. Health care needs are fully met. Some aspects of medication could be strengthened to ensure protection of residents. Residents are treated with respect and dignity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Samples of care plans inspected showed that they were based upon preadmission assessments and were reviewed/updated on an ongoing basis. Funded residents are generally reviewed annually by Social Services and selfGreenway House DS0000004948.V358579.R01.S.doc Version 5.2 Page 12 funding residents reviewed by the home on a regular basis. Views of residents/relatives are sought and care plans signed. There is a regular monthly review by a Manager for all residents. Care plans contained some good information about care needs. For a highly dependent resident there were very clear instructions in the care plan and bedroom of the person outlining actions for bed-bath, hoisting with slings and nutritional assessment with clear instructions. Skin was intact with good tissue viability assessment and care with overlay and pressure-relieving cushion in place. The District Nursing service visits twice weekly to monitor progress. The health, personal and social care of a 102 yr resident was reviewed and found to be to a very high standard. There was some detail about chosen lifestyle, personal preferences, likes/dislikes etc. There was an absence of social histories and the home given advice/options of obtaining this information which is important to provide an holistic view of care needs. Recording of health care matters was good and evidence of involvement of healthcare professionals at required times were seen. Scabies was imported into the home by a resident from a former setting. The home dealt with this in an excellent way – responding swiftly and seeking immediate advice from GP and the Health Protection Agency, following strict routines of hygiene to limit the spread of infection. The matter was resolved swiftly and effectively due to prompt action and consultation with relevant healthcare professionals. Individual risk assessments were in place relating to daily living, for example a recently admitted resident who goes out unescorted for daily walks has a risk assessment in place. Daily notes were seen and contained adequate information to denote daily progress. There are 3 staff handover times each day and written notes are provided. There was discussion about possible duplication of these records and alternatives discussed which would reduce some recording and maybe provide more detailed recording of night care. The medication system was inspected. One person self-medicates and there is a risk assessment in place relating to this. All staff administering medication have had appropriate training. Two areas of medication administration could be improved: Three separate creams seen in a bedroom were not labelled and not entered on the MAR sheet. It is important that all prescribed creams contain individual detailed instructions for their use, are entered on MAR sheets and signed when Greenway House DS0000004948.V358579.R01.S.doc Version 5.2 Page 13 administered. It will be necessary to approach the community pharmacist to ensure that the clear instructions of the prescriber are attached. There was a list of homely remedies including paracetamol, immodium, kaolin & morphine. There was no policy/procedure for homely remedies, they had not been cleared with the GP and not entered on MAR sheets when administered. If homely remedies are to continue it is important that the GP individually reviews, agrees and signs protocols for their use. Alternatively they can be prescribed individually. It is important to have a reducing balance for example of paracetamol, which can be checked/audited. Residents were seen to be treated with respect during the inspection and their privacy ensured. This was confirmed in discussions with residents who said that staff were “very caring and excellent”. Greenway House DS0000004948.V358579.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards12 – 15 were inspected on this visit. Resident are satisfied with their chosen lifestyles and activities in the home. Their individual social, recreational and religious needs are met. Contacts with family/friends are an integral part of care provision. There is high satisfaction with food provision. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This is a small home with a high standard environment. All areas have plenty of natural light. Furnishing, fittings and equipment are of high quality and present a very homely environment which resembles a large family home. All bedrooms are for single use and have en-suite facilities. Residents take advantage of this environment and the size of the home. There is a large communal lounge with conservatory. During the inspection a group of residents were playing cards at one end of the lounge and small group of resident at the other end chatting happily together with staff uninterrupted. Greenway House DS0000004948.V358579.R01.S.doc Version 5.2 Page 15 There is adequate space. Residents said that their chosen lifestyles were known and “we are able to choose what we want to do each day”. All residents had breakfast served in their bedrooms on the day of this unannounced inspection, some came to the lounge areas during the morning, others stayed in their bedrooms, one received a visitor in her bedroom. There was evidence of choice and preference. A recently admitted resident said that she had settled well staff had been very supporting towards her. She goes to the dining room for meals but preferred the privacy of her bedroom throughout the day, being able to follow her particular interests. She goes out alone for a short walk each day (risk assessment in place) which she enjoys. She also enjoys the privacy of her room. Most residents were spoken with in the lounge and bedroom areas. All confirmed they were well cared for and able to make individual choices. Activities are listed 3 mornings each week and most residents take advantage of them. There are additional visits by a music/movement provider, hairdresser etc. At the time of the last inspection activities were recorded for the group for not for individuals. It was important to record 1:1 inputs for residents also. This has been done, there is a diary of activities recorded and also individual activities which included reminiscence, individual discussions and a member of staff reads poetry to a resident by request. Specific activities and time is allocated to ensure people with dementia have equal activity choice. Coffee mornings, sherry & mince pie evening etc are arranged where families are invited. Clergy visit the home and there have been specific arrangements made to meet individual denominational needs. Visitors are encouraged to visit at any time. A visitor seen said that he is always welcomed by staff, is kept informed of progress and able to visit his relative in her bedroom – her chosen venue. Food provision has been traditionally good in this home. The dining room is attractive - well furnished with quality linen, cutlery, crockery, tabledecorations etc. and resembles a good class restaurant. All residents asked said that the food choice, quality, quantity and presentation are “excellent”. Greenway House DS0000004948.V358579.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards 16 – 18 were inspected on this visit. Outcomes are good with a satisfactory complaints procedure in place and opportunities for residents to engage with staff, managers and owners. Staff are aware by training and discussion. of the broad definitions of abuse and procedures for reporting. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a satisfactory complaints procedure in place, displayed in the home and also contained the Statement of Purpose/Service Users Guide – all residents have a copy. There is a suggestions box for people to make anonymous complaints/express concerns. No complaints have been received by the home or the Commission since the last report. Residents spoken with said that they were aware of the complaints procedure and would speak to either staff or their relatives if they had any concerns. The Registered Managers are also owners and are available in the home on a daily Greenway House DS0000004948.V358579.R01.S.doc Version 5.2 Page 17 basis where they have a good dialogue with residents who could engage easily and freely with them. There has been staff training in the protection of vulnerable adults. The 2 Registered Managers and Assistant Manager have undertaken courses to become trained trainers in Safeguarding and Moving & Handling. Annual updated training for Moving & Handling has taken place and further updated training is Safeguarding is being arranged. Greenway House DS0000004948.V358579.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is excellent. Standards 19 – 26 were inspected on this visit. A safe and exceptionally well-maintained environment with good, safe access in all areas. Good facilities with aids to assist independence. Bedrooms are well furnished and personalised. Standards of hygiene are high. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Greenway House is located in a quiet lane in a desirable suburban area close to Wolverhampton. The house was transformed from a family home to provide accommodation for 12 older people. Greenway House DS0000004948.V358579.R01.S.doc Version 5.2 Page 19 This is an appealing modern building in its own well-tended, attractive gardens. It is maintained to an exceptionally high standard. All bedrooms are for single use and have en-suite facilities. Many bedrooms located on the ground floor. There is a shaft lift also. The communal areas are bright, comfortable and furnished along quality domestic lines. There are assisted bathrooms and toilets located within easy reach of the communal areas. The home has operated in family ownership for 10 years and there has been an ongoing replacement/refurbishment programme constantly maintaining the high standard environment. Since the last inspection there has been redecoration of the main lounge area with new carpets and soft furnishings. The hall/corridor areas have been redecorated and the kitchenette completely refurbished providing an attractive area for residents and visitors to make drinks etc. Vacant bedrooms are automatically refurbished. Some furniture in the dining area, bedrooms and lounge area has been replaced also. A sample of bedrooms seen were all bright, clean, well furnished and also well personalised reflecting the individuality of residents. Standards of hygiene throughout the home were observed to be high during this inspection. Whilst the present need for laundering heavily soiled items is low, it is recommended that the home consider the use of alginate (degradable) bags for washing heavily soiled items. The home has category to admit people with a physical disability and all bedrooms, toilet and bathrooms have good access with aids to assist daily living. The large rear garden is attractive and easily accessible providing an exceptionally pleasant area to sit in the summer months with views of the surrounding countryside. Residents commented that they “love sitting in the garden area in the summer months”. Greenway House DS0000004948.V358579.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good. Standards 27 –30 were inspected on this visit. The numbers and skill mix of staff are adequate to meet needs at this time. Training is ongoing ensuring residents are well supported and safe. Recruitment procedures also protect residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are 14 part time care staff and over 50 have NVQ2 or above, some studying NVQ3. All staff have either completed or are involved in NVQ training. The Assistant Manager has completed NVQ4 and presently studying for the RMA (Registered Managers Award). Additionally there is one bank carer, 2 catering staff, one housekeeper and a handyperson. The number of staff on duty is quite adequate to meet the current dependency needs of the residents. Greenway House DS0000004948.V358579.R01.S.doc Version 5.2 Page 21 A sample of staff training records were seen and not shortfalls noted. Training is ongoing with planned further training in some areas of work. Three Managers are attending courses to be accredited trainers for Moving & Handling & Adult Protection. This will ensure more readily available training for new staff and updated training. The home will establish a simple staff training matrix to easily identify areas of need and further training. A sample of staff files was seen. All contained required information including 2 written references, POVA and/or CRB checks – all have CRB checks prior to commencing work. The home aim to provide more detailed health checks for staff following recent experiences. The home state that “Staff are recruited on the qualifications and experience and desire to care for the elderly” this seems a successful criteria and recent staff changes have been few. Staff on duty appeared relaxed, open helpful and competent. There were good observed engagements with residents. Greenway House DS0000004948.V358579.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is good. Standards 31-33 and 37 – 38 were inspected on this visit. Managers are well-qualified and experienced and there is an open and inclusive style of management in this small home. More regular checking of fire equipment and provision of fire drills should be provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Greenway House DS0000004948.V358579.R01.S.doc Version 5.2 Page 23 This is a family owned and run home. The two Registered Managers (Job Share) are also owners. An Assistant Manager has been appointed to assist the Registered Managers. The 2 Managers have obtained the Registered Managers Award and the Assistant Manager NVQ4 and presently studying for the RMA. Managers therefore have the qualifications and experience the run the home. Managers work in the home daily and available to discuss and problems/issues promptly. The AQAA states that “staff are recruited and selected carefully taking into account qualifications, experience and particularly dedication and commitment”. There is an open atmosphere in the home all residents having direct access to owners/managers. There is evidence that the home is run in the interests of residents. Training is in place in relation to Health & Safety issues and checks are carried out to ensure residents are protected. Fire records were inspected – some gaps in the weekly checking of the fire alarm system were evident. These must be carried out weekly. There had been annual Fire Safety Training provided by Staffsordshire Fire & Rescue Service. Fire drills had taken place but not regularly and the names of staff involved not recorded. It is important that all night staff have 3 monthly fire drills and day staff 6 monthly drills. It was noted that the newly refurbished kitchenette door was propped open although there was a sign saying “fire door, keep shut”. This has been discussed with the Fire Officer and a self-closing device will be fitted to ensure complete safety. A fire risk assessment was in place and individual fire risk assessments had been completed for all residents. Greenway House DS0000004948.V358579.R01.S.doc Version 5.2 Page 24 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 3 18 3 4 4 3 3 3 4 4 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 4 4 X X X 3 2 Greenway House DS0000004948.V358579.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13(2) Requirement All creams must be prescribed, clearly labelled, entered on MAR sheets and signed when administered. The fire alarm must be tested weekly and regular fire drills provided for all staff to protect residents. A self-closing device should be fitted to the kitchenette door. Timescale 08/02/08 2 OP38 23(4)(a)( b) 15/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP9 OP26 Good Practice Recommendations A Homely Remedies policy must be provided and individual items confirmed with and signed by the GP. Alternatively they can be prescribed individually. Consider use of alginate (degradable) bags for handling soiled laundry to further improve infection control. Greenway House DS0000004948.V358579.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Greenway House DS0000004948.V358579.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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