Inspection on 27/09/05 for Gadlas Hall Nursing And Residential Home

This inspection was carried out on 27th September 2005.

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... 11/09/06

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 Dudleston Heath Ellesmere Shropshire SY12 9DY Lead Inspector Lorraine Briggs Announced 27th September 2005 09:30 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 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 E56 S22246 Gadlas Hall V204034 AI 220905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Gadlas Hall Nursing and Residential Home Address Gadlas Hall Dudleston Heath Ellesmere Shropshire SY12 9DY 01691 690281 01491 690790 Telephone number Fax number Email 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 with Nursing 29 Category(ies) of Old Age (18) registration, with number of places Dementia (10) Learning Disability (1) Gadlas Hall Nursing and Residential Home E56 S22246 Gadlas Hall V204034 AI 220905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home must comply with the Staffing Notice issued by the Shropshire Area Health Authority dated 12 October 1999. 2. 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). Date of last inspection 3rd May 2005 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. A team of Registered Nurses and Carers, some of whom have achieved the minimum NVQ Level 2 in Care, provide care to Residents. Gadlas Hall Nursing and Residential Home E56 S22246 Gadlas Hall V204034 AI 220905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection reviewed key standards only as the home is currently considered to be well managed. The home is performing well and has necessary plans in hand to ensure improvements continue to be made, this therefore warrants the application of a reduced methodology. The inspection was announced and commenced at 9.30am. One Inspector undertook the visit which included observing activity within the home, inspecting the premises, looking at records and case tracking and talking to 7 staff, 2 visitors, a visiting Practice Nurse and a number of residents. The Manager and staff on duty were welcoming and helpful throughout the inspection. It was found that all of the National Minimum Standards assessed had been met. It was considered that the overall quality of care provided is good. All residents appeared happy, content and very well cared for and those who were able expressed complete satisfaction with their quality of life at the home. What the service does well: What has improved since the last inspection? 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 E56 S22246 Gadlas Hall V204034 AI 220905 Stage 4.doc Version 1.40 Page 6 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 Standards Statutory Requirements Identified During the Inspection Gadlas Hall Nursing and Residential Home E56 S22246 Gadlas Hall V204034 AI 220905 Stage 4.doc Version 1.40 Page 7 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 standard(s) 1, 2, 3, 4 and 5 Prospective Residents are enabled to make an informed choice as to whether they wish to enter the Home. Processes to ensure assessment of care needs, prior to admission, are diligently and effectively applied. Staff in post provide the type, and quality, of care required by Residents. EVIDENCE: Printed information, as issued to all new Residents, was observed and comprises the relevant information and policies relating to residency within the Home. Pre-admission assessment documentation was found in Residents’ files. Duty rotas showed staff numbers and staff skill-mix to be in accordance with the Statutory Staffing Notice. Staff files demonstrated evidence of training relevant to ensuring Staff are kept up-to-date in their practice. Gadlas Hall Nursing and Residential Home E56 S22246 Gadlas Hall V204034 AI 220905 Stage 4.doc Version 1.40 Page 8 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 standard(s) 7, 8 and 10 The health and personal needs of residents appear to be well 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. Staff who were spoken to during the inspection were extremely knowledgeable regarding the residents in their care. Care and assessment regarding the prevention of development of pressure ulcers is good. None of the residents are actively being treated for pressure ulcers at this time. Residents were being treated with respect and staff were working both professionally and sensitively in meeting individual needs. Those residents and visitors spoken to were complimentary regarding the quality of their lives at the home. Gadlas Hall Nursing and Residential Home E56 S22246 Gadlas Hall V204034 AI 220905 Stage 4.doc Version 1.40 Page 9 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 standard(s) 12, 13, 14 and 15 The routines of daily living at Gadlas Hall are flexible and each resident finds the lifestyle experienced in the home meets their individual needs. Many 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 pleasant 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, they spoke to the inspector and described many of the outings that had been enjoyed by residents. Additionally the staff perform an annual Pantomime for the enjoyment of the residents. Discussion with the Cook, residents, staff and visitors indicated that food provided by the Home is of excellent quality, well presented, of sufficient quantity, and offered good overall variety, with a choice each day. 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. Gadlas Hall Nursing and Residential Home E56 S22246 Gadlas Hall V204034 AI 220905 Stage 4.doc Version 1.40 Page 10 Visitors spoken to were complimentary regarding the quality of life for the residents at the home. Gadlas Hall Nursing and Residential Home E56 S22246 Gadlas Hall V204034 AI 220905 Stage 4.doc Version 1.40 Page 11 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 standard(s) 16 and 18 Concerns and complaints are dealt with promptly and professionally and robust 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 E56 S22246 Gadlas Hall V204034 AI 220905 Stage 4.doc Version 1.40 Page 12 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 standard(s) 19, 20,21,22,23, 24, 25 and 26 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: Residents, Visitors and Staff all expressed appreciation of the environment in which they live, work or visit. Since the last inspection the floor covering in Bathroom No.3 has been replaced. At the time of the last inspection it was found that the most recent Reports from the Environmental Health Officer and Fire Officer were satisfactory. Residents’ personal possessions were observed in many bedrooms. Risk assessment documentation, relating to Residents retaining bedroom keys, and to the use of table lamps in bedrooms is in place. The grounds are very well maintained, there is an enclosed courtyard area within the home which residents may access. Gadlas Hall Nursing and Residential Home E56 S22246 Gadlas Hall V204034 AI 220905 Stage 4.doc Version 1.40 Page 13 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 There is a stable staff group working positively and enthusiastically to provide the residents with a quality of life that meets their individual requirements and aspirations. EVIDENCE: The current Staff Rota, and those from the immediately preceding weeks, were examined and showed that the staff levels were in accordance with conditions of Registration. Also, discussions relating to staffing levels were held with Residents, Visitors and Staff. Two staff personal files were seen for recently recruited staff, these showed evidence of compliance with Statutory Regulations. Staff ‘Training Files’ indicated 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, infection control. Gadlas Hall Nursing and Residential Home E56 S22246 Gadlas Hall V204034 AI 220905 Stage 4.doc Version 1.40 Page 14 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 35 and 38 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. EVIDENCE: The proprietor, Mrs Roberts has run the home for a number of years. She is currently working towards NVQ4 level 4 in Management. 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. All staff have attended a health and safety and relevant training Gadlas Hall Nursing and Residential Home E56 S22246 Gadlas Hall V204034 AI 220905 Stage 4.doc Version 1.40 Page 15 At the time of this inspection no potential hazards were identified and records required are maintained. Gadlas Hall Nursing and Residential Home E56 S22246 Gadlas Hall V204034 AI 220905 Stage 4.doc Version 1.40 Page 16 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 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 Standard No 16 17 18 Score 3 x 3 x 3 3 x 3 x x 3 Gadlas Hall Nursing and Residential Home E56 S22246 Gadlas Hall V204034 AI 220905 Stage 4.doc Version 1.40 Page 17 No 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 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. Refer to Standard 38 Good Practice Recommendations That all bed rails in use throught the home are assessed in line with guidance issued by the Health & Safety Executive. Gadlas Hall Nursing and Residential Home E56 S22246 Gadlas Hall V204034 AI 220905 Stage 4.doc Version 1.40 Page 18 Commission for Social Care Inspection 1st Floor, Chapter House South Abbey Lawn 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 E56 S22246 Gadlas Hall V204034 AI 220905 Stage 4.doc Version 1.40 Page 19 - 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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