Inspection on 08/03/06 for Gallagher Residential Care Limited

This inspection was carried out on 8th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Gallagher Residential Care... 18/12/08

Gallagher Residential Care... 04/07/06

Gallagher Residential Care... 04/07/05

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

CARE HOME ADULTS 18-65 Gallagher Residential Care Limited 212 Charnwood Road Shepshed Leicestershire LE12 9NR Lead Inspector Joanne Vyas Unannounced Inspection 8th March 2006 08:00 Gallagher Residential Care Limited DS0000063965.V286032.R01.S.doc Version 5.1 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 Gallagher Residential Care Limited DS0000063965.V286032.R01.S.doc Version 5.1 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 Adults 18-65. 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. Gallagher Residential Care Limited DS0000063965.V286032.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Gallagher Residential Care Limited Address 212 Charnwood Road Shepshed Leicestershire LE12 9NR 01509 503113 01509 507239 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) Gallagher Residential Care Limited Mr Paul Anthony Gallagher Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Gallagher Residential Care Limited DS0000063965.V286032.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. None Date of last inspection 4th July 2005 Brief Description of the Service: Gallagher Care Residential Home is located on the outskirts of Shepshed, with easy links to Coalville and Loughborough and within easy reach of all local care and community facilities. The home offers nine places for Adults with a Learning Disability. The home briefly comprises of bedrooms sited on the ground, first and second floors, made up of seven singles and one shared room. On the ground floor there is a large lounge, smaller lounge and dining area. Bathrooms/shower rooms and toilets are sited on the ground and second floor. The house is set in a residential position, with a large rear garden, which is well maintained by a person who lives in the home. Gallagher Residential Care Limited DS0000063965.V286032.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the CSCI is upon outcomes for people who live in the home and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting three people who live in the home and tracking the care they received through looking at their records, discussion with them and care staff and observation of care practices. This unannounced inspection took place between 8am and 12:30pm on a weekday and was carried out by one inspector as part of the annual plan of inspection. 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. Gallagher Residential Care Limited DS0000063965.V286032.R01.S.doc Version 5.1 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Gallagher Residential Care Limited DS0000063965.V286032.R01.S.doc Version 5.1 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: These standards were not inspected on this occasion. Gallagher Residential Care Limited DS0000063965.V286032.R01.S.doc Version 5.1 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 9, 10 The individual needs and choices of people who live in the home are not fully addressed. EVIDENCE: • Although care plans have improved from the previous inspection, they still are not comprehensive. The inspector found that a strategy employed by the Registered Manager to manage the behaviour of one person who lives in the home had not been care planned for and also must be agreed in a multi-disciplinary forum due to the nature of the strategy. Risk assessments formed part of the care plan but were not comprehensive and did not cover all the risks identified. This has not changed since the previous inspection. Care files remain in an unlocked cupboard in the dining room as they were at the previous inspection. • • Gallagher Residential Care Limited DS0000063965.V286032.R01.S.doc Version 5.1 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: These standards were not assessed on this occasion although people who live in the home said that they found the food very good and enjoyed living at the home. Gallagher Residential Care Limited DS0000063965.V286032.R01.S.doc Version 5.1 Page 10 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 There were shortfalls in some areas relating to the safe handling of medication and these have the potential to place people who live in the home at risk. EVIDENCE: Some medication procedures have improved from the previous inspection. However, the medication administration sheets are still completed by the home and do not fully state all the details of the prescription such as dosage. The Registered Manager stated that he has contacted another pharmacist and is considering changing as this offers a more comprehensive service. The inspector observed poor medication practices. These included leaving medication next to the person they were for rather than asking the person to take the medication immediately and dispensing medication without referring to the medication administration sheets. These practices put people who live in the home at risk. All staff have received training in the safe handling of medication and more training has been planned. Gallagher Residential Care Limited DS0000063965.V286032.R01.S.doc Version 5.1 Page 11 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 People who live in the home are protected from abuse, neglect and self-harm. EVIDENCE: The Registered Manager has acquired the new protection of vulnerable adults (POVA) guidance but has not yet disseminated it to the staff team. Some staff have received training on POVA a few years ago. The Registered Manager was fully aware of his responsibilities under POVA. Gallagher Residential Care Limited DS0000063965.V286032.R01.S.doc Version 5.1 Page 12 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 People who live in the home live in a homely, comfortable and generally safe environment. EVIDENCE: The home is homely and comfortable. The inspector noted a shaving point over the upstairs bath. The Assistant Manager stated that it is never used. The cupboard where the boiler is kept downstairs should be locked. Gallagher Residential Care Limited DS0000063965.V286032.R01.S.doc Version 5.1 Page 13 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 The deployment, number and support of staff is poor, which may lead to service users being put at risk. Recruitment processes are robust. EVIDENCE: • Staffing levels have not changed at this home since the previous inspection. There remains one member of staff for most shifts to nine people who live in the home. However, the home has a good on-call system in place and if people who live in the home have healthcare appointments etc., extra staff are provided. The Assistant Manager felt the home runs effectively with the staffing levels it has. Lone working has not been risk assessed. Staff support remains poor. Staff do not receive 1:1 supervision sessions and they have held very few staff meetings. One member of staff has completed a level 2 National Vocational Qualification and another is currently completing the course. The Assistant Manager stated that two further staff are due to start the course. The Assistant Manager has started the National Vocational Qualification level 3 but this has not been completed. Staff have completed other training including first aid, POVA, person centred planning and the safe handling of medication. The Assistant Manager stated that the healthcare team are visiting the home to give staff training on healthy living. Recruitment processes are robust. DS0000063965.V286032.R01.S.doc Version 5.1 Page 14 • • • Gallagher Residential Care Limited Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42 People who live in the home are not currently protected by all of the home’s health and safety procedures. EVIDENCE: There are some good health and safety procedures in the home. All staff have completed mandatory courses and further courses have been planned. The home has environmental risk assessments in place, although this doesn’t include COSHH. The Assistant Manager stated that training in COSHH risk assessment was planned for later in the year. The boiler and electrics are checked on an annual basis. There is a fire risk assessment but fire checks are not carried out as recommended. The inspector found incidents written up in a person’s file that were reportable under regulation 37 that hadn’t been reported to the appropriate authorities. Gallagher Residential Care Limited DS0000063965.V286032.R01.S.doc Version 5.1 Page 15 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 1 34 3 35 3 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 2 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 1 X X X X X X 1 X Gallagher Residential Care Limited DS0000063965.V286032.R01.S.doc Version 5.1 Page 16 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 YA20 Regulation 13 Requirement The Registered Person must ensure that there are arrangements for the safe administration of medicines in the care home. The Registered Person must ensure the care home has the appropriate number of staff to ensure the health and welfare of service users. The Registered Person must ensure that persons working at the care home are appropriately supported. The Registered Person must ensure that all health and safety procedures are carried out as recommended. The Registered Person must notify the appropriate authorities in accordance with regulation 37. Timescale for action 15/03/06 2 YA33 18 15/03/06 3 YA36 18 30/05/06 4 YA42 23 15/03/06 5 YA42 37 15/03/06 Gallagher Residential Care Limited DS0000063965.V286032.R01.S.doc Version 5.1 Page 17 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 6 Refer to Standard YA6 YA9 YA10 YA24 YA33 YA36 Good Practice Recommendations It is recommended that care plans are comprehensive and reflect all the needs of the service users. It is recommended that risk assessments are comprehensive and reflect all the risks that affect each service user. It is recommended that all care files are stored in a secure cupboard. It is recommended that a lock is fitted to the cupboard housing the boiler and that a shaving point above the bath is removed. It is recommended that risk assessments are completed for lone working to ensure risks to staff and service users are minimised. It is recommended that staff receive six supervision sessions each year, which should include an annual appraisal and regular staff meetings are held. Gallagher Residential Care Limited DS0000063965.V286032.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Gallagher Residential Care Limited DS0000063965.V286032.R01.S.doc Version 5.1 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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