Inspection on 11/09/06 for Gadlas Hall Nursing And Residential Home

This inspection was carried out on 11th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Gadlas Hall Nursing And... 02/07/08

Gadlas Hall Nursing And... 25/01/08

Gadlas Hall Nursing And... 28/08/07

Gadlas Hall Nursing And... 27/09/05

Gadlas Hall Nursing And... 18/11/04

Gadlas Hall Nursing And... 23/06/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Gadlas Hall Nursing And Residential Home Gadlas Hall Dudleston Heath Ellesmere Shropshire SY12 9DY Lead Inspector Janet Oxley Key Unannounced Inspection 11th September 2006 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Gadlas Hall Nursing And Residential Home DS0000022246.V297118.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. Gadlas Hall Nursing And Residential Home DS0000022246.V297118.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gadlas Hall Nursing And Residential Home Address Gadlas Hall Dudleston Heath Ellesmere Shropshire SY12 9DY 01691 690281 01691 690790 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 Michelle Roberts Care Home 29 Category(ies) of Dementia (10), Learning disability (1), Old age, registration, with number not falling within any other category (18) of places Gadlas Hall Nursing And Residential Home DS0000022246.V297118.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home must comply with the Staffing Notice issued by the Shropshire Area Health Authority dated 12 October 1999. The home is registered to care for one person, aged under 65, with Dementia, who is named in the attached Schedule (not to be displayed). 27th September 2005 Date of last inspection Brief Description of the Service: Gadlas Hall is owned and managed by Mrs Michelle Roberts, and is situated in the village of Dudleston Heath, just outside the town of Ellesmere, on the North Shropshire/Welsh border. The Home provides residential and nursing care for up-to 29 older people, some of whom require specialist care for Dementia. The building is purpose built with spacious communal areas and wide corridors to accommodate wheelchair users, and people with mobility difficulties. Three bedrooms are designed for double occupancy with privacy screening, the remainder being single occupancy. Bathing and toilet facilities are shared but all of the bedrooms have hand wash basins. Internal decoration is light and bright, and there is a courtyard accessible to Residents and their visitors. The surrounding garden, with views of the countryside, provides a pleasant external environment. The home makes their services known to prospective service users in The Statement of Purpose and Service User Guide. The inspection report is mentioned in these documents and is given out on request. Fees are reviewed annually and range from £263 - £445. Any additional charges are clearly laid out in the contracts. Gadlas Hall Nursing And Residential Home DS0000022246.V297118.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A range of evidence was used to make judgements about this service. This includes: information from the provider, looking at relevant records pertaining to key standards, chats with residents and 3 visitors, discussions with senior nurse on duty and 2 staff on duty, tour of the premises, previous inspection reports, quality assurance process, Fire Authority reports, Environmental Health Office reports and observation of care experienced by people using the service. What the service does well: What has improved since the last inspection? No requirements were made at the time of the last inspection. No alterations or changes have been made since. Gadlas Hall Nursing And Residential Home DS0000022246.V297118.R01.S.doc Version 5.2 Page 6 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. Gadlas Hall Nursing And Residential Home DS0000022246.V297118.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 Gadlas Hall Nursing And Residential Home DS0000022246.V297118.R01.S.doc Version 5.2 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The policies and procedures that are in place, and have been professionally followed, ensure that the home undertakes all necessary assessments for successful and satisfactory admissions to take place. EVIDENCE: The home has a Statement of Purpose and a Service Users Guide, which includes all the required information for prospective residents. Documentation examined indicated that individuals have a comprehensive assessment of their needs prior to admission, which is reviewed and amended as requirements change. Discussions with residents, 3 visitors, the nurse and staff on duty indicated that the home continues to meet the individual needs of the elderly people living at the home. Gadlas Hall Nursing And Residential Home DS0000022246.V297118.R01.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal needs of service users are met with evidence of regular review and of good multi disciplinary working taking place on a regular basis. EVIDENCE: It was evident during the inspection from looking at records, inspecting the facilities and chatting to staff, visitors and residents that individual health, personal and social care needs were being met. Residents were being treated with respect and staff were working sensitively in meeting individual needs. Those residents spoken to were complimentary regarding the quality of their lives at the home and those frail residents being nursed in bed looked comfortable and well looked after. Gadlas Hall Nursing And Residential Home DS0000022246.V297118.R01.S.doc Version 5.2 Page 10 At the time of this inspection matters pertaining to the administration, recording and securing of medication appeared to be generally satisfactory. Only qualified nursing staff administer the medication. Gadlas Hall Nursing And Residential Home DS0000022246.V297118.R01.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines of daily living at Gadlas Hall are flexible and each resident finds the lifestyle experienced in the home meets their individual needs. A number of activities take place, there is an open visiting policy and the menu offers a choice of well balanced and wholesome meals. EVIDENCE: The residents are encouraged and enabled to personalise their bedrooms, enjoy good meals in the two dining areas or in their own rooms and have a number of activities arranged for them within the home and outside. There are two staff members that take responsibility for activities and the nurse in charge described many of the outings that had been enjoyed by residents. Discussion with the Cook, residents, staff and visitors, the menus and the meal seen and tasted, indicated that food provided by the Home is of good quality, well presented, of sufficient quantity, and offered good overall variety, with a choice each day. Gadlas Hall Nursing And Residential Home DS0000022246.V297118.R01.S.doc Version 5.2 Page 12 Residents are certainly enabled to exercise choice and control over their own lives as far as they are able and there is a good range of information for residents and visitors within the home. Visitors are made welcome, are included in events and are given all the necessary information on aspects of the home and the welfare of the residents. Those visitors spoken to at the time of this inspection were complimentary regarding the care their relatives were receiving. Gadlas Hall Nursing And Residential Home DS0000022246.V297118.R01.S.doc Version 5.2 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Concerns and complaints are dealt with promptly and procedures and practices are in place to ensure that individuals are protected from abuse. EVIDENCE: The home has a clear complaints procedure which is given to residents and their relatives before they move into the home. No complaints have been received since the last inspection by the CSCI. Minor concerns, received by staff at the home, from residents, are dealt with in a professional manner without delay. The home has all necessary documentation in relation to the protection of vulnerable adults and this subject has been included in staff training. Gadlas Hall Nursing And Residential Home DS0000022246.V297118.R01.S.doc Version 5.2 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Gadlas Hall provides Residents with a safe environment, with generally well maintained standards of decoration and furnishing, complemented by pleasant grounds, which are equally well maintained. EVIDENCE: All areas of the home were seen to be generally well maintained and homely. One radiator cover was in need of replacement. All residents bedrooms are personalised and are used as private places. The home is furnished and equipped to a generally satisfactory standard throughout. Lounges, dining areas and a fully fitted kitchen are provided and outdoor space is proportionate to the number of people residing at the home, is attractive and well maintained with pleasant seating areas. Gadlas Hall Nursing And Residential Home DS0000022246.V297118.R01.S.doc Version 5.2 Page 15 At the time of this inspection the standard of cleanliness and hygiene was satisfactory and at the time of the most recent Fire Officers and Environmental Health Officers inspections matters were reported to be satisfactory and any requirements made have been complied with. Laundry facilities are good and following a full Infection Control Audit in May 2006 recommendations made have been complied with. Two of the four baths at the home have been decommissioned, as they were no longer being used, this is not satisfactory as the National Minimum Standard is that there should be at least one assisted bath or shower for every 8 residents. Gadlas Hall Nursing And Residential Home DS0000022246.V297118.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users appear to be supported by a committed staff group who are meeting the needs of each individual in a sensitive and professional manner. The quality of care provided to service users may be compromised if staff do not receive a structured recorded induction and necessary training. Staff files did not show evidence of pre appointment checks. Service users are at risk if the home is failing to carry out these checks before confirming staff in post. EVIDENCE: The current Staff Rota and staff on duty at the time of this inspection indicated that the staff levels were in accordance with conditions of Registration. Domestic, laundry and maintenance support is also available. Documentation in staff personal files showed evidence of only partial compliance with Statutory Regulations, in that photographs, 2 satisfactory references, police checks, record of interviews, a fully completed application form and declarations of medical fitness/medical references were not found in all instances. All staff files must be checked to ensure compliance. Gadlas Hall Nursing And Residential Home DS0000022246.V297118.R01.S.doc Version 5.2 Page 17 Discussions indicated that all staff are subject to a thorough, and relevant orientation/induction programme, which is followed by comprehensive ‘foundation’ training, e.g. manual handling and lifting, fire safety, simple infection control. However there was no written evidence available to demonstrate that the last three staff recruited had received the relevant induction training. NVQ level 2 attainment is poor and the minimum ratio of having 50 of care staff trained to NVQ level 2 has not been reached, only 2 members of staff have completed NVQ2, 3 have completed NVQ3. However 7 members of staff are now undertaking the training. Comments made by Residents and Visitors, relating to Staff, were very positive reflecting appreciation of care provided. Gadlas Hall Nursing And Residential Home DS0000022246.V297118.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are clear lines of accountability within the homes management structure and the management approach creates an open and positive atmosphere from which the residents benefit. The home has reviewed all aspects of its performance through a programme of self review, questionnaires and consultations and meets the requirements of the Fire Officer and Environmental Health Officer, promoting the health, safety and welfare of the residents. EVIDENCE: The proprietor, Mrs Roberts has run the home for a number of years. She is a qualified nurse and is currently working towards NVQ4 level 4 in Management. Gadlas Hall Nursing And Residential Home DS0000022246.V297118.R01.S.doc Version 5.2 Page 19 Mrs Roberts involves herself fully in the day-to-day running of the home, works alongside the staff with a clear sense of purpose and can relate to matters pertaining to the National Minimum Standards. Quality assurance systems are in place and there was evidence available to indicate the proprietor ensures, so far as is reasonably practical, the health, safety and welfare of service users and staff. It was reported that all staff have received, or are booked on to, health and safety, basic food hygiene and manual handling training. At the time of this inspection no potential hazards were identified and records required are maintained. There was insufficient evidence available to demonstrate that a first aider is on duty at all times. The accident records appeared to be satisfactory. Gadlas Hall Nursing And Residential Home DS0000022246.V297118.R01.S.doc Version 5.2 Page 20 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 x x 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 2 x x 3 x 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Gadlas Hall Nursing And Residential Home DS0000022246.V297118.R01.S.doc Version 5.2 Page 21 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 OP21 Regulation 23(2)(j) Timescale for action That the home provide a ratio of 30/11/06 at least 1 assisted bath or shower for every 8 residents. That a minimum of 50 care 30/11/06 staff are trained to level NVQ2. That all staff files indicate a 31/10/06 robust recruitment procedure and contain all elements as laid down by Schedule 2, 2 written references and satisfactory police checks before staff are confirmed in post. All staff must receive structured 31/10/06 and recorded induction in line with the homes policies and procedures. That a qualified first aider be on 30/11/06 site at all times. Requirement 2 3 OP28 OP29 18(1)(a) 19(4)© 4 OP30 18(1)(a)9 c) 5 OP38 12(1) Gadlas Hall Nursing And Residential Home DS0000022246.V297118.R01.S.doc Version 5.2 Page 22 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 Gadlas Hall Nursing And Residential Home DS0000022246.V297118.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE National Enquiry Line: 0845 015 0120 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 Gadlas Hall Nursing And Residential Home DS0000022246.V297118.R01.S.doc Version 5.2 Page 24 - 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!