Inspection on 29/11/06 for Gallimore Lodge

This inspection was carried out on 29th November 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Gallimore Lodge 29/04/08

Gallimore Lodge 08/06/07

Gallimore Lodge 31/12/05

Gallimore Lodge 26/08/05

Gallimore Lodge 02/11/04

Gallimore Lodge 17/02/04

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

CARE HOME ADULTS 18-65 Gallimore Lodge Meesons Lane Grays Essex RM17 5HR Lead Inspector Helen Laker Key Unannounced Inspection 29th November 2006 11:00 Gallimore Lodge DS0000015534.V312999.R01.S.doc Version 5.2 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 Gallimore Lodge DS0000015534.V312999.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 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. Gallimore Lodge DS0000015534.V312999.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gallimore Lodge Address Meesons Lane Grays Essex RM17 5HR 01375 396174 01375 396174 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) Mosaic Essex Mrs Evelyn Thomson Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Gallimore Lodge DS0000015534.V312999.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Excluding any person who is liable to be detained under the provisions of the mental Health Act 1983 6th January 2006 Date of last inspection Brief Description of the Service: Gallimore Lodge is a purpose built double bungalow situated on a private residential road in Grays. Public transport by both rail and bus is available approximately 1 mile away. The home has its own minibus. All bedrooms are single occupancy and the home provides nursing care for 8 adults with learning disabilities. Services provided include personal, psychological, social, emotional and educational care by a multidisciplinary team and enabling the service user to remain as independent as possible. Service users within the home can access a range of formal day care placements and are encouraged to participate in leisure pursuits within the local community. The home was first registered in April 1993 The Service User Guide and Statement of Purpose are available and are updated as required. The residents and their representatives can be provided with this information and the deputy manager stated previously that the home would provide them with Commission for Social Care Inspection reports too. These can be displayed for reference. At the time of this report the nurse in charge was unable to confirm the range of fees charged. Gallimore Lodge DS0000015534.V312999.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine, unannounced inspection which took place over one day with one inspector in the home. There was a tour of the premises and grounds and an inspection of records and documentation. Time was spent discussing the care of the eight service users. Three members of staff were spoken with. The manager in charge of the day to day management of the home was on this occasion rostered on a day off, four staff and residents were spoken with. Further feedback was also received from service users and care staff through discussion. Responses have been included in the relevant sections of the report. A pre-inspection questionnaire and other reports and correspondence provided by the staff on duty were also used as evidence to inform this report. Twenty two National Minimum Standards were inspected on this occasion, fifteen overall outcomes were met and there were five requirements and two recommendations detailed in the full report. Discussion of the inspection findings took place with the nurse in charge at the end and throughout the inspection and guidance was given. The manager at the time of this inspection was rostered on a day off. What the service does well: What has improved since the last inspection? At the last inspection the communal areas of the home were noted to be in need of repair and decoration these have now all been attended to. All but four service user rooms have also been fully redecorated. The care plans and daily records continue to be developed to reflect the welfare of the service users. Support and supervision of staff was noted previously to be more structured. Requirements at this inspection have increased and this was discussed with the nurse in charge on the day of the inspection and the required standards for each. Gallimore Lodge DS0000015534.V312999.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. Gallimore Lodge DS0000015534.V312999.R01.S.doc Version 5.2 Page 7 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 Gallimore Lodge DS0000015534.V312999.R01.S.doc Version 5.2 Page 8 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): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The admission procedure does include an adequate assessment which ensures that service users needs can be met. The home provides a caring environment where visitors are made welcome. EVIDENCE: The care plan of a service user recently admitted to the home contained a comprehensive assessment. This was reviewed at the homes inspection on 26th August 2006 The assessment also contained information gained from professionals as well as the service users families. There have been no new admissions to the home since May 2005 Gallimore Lodge DS0000015534.V312999.R01.S.doc Version 5.2 Page 9 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, 7 and 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Each service user has an individual plan and service users are supported to take risks as part of an independent lifestyle via a process of assessment. The health needs of service users are well met however the development of better documentation would ensure clarity of needs. Due to service users profound learning disabilities they are only able to make limited decisions but staff facilitate this as much as possible. EVIDENCE: Care plans were seen to be generally comprehensive and person centred. Reviews on a regular basis were not evident. Care plans included assessments but evidence of involvement of service users and their families/representatives was not seen. Daily records varied in quality. These were discussed with the nurse in charge regarding improvements to ensure they fully reflect the welfare of the service user, how they spend their time and the progress of the care plan. The inspector was informed that the home care planning system has now reverted to Person Centred Planning (PCP). Gallimore Lodge DS0000015534.V312999.R01.S.doc Version 5.2 Page 10 Risk assessments are contained in all service users files. These were seen to generally be to a good standard and detail how staff are to manage the risk. Not all were seen to be regularly reviewed or in the case of bedrails detail the risk of entrapment. Gallimore Lodge DS0000015534.V312999.R01.S.doc Version 5.2 Page 11 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): 12,13,15,16 and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Social activities take place and service users are generally happy with the choices in routine available to them. Links with families, friends and advocates are good and contact is maintained. Visitors are made welcome and overall the service users rights and responsibilities are recognised in their daily lives. EVIDENCE: The nurse in charge informed the inspector that the home encouraged service users to participate in a wide range of activities, including colleges and day centres. However it was not possible to establish fully their views. Disappointingly the local college has changed their policy on age and service users now cannot enrol or attend courses, and secondary to this the day centre that the service users attended has now closed. The nurse in charge stated that the home was exploring further external avenues but with no success so far and that this was proving difficult. Gallimore Lodge DS0000015534.V312999.R01.S.doc Version 5.2 Page 12 The home encourages and supports service users to gain access to all the local community facilities. These include cinemas, pub, restaurants, bowling and theatre. Some service users are able to access public transport. Others can use a specially adapted taxi service and the home has its own transport which only two staff are authorised to drive. Service users have an annual holiday and this year three attended a four day cruise and five went to Butlin’s. The home operates an open visitors policy whereby service users can receive their family, friends and representatives at any time and see them in the privacy of their own bedrooms or in one of the two lounges or sensory room. The nurse in charge stated that service users are encouraged to maintain personal friendships where they wish. The home has a pictorial menu and menu planner. The meal of the day was displayed in the home. Nutrition records are maintained for each service user and these were seen. All service users are supervised at meal times with three service users requiring assistance with feeding. One service user has their food pureed, drinks and snacks are available throughout the day. Staff shop locally for all the homes food and service users are encouraged to help with the shopping. Gallimore Lodge DS0000015534.V312999.R01.S.doc Version 5.2 Page 13 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): 18,19 and 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that the health care needs of service users are identified and met. EVIDENCE: Wherever possible service users are encouraged to choose their own clothes and hairstyles. Service users receive specialist input as and when required. Service users are allocated Key workers. Personal care is carried out either in private in service users bedrooms or in the bathrooms. Service users likes and dislikes are recorded in their care plans. Service users are supported to obtain all health care services. Records of visits are maintained in their care plan. The nurse in charge reported that no service users had been admitted to A & E since the last inspection. Medication records were found to be accurate although staff are advised to ensure two signatures are evident for transcribed medications. Appropriate protocols were seen to be in place. Only nursing staff administer medication. The inspector was previously informed that all nursing staff had received training in medication administration but no records were available to inspect. Medication was seen to be stored appropriately and securely. Gallimore Lodge DS0000015534.V312999.R01.S.doc Version 5.2 Page 14 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): 22 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has an appropriate complaints policy which informs complainants of their rights and assures them their complaint will be taken seriously. Staff are aware of the issues relating to the protection of vulnerable adults. EVIDENCE: The nurse in charge stated that one complaint had been received since the last inspection. This was noted to have been appropriately dealt with. The home has appropriate policies and procedures in place to meet this standard including a pictorial complaints procedure for the service users. The home has an Adult Protection Policy and copies of the Essex and Thurrock Adult protection procedures. A copy of the document ”No Secrets” was available in a copied format. Staff have attended training in the protection of Vulnerable Adults. This was last held on 18th June 2006 Gallimore Lodge DS0000015534.V312999.R01.S.doc Version 5.2 Page 15 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 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Gallimore Lodge was clean and bright and provided the service users with homely and comfortable surroundings. Internal maintenance and decoration issues have been addressed. Gallimore Lodge DS0000015534.V312999.R01.S.doc Version 5.2 Page 16 EVIDENCE: At the last inspection some communal areas of the home were in need of redecoration and this has now been addressed. The bedroom accommodation remains unchanged and ceiling fans have been installed in all bedrooms and all but four redecorated. All service users bedrooms were seen to be well furnished and personalised to individual needs and tastes. Bedroom doors were lockable but only one service user has made use of this facility. The home is generally well maintained inside and out. The carpet in one of the lounge areas was noted to be threadbare and replacement required. Routine maintenance is recorded in a book, and upon previous discussions with the manager it was agreed that actions, dates and outcomes be recorded also. Environmental risk assessments were previously seen and are stored separately. The garden was found to be neat and tidy. The proprietor is to look at a format, which records planned renewal and decoration, carried out at the premises. The home was found to be clean and tidy throughout and odour free. The homes laundry facilities were sufficient to meet the standard. Gallimore Lodge DS0000015534.V312999.R01.S.doc Version 5.2 Page 17 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, 34 and 35 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Adequate recruitment procedures were not demonstrated on this or previous occasions and corporate policies are in place. Overall the home has an effective and competent staff team who receive training to the required standard and updates are generally addressed. EVIDENCE: Service users are appointed a keyworker. The role of the key worker was evident within staff records and most staff appeared clear as to the specific role required. Four staff employment files were inspected. All did not contain job descriptions, evidence of induction training, two work references, adequate evidence of criminal records disclosure (CRB), copy of passport or permissions to work. The process regarding volunteer and agency recruitment and CRB checks was discussed. Attention should be paid when recruiting, to work addresses for references, incomplete application forms, comprehensive work history information covering a minimum of last five years minimum, NMC pin checks, proof of identity and permissions to work. The nurse in charge was advised that staff members should not start work at the home until all relevant recruitment checks have been completed. This has been an issue at all of the homes inspections and now urgent action is required to address this both by Gallimore Lodge DS0000015534.V312999.R01.S.doc Version 5.2 Page 18 the home and Family Mosaic’s Human Resources department. The manager was advised previously that even if a staff member is transferred from another home in the group the mandatory recruitment procedures apply and documentation must be in place. The Manager previously advised the inspector that she was moving towards ensuring that the home has a training and development plan and all staff have an individual training and development assessment. The Manager was previously advised that staff working in learning disability services use the Learning Disability Award Framework TOPPS. On inspection of staff supervision records individualised training and development plans were evident and mandatory training in some cases was noted to require some updates but this was being addressed. The inspector was advised that the home has access to the proprietor’s corporate training budget. Staff have access to a wide range of training. Training records were available to inspect and were generally satisfactory with a training plan in place which was seen. The inspector was informed that supervision is now carried out regularly in a planned way. Gallimore Lodge DS0000015534.V312999.R01.S.doc Version 5.2 Page 19 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): 37, 39 and 42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There is guidance and direction to staff and the home has in place practices that will promote and safeguard the health, safety and welfare of the people using the service. The home needs to ensure all safety inspections are undertaken and up to date documentation available. EVIDENCE: The manager was on a day off on the day of inspection and is a qualified RNMH and has experience with people who have learning and physical disabilities. She is the registered manager at Gallimore Lodge and was previously acting manager for several years. The Manager previously advised the inspector that she is currently undertaking NVQ Level 4 and the inspector was informed by the nurse in charge that she has now completed this. She has undertaken a variety of training, some courses were noted to require refresher courses. Although the manager was not present at this inspection Gallimore Lodge DS0000015534.V312999.R01.S.doc Version 5.2 Page 20 some documentary evidence was available for inspection by means of a key being left for the inspector to enable accessibility to records. This is seen as good practice. The nurse in charge, on duty during the day was aware of health and safety issues in the home. Regular regulation 26 reports are received by the commission and a visit had been undertaken on the morning of this key unannounced inspection. Safety certificates were seen for gas and fire prevention. An updated five yearly electrical certificate was not available to inspect and must be followed up. Regular weekly tests are maintained as are the homes fire precautions. Fire drills are generally held on a monthly basis. The deputy manager previously advised that staff have received COSHH training and the home has appropriate policies and procedures in place. Risk assessments for safe working practises were in place. Up to date employers liability insurance was seen. Gallimore Lodge DS0000015534.V312999.R01.S.doc Version 5.2 Page 21 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 3 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 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Gallimore Lodge DS0000015534.V312999.R01.S.doc Version 5.2 Page 22 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 YA6 Regulation 13 (7) & (8) 15 Requirement Timescale for action 08/01/07 2. YA9 13 (4) (b) 3. YA34 17(3b) Sch 4(6) 4. YA35 12(1) 18(1).. The Registered Person must prepare a written plan (“service user’s plan”) with consultation with the resident as to how their needs will be met. It must include clear instructions for staff as to how the care is to be provided. It must be written in consultation with the resident and regularly reviewed. This with reference to variations in recording The registered person must 08/01/07 ensure that comprehensive risk assessments are carried out and reviewed regularly for all service users, including specific details within individualised plans of care. This with specific reference to bedrails and the risk of entrapment being clear. Recruitment records required by 08/01/07 regulation for the protection of service users and for the effective and efficient running of the business must be maintained, up-to-date and accurate. 12(1) 18(1) 17(3b) Sch 4(6) 08/01/07 The Registered Person ensures DS0000015534.V312999.R01.S.doc Version 5.2 Gallimore Lodge Page 23 5. YA42 12 (1) (a) 13 (4) that there is a staff training and development programme which meets National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. Records required by regulation for the protection of service users and for the effective and efficient running of the business must be maintained, up-to-date and accurate. This with specific reference to evidence of newly recruited staff’s inductions and training updates. Arrangements must be in place 08/01/07 to ensure that all parts of the home to which service users have access are, so far as is reasonably practicable, free from hazards to their safety. This with particular reference to production of up to date safety certificates for all maintenance inspections undertaken within the home. This with specific reference to an up to date five year electrical inspection being undertaken. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA20 YA24 Good Practice Recommendations Where medication is transcribed two signatures must be evident. The thread bare carpet in one of the lounges should be replaced. Gallimore Lodge DS0000015534.V312999.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Gallimore Lodge DS0000015534.V312999.R01.S.doc Version 5.2 Page 25 - 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. 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