Inspection on 19/08/08 for Gallions View Nursing Home

This inspection was carried out on 19th August 2008.

CSCI found this care home to be providing an Adequate service.

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

Gallions View Nursing Home 25/06/07

Gallions View Nursing Home 24/07/06

Gallions View Nursing Home 13/02/06

Gallions View Nursing Home 25/07/05

Gallions View Nursing Home 21/12/04

Gallions View Nursing Home 05/08/04

Gallions View Nursing Home 10/02/04

Extracts from inspection reports are licensed from CQC, this page was updated on 13/11/2008.

CARE HOMES FOR OLDER PEOPLE Gallions View Nursing Home 20 Pier Way Thamesmead London SE28 0EU Lead Inspector Pauline Lambe Unannounced Inspection 19th August 2008 09:40 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 Gallions View Nursing Home DS0000006761.V369628.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. Gallions View Nursing Home DS0000006761.V369628.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gallions View Nursing Home Address 20 Pier Way Thamesmead London SE28 0EU 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) 020 8316 1079 020 8854 5331 condonc@bupa.com www.bupa.com BUPA Care Homes (CFHCare) Ltd Manager post vacant Care Home 120 Category(ies) of Dementia (30), Old age, not falling within any registration, with number other category (90) of places Gallions View Nursing Home DS0000006761.V369628.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP (maximum number of places: 90) 2. Dementia - Code DE (maximum number of places: 30) The maximum number of service users who can be accommodated is: 120 25th June 2007 Date of last inspection Brief Description of the Service: Gallions View is a Nursing Home for 120 residents, run by BUPA Care Homes. It is situated in spacious grounds in West Thamesmead and is within striking distance of the town centres of Plumstead and Woolwich with their thriving and varied range of shops and markets. The Home consists of four purpose built bungalows, each accommodating thirty residents, and a central two-storey building housing the administrative staff, the laundry, kitchen and hairdressing salon. The Bevan Unit, an NHS Intermediate Care Unit, shares the site and the service functions with the Home but is exempt from registration. Each unit has its own Statement of Purpose, and one unit offers specialist nursing care for people suffering from dementia. All the rooms are for single occupancy, with hand washbasins and adequate numbers of shared bathroom and toilet facilities are provided. The site is attractively landscaped, with gardens adjacent to each unit, secure fencing around the perimeter including gates that are locked at night. There is car parking to the front of the building. The fees charged by the home range from £571.77 - £819.00 per week. This does not include additional charges such as chiropody, hairdressing, newspapers and toiletries. This information was supplied to the commission on 22/08/08. Gallions View Nursing Home DS0000006761.V369628.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced key inspection took place over three visits 19/8/08, 22/8/08 and 2/9/08. Three inspectors were involved on the first date and one on the subsequent dates. The deputy manager was in charge of the home and together with residents and staff assisted with the inspection. The inspection process included a review of information held on the service file, a tour of some of the houses, a review of records, spending time talking to residents, staff and management and reviewing compliance with previous requirements. Inspectors spent time on Duncan, Benn and Squires Houses. One inspector completed a short observational framework for inspection (SOFI) on Squires house. The information included in the Annual Quality Assurance Assessment (AQAA) was also reviewed. Since the last inspection there had been two changes of home manager. At the time of this inspection the deputy manager was managing the service until the recently recruited manager took up post in September 2008. The home was generally well managed and the residents spoken with were satisfied with the care provided. The acting manager said that the home was due to be refurbished in 2009, which will enhance the environment for the benefit of the residents. However environmental issues noted on Squires house must be addressed sooner. Feedback received from residents and relatives indicated that activity provision could be better. What the service does well: Admission procedures were followed. Staff spoken with displayed a good understanding of the residents in their care and their needs. Residents said they could choose their meals, choose what to wear and how to spend their day. Activity staff presented as committed to their work but had limited time to do this and to keep records up to date. Staff worked with external healthcare professionals to ensure resident’s healthcare needs were met. Residents and relatives were satisfied with the visiting arrangements. Staff received training relevant to their work. Good staff/ resident interactions were noted particularly on Squires house, the dementia care unit. Gallions View Nursing Home DS0000006761.V369628.R01.S.doc Version 5.2 Page 6 Satisfactory systems were in place to manage resident’s personal finances, complaints and to ensure residents were safe. A number of residents spoken with said they felt safe in the home. 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. The summary of this inspection report can be made available in other formats on request. Gallions View Nursing Home DS0000006761.V369628.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Gallions View Nursing Home DS0000006761.V369628.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3, standard 6 did not apply to the service. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents were admitted based on an assessment of need. Not all files seen for residents provided evidence that residents received written confirmation that based on assessment the service was suited to meeting their needs. EVIDENCE: A total of 6 sets of care records were viewed on the units visited. These included copies of the pre-admission assessment. There was no evidence seen on the files for the residents case tracked to show that the people received written confirmation that based on assessment the service was suited to meeting their needs. Three other resident personal files were viewed and one of these had a letter as required by regulation 14. Requirement 1. Gallions View Nursing Home DS0000006761.V369628.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7 – 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans were prepared but required some improvements. Staff ensured residents healthcare needs were met. Medicines management required improvements. No concerns were noted or raised in relation to resident privacy. EVIDENCE: Six care plans were viewed in total. The records seen included care plans and risk assessments. There was evidence to show that care plans were kept under review. Care plans were generally well prepared and showed how assessed needs were to be met. However a new care plan was not always written when people’s needs changed. For example on one person’s care profile the guidance said the person liked to stay in bed until mid morning but the care plan stated to get the person up by 08:30 and have breakfast in the lounge. The care plan also said the person needed a pressure relieving cushion on the chair but this was not provided and the person had lost weight and had been referred to the dietician but there was no additional guidance for staff in relation to managing or monitoring the person’s nutrition. Relatives Gallions View Nursing Home DS0000006761.V369628.R01.S.doc Version 5.2 Page 10 seen said staff communicated with them about the care provided and contacted them appropriately regarding their relative’s health and welfare. Feedback received from residents indicated they were satisfied with the care provided. One inspector spent two hours observing resident care and interaction using SOFI on Squires house. The findings from this were that good early morning routines were in place and were flexible but the timing of medicine administration and meal times needed review. For example a person who had their medicine and breakfast late were given lunch and medicines at the same time as other residents. Staff interaction with residents was generally good but staff must ensure the outcome benefits the resident. For example staff were seen having a chat with a resident and then turning away to talk to staff leaving the interaction unfinished. Most interactions observed between staff and residents were task orientated however provided the person was involved with the task then this interaction was considered positive. Overall the interactions observed were generally positive and overall residents presented as being in a state of wellbeing. One resident was asleep throughout the observation period. As the morning progressed and staff became busier interactions with residents were shorter, less effective and therefore less positive for the resident. Requirement 2 and recommendation 1. Residents were registered with a GP records seen showed they were supported to receive other healthcare such as dental, optical and chiropody. For other healthcare residents were referred by the GP. Management said that four people in the home had pressure ulcers. The records for three people were viewed and all included on-going wound assessments, dressing records and evidence that advice had been obtained from relevant healthcare professionals. Management completed a monthly audit on pressure sore incidents and care for head office. Residents and relatives spoken with were satisfied with how healthcare needs were met. Medicine management was viewed in the Houses visited. On Benn and Squires Houses medicines were stored properly and records kept for receipt, disposal and administration of medicines. A policy and procedure was provided and was last reviewed on 5th December 2006. On Benn House 8 medicine administration charts were viewed and had been fully completed. Medicine supplies were checked for 4 residents. For 2 residents all medicines were in the blister packs and were correct. The medicines for the other 2 residents were mainly in individual boxes and of a total of 10 medicines stocks checked errors were noted in 8 of these. The amount of stock remaining did not tally with the amount dispensed and administered. On Squires House medicines administration charts were viewed for 8 people and there was one gap in recording. Medicine stocks supplied in individual boxes were randomly checked for 4 people and one error noted. The amount of medicines in stock did not tally with the amount dispensed and administered. For one person one dose of a medicine was not given, as the person was asleep. The medicine was not prescribed as an ‘as required’ dose Gallions View Nursing Home DS0000006761.V369628.R01.S.doc Version 5.2 Page 11 and therefore should have been administered. Also in this house errors were noted in the recording of controlled drugs. At the end of the last cycle the amount of doses for one medicine left in stock for 4 people had not been brought forward on to the new administration charts. This made it difficult to check stock and do an audit trail. However the amount of all medicines in stock were accurate when checked using the old administration charts and the controlled drug register. One nurse administered medicines in the morning in each house to 30 residents and it was observed that the process was not completed until 12md, staff spoken with said the medicine round usually finished at 11.30. This issue must be reviewed by management and discussed with the GP to ensure adequate time had elapsed between administrations of medicines as lunchtime medicines were administered about 13.00. Homely remedies were kept in the home and administered as agreed by the GP. However the guidance for the administration of these medicines was held with the home’s policies and procedures and not made available on the houses. Homely remedy medicine supplies checked were correct. There was evidence to show that staff were assessed annually as being competent to manage medicines. No medicine errors were noted with the medicines and records checked on Duncan House. Staff said that none of the residents on the houses visited were currently managing their own medicines. Requirement 3. Staff responded to residents in a professional manner. Residents said staff were mostly kind and caring but one person said ‘you get good and bad staff’ and clarified this by saying some will do what they have to an others do more for you. However residents spoken with said they felt safe in the home and that staff maintained their privacy. Residents were appropriately dressed and female residents were wearing make up and jewellery and men were clean shaven. Gallions View Nursing Home DS0000006761.V369628.R01.S.doc Version 5.2 Page 12 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): Standards 12 – 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives felt more social activities could be provided, were satisfied with the visiting arrangements, the way individual choice was encouraged and with the meals provided. EVIDENCE: Three activity organisers were employed with plans in place to increase this to a forth person working a 30 hour week. Currently 78 hours activity hours were provided. The senior activity organiser said that a variety of activities such as bingo, film shows, sing-along and quizzes were provided flexibly for residents. Since the last inspection 2 trips to Southend and one to Polehill garden centre had been organised. Outings were costly to organise and only a limited number of places were available. Activity staff also arranged for entertainers to visit the home twice a month and residents who wanted to attend were taken from all units to these sessions. A number of residents spoken with on Benn House said there was very little activities provided and some said they played bingo on Monday and Fridays. A bingo session was observed on the day of the inspection. Care records viewed for two people on Benn House showed that one person who had recently been admitted to the home had taken part in two bingo sessions and the second person had taken part in a Gallions View Nursing Home DS0000006761.V369628.R01.S.doc Version 5.2 Page 13 variety of activities on 10 occasions since 6/6/08. The one-to-one sessions recorded for the person did not specify what the activity was. Two residents spoken with on Benn House said they were disappointed as not being included in the Southend outings and some residents indicated they did not want to take part in activities. An activity person was employed for Squires House for 18 hours a week. On Squires house a small number of residents were observed taking part in a craftwork session for about half an hour. Records seen for one person showed that since April 2008 they had only taken part in 4 activity sessions. The nursing staff prepared social and activity care plans and those seen could be improved to ensure they provided adequate detail in relation to the person’s preferences and social interests. The method for recording activities was considered very time consuming for the activity staff. They had to make entries on individual people’s care records when they took part in activities. Management should consider other methods to record activities so that activity staff can spend most of their time with residents. Recommendation 2. Residents spoken with were satisfied with the visiting arrangements. During the course of the inspection 9 relatives were spoken with. Currently the Commission does not send satisfaction surveys to relatives to obtain their views of the service. Relatives seen were generally satisfied with the service, the food provided and communication with staff. However concerns were raised in relation to the probable lack of leisure activities, the décor and furnishings provided. This was particularly an issue on Squires house. A number of residents spoken with had the ability to make their needs known and said staff listened to them and encouraged them to make daily choices about their life. In some care records seen guidance was provided for staff in relation to encouraging independence and choice. Residents said that staff usually responded to call bells within acceptable time limits both during the day and night. It was noted that when the telephone rang in the houses it was extremely loud in the lounge areas. This was considered to be irritating and intrusive for residents who may be reading, enjoying activities or dozing. Management should consider how this noise could be reduced for the benefit of the residents. Recommendation 3. Meals were brought to the house from the main kitchen in heated trolleys. A four weekly menu was provided and showed that a varied diet was provided. Residents were encouraged to choose a meal from the daily menu and if the meals on offer were not to their liking they could choose an alternative such as omelette, jacket potato or a salad. Residents were seen having lunch on the houses visited and those spoken with said they were satisfied with the meals provided. It was evident at lunch that a choice of meal was provided. Staff were observed assisting residents with their meals. On the day of the second visit lunch was observed on Squires house. A high percentage of residents on this house needed assistance with their meal. Pureed foods were served separately and some families visited at lunchtime to help their relative with Gallions View Nursing Home DS0000006761.V369628.R01.S.doc Version 5.2 Page 14 their meal. On Benn house a family regularly brought in meals for their relative, as the resident did not always like what was provided. This was an issue for the kitchen staff as the family wanted meals frozen and stored in the home. The cook was advised to get advice from the environmental health department so they could help the family to meet the resident’s request. Gallions View Nursing Home DS0000006761.V369628.R01.S.doc Version 5.2 Page 15 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): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Satisfactory systems were in place to manage complaints made about the service and to ensure resident safety. EVIDENCE: A copy of the complaints procedure was displayed in the main reception area and by the entrance door to each of the houses. The procedure provided information for residents and relatives about whom they should speak to if they have any concerns and how the complaint procedure was implemented. Relatives and residents spoken with knew who to talk to if they had any concerns. A system was in place to record complaints made about the service. From information included in the AQAA 17 complaints had been made about the service and following investigation 6 were upheld. Complaint records seen included the original complaint, the investigation and the response to the complainant. A monthly audit was completed on complaints and sent to head office. A policy and procedure was provided in relation to safeguarding adults. Staff spoken with displayed a good understanding of safeguarding adults and knew what action they should take if abuse was suspected or alleged. All allegations of abuse were notified to the Commission and social services. Gallions View Nursing Home DS0000006761.V369628.R01.S.doc Version 5.2 Page 16 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): Standards 19, 21, 24 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was clean and tidy but the furniture and décor on Squires house required attention. More effort should be made to personalise the bedrooms on this house. EVIDENCE: The deputy manager said that the home was due for refurbishment in 2009. Systems were in place to monitor the environment and a maintenance technician addressed day-to-day repairs. During the last key inspection it was noted that in Squires house that the condition and standard of some of the furniture was poor. A very worn three-piece suite was provided in one are of the lounge for residents. The suite was dirty and in need of cleaning and some of the covers on the chairs were torn exposing the upholstery. The large ‘stroke’ armchairs provided for residents were also in need of cleaning and again some covers were torn exposing the padding beneath. The deputy manager said that 4 ‘stroke’ chairs were on order for this house. Some of the Gallions View Nursing Home DS0000006761.V369628.R01.S.doc Version 5.2 Page 17 commodes seen required cleaning mainly around the frames and some of these were very old and should be replaced. Requirements made at the last inspection in relation to the environment on Squires house were not met. The décor in Squire and other houses was tired and dated and required updating. Although the décor could be addressed in the refurbishment programme the items referred to on Squires house must be replaced or repaired sooner for the benefit and comfort of the residents. Duncan and Benn houses were generally clean and tidy but as on Squires house the environment overall required updating. Some residents and relatives spoken with were not satisfied with the standard of the environment. Requirement 4. Toilets and bathrooms seen on the houses visited were clean and hot water temperatures checked were within safe limits. A number of bedrooms viewed on Squires house were found to lack a personal touch such as having mementoes, pictures or photographs. Bedrooms seen on Benn and Duncan houses were clean, tidy and many were personalised with photographs, pictures and small personal items. Recommendation 4. Sluice rooms were provided in each house and staff had access to hand washing facilities and protective clothing. Antibacterial hand gel was located by house entrances and in other appropriate areas. Gallions View Nursing Home DS0000006761.V369628.R01.S.doc Version 5.2 Page 18 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): Standards 27 – 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Adequate staffing levels were generally maintained. The staff team had the skills to meet the needs of the residents. Recruitment procedures were followed but needed a little improvement and staff were provided with training relevant to their work. EVIDENCE: The staff team included a full time deputy manager, trained nurses, care assistants, activity organisers and ancillary staff. Each house accommodated 30 residents. The planned roster was to have 7 staff in the mornings (included 2 trained nurses), 5 in the afternoons (included 1 trained nurse) and three staff at night (included 1 trained nurse). Staff rosters viewed for a twoweek period showed that the staffing levels provided did not always meet the planned staffing levels both in relation to skill mix and numbers. For example there was not always two trained nurses on duty in the mornings or the planned number of care assistants on every shift. Requirement 5. The care staff team comprised of trained nurses and care assistants. From information provided in the AQAA 75 care staff were employed and 47 people had achieved NVQ level 2 or above and 6 people were working towards this qualification. Gallions View Nursing Home DS0000006761.V369628.R01.S.doc Version 5.2 Page 19 Five staff files were viewed to check recruitment practice. All files included application forms, interview notes, proof of identity, health declaration and evidence of completed CRB checks. On the second visit to the home the full CRB check documents were seen. References received had been verified as genuine. However on reviewing application forms some references received were not from the employers listed in the applicant’s employment history. For one person a reference had not been obtained from their last care employer. Requirement 6. New staff were provided with a structured induction programme including three days ‘shadowing’ staff. Core training such as moving and handling was provided for new staff prior to starting work and other training such as health and safety, fire, infection control, manual handling, safeguarding adults, accident reporting and Personal Best were included in the induction programme. There was a training plan for 2008 to show details of the training provided each month. A number of staff were accredited moving and handling trainers, which enabled new staff to receive training in the houses. Some staff training was provided in house and other training was provided throughout the BUPA homes in the South East. Individual training records were kept for staff. The records seen were not all up to date and this made it difficult to check that the person had received mandatory training, training relevant to their role or 3 days training a year in line with the national minimum standards. Staff spoken with were satisfied with the training provided. Recommendation 5. Gallions View Nursing Home DS0000006761.V369628.R01.S.doc Version 5.2 Page 20 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): Standards 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well managed and systems were in place to monitor and improve the standard of care provided. Safe systems were in place to manage resident’s money and attention was given to providing a safe environment. EVIDENCE: Since the last inspection the service has had two manager changes. Currently the deputy manager was in charge of the service and will continue to do so until the newly recruited manager takes up post in September 2008. The deputy manager had the qualifications to manage the service but was not an experienced manager. Staff, residents and relatives spoken with said that people managing the home visited the houses regularly to offer support and monitor care practices. Requirement 6. Gallions View Nursing Home DS0000006761.V369628.R01.S.doc Version 5.2 Page 21 The home had a quality assurance system in place. The system included monthly audits of specific topics such as medication, record keeping and health and safety. The house sisters completed the audits and the quality manager checked the findings to ensure that they were accurate and that appropriate action was taken to improve the service. Some completed audits were seen and these included action plans to address and deficits identified. Annual satisfaction surveys were sent to residents and relatives and feedback was obtained from through relative and resident meetings. The last relative/resident meeting was held on 30/3/08. Staff meetings were held on the houses and management held regular meetings such as clinical, head of departments, GP and night staff meetings. Management provided support and assistance for residents to manage personal allowance money. Safe systems were in place to do this. Residents’ money was held in a shared bank account with interest paid proportionately to individual residents. Records were kept for money received and receipts kept for money spent on the resident’s behalf. Individual records were kept on the computer for residents and were made available to relatives, residents and other interested parties as needed. Records were checked for three people and were up to date and accurate. A safe was provided to hold money and valuables for residents. A record of the items stored in the safe was maintained and held securely. Accident records were viewed and were well completed. Records included the personal details of the person, the time and place of the accident, noted if any injuries were sustained and if any medical treatment was needed. Accidents and other issues, which may affect resident’s health or well-being, were reported under regulation 37 to the Commission. From information provided in the AQAA attention was given to providing a safe environment for residents and others. The information included the last service date for moving & handling equipment, gas and electricity supply service and fire safety equipment. A maintenance technician was employed to attend to everyday repairs and address health & safety issues. Gallions View Nursing Home DS0000006761.V369628.R01.S.doc Version 5.2 Page 22 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 3 X 2 X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Gallions View Nursing Home DS0000006761.V369628.R01.S.doc Version 5.2 Page 23 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 OP3 Regulation 14 Requirement Residents must receive written confirmation that based on assessment the service is suited to meeting their needs. Care plans must be kept up to date and when a resident’s needs change the care plans must be rewritten to show how the changed needs will be met. Accurate records must be maintained for all medicines brought into the home. Medicines records must be kept in such a way as to enable an audit trail to be completed. Management must review the time taken to administer the morning medicines and discuss this with the GP. The following issues must be addressed on Squires house: Clean or replace the commodes that are stained Upholster or replace the covers on the ‘stroke’ chairs (Timescale of 17/10/07 was not met). Adequate staffing levels must be provided for all shifts including DS0000006761.V369628.R01.S.doc Timescale for action 31/10/08 2 OP7 15 31/10/08 3 OP9 13 31/10/08 4 OP19 23 31/10/08 5 OP27 18 31/10/08 Gallions View Nursing Home Version 5.2 Page 24 6 OP29 7 OP31 having 2 trained nurses on duty for the morning shifts. 19 All the information required by 31/10/08 regulation must be obtained for employees and made available for inspection. This includes obtaining a reference from the last employer if in that employment the applicant worked with vulnerable people. Care The person managing the service 31/10/08 Standards must register with the Act 2000, Commission to ensure Part II (11 compliance with this section of – (1)) the Care Standards Act. The Commission must be informed in writing of the action taken to comply with this requirement. 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 OP7 OP12 Good Practice Recommendations Staff should ensure that all interactions with residents are completed, involve the person and provide a positive outcome for the person. Management should ensure social care plans reflect resident choice and interest. Consideration should be given to the recording of activities to ensure activity staff spend most of their time with residents. Management should review the current telephone arrangements to the individual houses and try to reduce the noise in the lounge areas when the phone rings. Staff should work with relatives and residents to personalise bedrooms for residents particularly on Squires house. Individual staff training records should be kept up to date and include the person’s designation. 3 4 5 OP14 OP24 OP30 Gallions View Nursing Home DS0000006761.V369628.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Gallions View Nursing Home DS0000006761.V369628.R01.S.doc Version 5.2 Page 26 - 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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