Inspection on 28/08/07 for Gadlas Hall Nursing And Residential Home

This inspection was carried out on 28th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

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

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

Gadlas Hall Nursing And... 11/09/06

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 Joy Hoelzel KEY Unannounced Inspection 28th August 2007 09:30 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.V344693.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.V344693.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.V344693.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). 11th September 2006 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 accommodation, 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. Weekly fees range from £336.00 - £ 454.80. Information of the home and the provision of the service are available in the statement of purpose and service user guide. Commission for Social Care Inspection reports for this service are available from the provider or can be obtained from www.csci.org.uk. Gadlas Hall Nursing And Residential Home DS0000022246.V344693.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five hours on Tuesday 28th August 2007. It was conducted by one Commission for Social Care Inspection regulation inspector. Twenty three of the thirty-eight National Minimum Standards for Care Homes for Older People were inspected as they are viewed as key standards for services. Twenty seven people are currently living at the home and during the inspection were observed to be accessing areas around the home. The deputy manager was on the premises supported by five care staff, and ancillary personnel. The owner /manager arrived at the home during the morning of the inspection The care provided for four people was examined in detail, relevant documents were inspected, discussions were held with people living at the home, visitors, members of staff and the manager. Observation was made of the various daily activities and a tour of the premises was conducted. An Annual Quality Assurance Assessment (AQAA) had been completed by the manager and submitted to CSCI prior to this inspection, offering an overview and the managers opinion of the home and service provision. On site surveys were distributed during the inspection and completed by people living, working and visiting the home. The comments received are included in this report. Two random unannounced inspections have been conducted in May and July 2007 in regard to safeguarding adult referrals. Random inspection reports have been produced and are available upon request. What the service does well: Included on the in site survey staff stated that – • • • • Staff work together as a team Makes everyone feel welcome Happy and clean environment Work efficiently and professionally. DS0000022246.V344693.R01.S.doc Version 5.2 Page 6 Gadlas Hall Nursing And Residential Home Included on the in site survey a relative/visitor commented – • Care good, staff very caring and attentive. Included on the in site survey a person living at the home commented – • Good care Other people stated that the food was good, overall that they were satisfied with the care provided, and were generally happy with the accommodation. What has improved since the last inspection? What they could do better: The care plans would benefit from being more comprehensive and prescriptive for the care to be provided to each individual. The plan must detail the action needed to be taken by staff to ensure that all aspects of the health, personal and social care needs are fully met. Each individual has a care plan but practice of involving people in the care planning process is variable. It is acknowledged that people may not wish to or are unable to contribute to the care planning process, but efforts must be made to ensure they are offered the opportunity to discuss and agree the care that is to be provided. The social, leisure and recreational programme could be improved with particular consideration given to people with cognitive impairments and other disabilities. A review is needed for the preparation and presentation of meals and mealtimes. Infection control procedures could be further enhanced by the provision of appropriate hand wash facilities in the communal and private areas of the home. Gadlas Hall Nursing And Residential Home DS0000022246.V344693.R01.S.doc Version 5.2 Page 7 Staff training opportunities should be improved to ensure that all staff receive training and regular updates in the core and specialist topic areas. Staff recruitment procedures must be reviewed to ensure the protection of people living at the home. The policies and procedures relating the home should be reviewed at regular intervals. 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. Gadlas Hall Nursing And Residential Home DS0000022246.V344693.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 Gadlas Hall Nursing And Residential Home DS0000022246.V344693.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): OP 3,6 Quality in this outcome area is good. Prospective service users have their care needs assessed before moving into the home and whenever possible have the opportunity to visit the home to assess its quality, facilities and ability to meet their needs prior to admission This judgement has been made using available evidence including a visit to this service. EVIDENCE: The case file of the person who recently moved into the home contains preadmission information from the local Primary Care Trust and a review of the care plan from a previous social care placement. An assessment of care needs including the twelve activities of daily living was carried out at the point of admission from which an initial basic plan of care is developed. Gadlas Hall Nursing And Residential Home DS0000022246.V344693.R01.S.doc Version 5.2 Page 10 Other case files inspected included similar information received prior to admission. The completed AQAA indicates that people are encouraged to visit the home prior to admission, one visitor at the home confirmed this by stating that they had ‘ a look round’ on behalf of their relative prior to them moving in and further commented that they were satisfied with the service provided. The home does not provide an intermediate care service. Gadlas Hall Nursing And Residential Home DS0000022246.V344693.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): OP 7,8,9,10 Quality in this outcome area is adequate. Each individual has a care plan but practice of involving people who use the service in the development and review of the plan is variable. The plan includes basic information necessary to deliver the resident’s care but is not detailed or person centred without this there is no guarantee that care needs can be fully met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All people living at the home have a plan of care, which is developed at the point of admission, or as soon after as practically possible. Examination of four sets of records were looked at in depth to see if they provided staff with appropriate guidance to safely care for people in the way Gadlas Hall Nursing And Residential Home DS0000022246.V344693.R01.S.doc Version 5.2 Page 12 they preferred. The people whose records were looked at had a range of complex care needs, including psychological and physical challenges. The care plans are based on the nursing needs/problem, expected outcome and nursing interventions, with the reviewer’s signature and date for the next anticipated review. There was no evidence in any of the four case files of the involvement, in the care planning process, of the person and/or their representative. One visitor stated that they were not involved in this process but was sure that another relative would be and went on to express a satisfaction with the service provided. In two files the next of kin had given their consent to the use of bed rails following an assessment for maintaining a persons safety whilst in bed. A care plan inspected at the Random inspection conducted in May 2007, indicated the use of a cocoon type bed cover to reduce the risk of a person falling out of bed. At the time the person in charge confirmed that this type of bed cover was no longer used. Two of the care plans examined at this inspection identified the use of these bed covers in addition to the use of bedrails. The care plans have been reviewed each month with general comments of ‘no change’. The care plans of two people who have dementia were looked at and evidenced that risk assessments for both these people had been developed in July 2007 for ‘going out of the fire doors’. (Following an incident where they had left the building without the knowledge of the staff). There were no further details of the action staff should take but staff were observed to be guiding the people away from the exit areas. One person had a specific care plan for ‘confusion and agitation’ with instruction for interventions as ‘diversional therapy’, when asked the staff were not aware of any therapy. There was no plan of care or assessment as to the person’s preferences for social, leisure and recreational activities in any of the four plans examined. The care plans for dealing with pressure ulcers and their treatment are kept in the daily report file. Instructions for the type and frequency of the dressings are documented but for ease of reference it was suggested that a separate plan be made for each wound area. One case file documented the contact with the tissue viability nurses and G.P. None of the four case files contained assessment for maintaining adequate nutrition, but one care plan identified a risk of ‘poor dietary intake’, with instructions for supplements to be offered. It was not possible to establish if these are offered on a regular basis as no records are kept. However new documentation for nutritional assessment has been implemented but the Gadlas Hall Nursing And Residential Home DS0000022246.V344693.R01.S.doc Version 5.2 Page 13 documents had not been fully completed to give an overall view of nutritional status. All care plans are being reviewed at regular intervals. Interventions for assisting with personal care were undertaken in private and in an appropriate manner. Staff were observed to be administering the medication during the morning and appeared to be completing the Medication Administration Record at the point of administration. Inspection of medicine storage and administration records showed the home to be in accordance with currently accepted good practice. Gadlas Hall Nursing And Residential Home DS0000022246.V344693.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): OP 12,13,14,15 Quality in this outcome area is poor. The limited social activities are being arranged by the care staff but are very much determined by the constraints of time and workload. People are offered very little choice and are not consulted as to their personal preferences. Mealtimes are very functional with little opportunity to make eating and dining a sociable and enjoyable event for the people living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Many people were sitting in the lounge areas with the television on, some people were in their bedrooms and others were wandering around the home. There appeared to be very little structured activity organised during the day and very little happening socially. The home does not employ a person for coordinating activities but relies on the care staff for facilitating the planned activities. Gadlas Hall Nursing And Residential Home DS0000022246.V344693.R01.S.doc Version 5.2 Page 15 The care staff appeared to be very busy attending to personal care needs of individuals, with the deputy busy with managerial duties. The Annual Quality Assurance Assessment completed by the matron stated that there have been ‘ trips to town and to the village pub to watch the bowls’. There are plans within the next 12 months to employ an activities coordinator and to provide more ‘outside activities’. The service user guide includes sections on the social activities ‘that are provided by the activities coordinators and include bingo, skittles, singing, crafts etc. The gardens are used regularly that allows residents to sit outside’. One person stated they would like to go out more but feels disinclined to ask the staff as they feel the staff are very busy and would not have the time. Many visitors were at the home during the morning and afternoon all appeared to be at ease. One visitor stated the home was ‘ friendly and comfortable’ and they were able to visit at suitable times. One relative indicated on the on site survey – • Pleased with all aspects of care, relatives informed of residents needs. During the tour of the premises many of the bedrooms were personalised with a persons possessions. Meals are served in the dining areas or a person’s own room if preferred. The two dining rooms were not prepared in advance of the meals. There were no condiments, cutlery, serviettes or drinks on the tables. The matron explained this was because people would remove the items from the tables before the meal was served. There was only one choice of main meal and dessert. The cook stated that the people who preferred a vegetarian option had the roast dinner without the meat but an option is usually available. Generally people appeared to be enjoying the meal, and staff were observed to be assisting in an appropriate manner. Two people stated they do not know what they were having for lunch and stated they are not offered a choice but the food is placed in front of them. Most people said the food was OK. One person would like more fresh fruit and vegetables. The four weekly rotational menu indicates that only one option is available, the cook stated that alternatives are provided when requested. In the ‘what could be done better’ section of the on site surveys some care staff indicated that improvement could be made in relation to more activities and more choice of food. Gadlas Hall Nursing And Residential Home DS0000022246.V344693.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): OP 16,18 Quality in this outcome area is adequate. Written procedures are in place for protecting service users from harm, and links with external agencies are adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is displayed on the notice board at the entrance to the home, and is included in the service user guide. The Annual Quality Assurance Assessment indicates that 2 minor complaints have been made and are recorded in the complaints book. A copy of the Telford and Wrekin Multi Agency Safeguarding procedures is in the office for staff reference if required. Three referrals to the multi agency safeguarding adults group have been made following allegations of potential abuse. Two of the investigations have been closed with recommendations made to the home with the other one still to reach a satisfactory conclusion. Gadlas Hall Nursing And Residential Home DS0000022246.V344693.R01.S.doc Version 5.2 Page 17 Two additional visits were made to the home as a result of the referrals in May and July 2007. The first visit took place after an incident of a person falling out of bed, resulting in the need for medical and hospital intervention. Following examination of the care plan, the person’s bedroom and the equipment in use, an immediate requirement was issued to – Ensure the correct fitting and positioning of the bedrails Ensure the compatibility of the bed rail and bed, mattress and occupant combination Ensure an assessment is carried out to identify a specific need for their use. Establish and maintain routine checks of the rails and to record the findings A letter for compliance was subsequently received from the home. During this inspection on the tour of the premises one set of bed rails were incorrectly fitted. A second referral was made to the multi agency safeguarding adults team following reports that two residents had been found on the roadside near Gadlas Hall. It was reported that both were distressed, wet from the rain and that one of the women had fallen onto the grass. It was reported that the three staff that came from Gadlas to collect the residents said that the home was “short staffed”. This referral triggered an unannounced visit to the home in July 2007. It was established from the duty rotas examined that the home was short of staff when the two people went out of the building; the nurse in charge confirming the problems with maintaining adequate staffing levels was due to staff sickness. Observation of records and documents evidenced that they did not contain any risk assessments or details of the incidents. Four additional requirements were made for identifying any potential risks, ensuring sufficient numbers of staff are on the premises, maintaining adequate records and notifying CSCI of any significant incidents. The matron stated that no money is held for safekeeping on behalf of any people living at the home, any sundry expenses incurred are invoiced to the person’s family or representative. Gadlas Hall Nursing And Residential Home DS0000022246.V344693.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): OP 19, 26 Quality in this outcome area is adequate. The home provides a physical environment that meets the specific needs of the people who live there. There are one or two areas that pose a potential risk to people living and working at the home e.g. the procedures for maintaining the safety of the equipment and infection control. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All areas of the home were generally clean, homely and domestic in character. Gadlas Hall Nursing And Residential Home DS0000022246.V344693.R01.S.doc Version 5.2 Page 19 The main office door was propped open with a wooden wedge; in other areas some wedges were seen but were not in use. The matron spoke of the imminent plans for one of the bathrooms to be completely refitted and decorated, with an agreed completion date of 31st October 2007. The matron confirmed that all bedrails in use had been checked for correct fitting and suitability. During the tour of the premises it was found that one set of bedrails were incorrectly fitted, with the potential of an entrapment incident. The wardrobes supplied by the home in the bedrooms are all free standing and not securely fixed to ensure they do not become unstable and topple over. Not all areas have been provided with suitable hand wash facilities, in some communal toilets and bathrooms cloth towels were in use. For basic hygiene purposes and for the control of infections suitable facilities must be provided in all communal areas and at the point of delivery of care. Two of the bathrooms had numerous items of toiletries (bubble bath, shampoo etc), none were named it was impossible to establish which items belonged to whom. One person commented that she would prefer to be at home but she was ‘ok’. She had a single room that was well furnished with personal items, she said the bed was comfortable, and had her own TV and radio if she preferred to be alone. Gadlas Hall Nursing And Residential Home DS0000022246.V344693.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): OP 27,28,29,30 Quality in this outcome area is poor. Recruitment practices are poor with appropriate checks not being obtained prior to offering a person employment, this has the potential to put service users at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A rota is maintained to show which staff are on duty at any given time of the day or night. During the morning of the inspection the deputy matron was supported by five care staff on the premises with catering and domestic staff additional. The matron arrived at the home during the morning. The matron confirmed the usual staffing levels as – • • • 8am –3pm 5 care staff and 1 registered nurse. 3pm-10pm 3 / 4 care staff and 1 registered nurse. Nights 1 registered nurse and 1 care staff. Gadlas Hall Nursing And Residential Home DS0000022246.V344693.R01.S.doc Version 5.2 Page 21 The random inspection in July 2007 indicated that at times staffing levels are low, with replacements not being sought to cover for sickness. The deputy manager stated that two people have recently been recruited as part of the care staff team; the home now has no vacancies. Three staff personnel files were selected for inspection and showed that two out of the three lacked some necessary information. One person’s file did not include a criminal record bureau disclosure, the deputy matron confirmed that one had been received but was unable to produce the copy. The file of the person due to start work at the home did not contain any references; the deputy manager confirmed the imminent start date and stated the references had been sent for but had not been received. A requirement was made at the last key inspection in September 2006 • ‘That all staff files indicate a 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’. The Annual Quality Assurance Assessment indicates that of the 22 permanent staff 12 have been accredited with National Vocational Qualification level 2 or above with 5 people working towards it. The NVQ training file indicates that of the 22 staff 9 have NVQ accreditation with another 2 almost completed. Certificates and accreditations for training are kept in other files. It was difficult to establish the training identified or completed by each individual as no matrix is maintained. In the fire safety training file certificates for attendance were not available for all staff listed on the duty rota. The deputy matron stated that all staff had received recent training. There was only one certificate for dementia care training for one person this was dated July 2005. The home is registered of people with dementia and has a high percentage of people with some cognitive difficulties. Staff indicated in the onsite surveys that training opportunities have increased recently with others indicating that more training would be beneficial. Gadlas Hall Nursing And Residential Home DS0000022246.V344693.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): OP 31,33,35,38 Quality in this outcome area is poor. The homes current systems do not promote the health, safety and welfare of residents and as such has the potential of placing people at risk of harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The matron/owner Michelle Roberts has been at the home for a number of years. She is a first level nurse and is working towards accreditation at National Vocational Qualification Level 4 in management. Gadlas Hall Nursing And Residential Home DS0000022246.V344693.R01.S.doc Version 5.2 Page 23 The Annual Quality Assurance Assessment indicates that she plans to complete the course in the next 12 months. Mrs Roberts states she is very ‘hands on’ and works in a clinical capacity over the 24-hour period. The duty rotas examined during the random inspection in July 2007 indicated that the manager has very little supernumery time but works mainly as a nurse in a clinical role. For the whole day the deputy matron was extremely busy attending to managerial tasks in addition to clinical duties. Mrs Roberts strongly expressed the view that she thought the management team was working well and that they ‘are always as busy as this’ and does not feel there is a need for any further staff. An audit of the quality of care was completed in March 2007, and identified some training needs for staff in moving and handling and first aid. As documented earlier it was difficult to establish if all staff have received training and updates in the safe working practice topics as the certificates for training are kept in separate files, there is no training matrix for ease of reference as to a persons training position. There was no reference in the staff personnel files of any training and development requirements or any training that had been facilitated for staff. It was not possible to establish when a full review was conducted on the policies and procedures relating to the home. The policies and procedures at the home are not dated and no date is included in the policies and procedures section of the completed Annual Quality Assurance Assessment. The matron stated that no money is held for safekeeping on behalf of any people living at the home, any sundry expenses incurred are invoiced to the family or representative. Documents were seen for the routine weekly, monthly and annual safety checks (fire alarms, hot water, etc). The manager stated that safety checks had been carried out on all bedrails in use, however during the tour of the premises one set of bedrails was not fitted correctly. Records are kept of the temperatures of the fridges and freezers, however on observation, one freezer did not have a thermometer but the cook stated that the temperature is taken each day. In other units the thermometer was at the very bottom with all food having to be removed to reach the thermometer. Staff receive induction training following their appointment at the home, A copy of the induction checklist was forwarded to the inspector following this inspection but did not include details of induction to the safe working practice topics to meet the specifications of Skills For Care. Gadlas Hall Nursing And Residential Home DS0000022246.V344693.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 X X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Gadlas Hall Nursing And Residential Home DS0000022246.V344693.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15.1 Requirement The care plan must be in sufficient detail to ensure that all care needs can be fully and effectively met. Risk assessments must be fully completed, with the findings recorded and the action needed to be taken to reduce the risk of a person being placed at harm People must be given the opportunity for stimulation through appropriate social and leisure activities that suit their needs and preferences. Particular consideration should be given to people with cognitive impairments. That all staff files indicate a robust recruitment procedure and contain all elements as laid down by Schedule 2, of the regulations with two written references and satisfactory police checks before staff are confirmed in post. Date for compliance 31/10/06 not met. Staff must receive training and regular updates in the core topic DS0000022246.V344693.R01.S.doc Timescale for action 31/12/07 2. OP8 12(1) 31/10/07 3 OP12 16(2) 31/10/07 4 OP29 19 30/09/07 5 OP30 18(1) 31/10/07 Gadlas Hall Nursing And Residential Home Version 5.2 Page 26 areas and any specialist areas relating to the service provision. 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 4 5 Refer to Standard OP7 OP14 OP19 OP19 OP26 Good Practice Recommendations When ever possible care plans should be developed, agreed and reviewed with the individual person and/or representative A review is needed for the preparation and presentation of meals and mealtimes. The practice of propping open doors within the home should cease. All equipment provided and in use at the home should be safe, checked regularly and fit for the purpose. For basic hygiene purposes and for the control of infection paper towels, liquid soap and a lidded disposal bin should be provided in all toilets and bathrooms and in all areas at the point of the delivery of care 50 of care staff should be trained at National Vocational Qualification level 2 in care or above. The matron should attain the National Vocational Qualification level 4 in management accreditation by the end of the year. Policies and procedures relating to the home should be reviewed on a regular basis. The documents should be dated upon review. All staff must receive training and updates in all safe working practice topics. 6 7 OP28 OP31 8 9 OP33 OP38 Gadlas Hall Nursing And Residential Home DS0000022246.V344693.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Shrewsbury Local Office Commission for Social Care Inspection 1st Floor, Chapter House South Abbey Lawn Abbey Foregate Shrewsbury SY2 5DE 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 Gadlas Hall Nursing And Residential Home DS0000022246.V344693.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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