Inspection on 24/07/06 for Gallions View Nursing Home

This inspection was carried out on 24th July 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 but made no statutory requirements on the home.

Other inspections for this house

Gallions View Nursing Home 19/08/08

Gallions View Nursing Home 25/06/07

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Gallions View Nursing Home 20 Pier Way Thamesmead London SE28 OEU Lead Inspector Maria Kinson Unannounced Inspection 24th July 2006 09:35 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.V291537.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 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.V291537.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Gallions View Nursing Home Address 20 Pier Way Thamesmead London SE28 OEU 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 www.bupa.com BUPA Care Homes (CFHCare) Limited ***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.V291537.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 90 beds for general nursing care of people aged 50 years 30 beds for people with dementia aged 50 years Date of last inspection 13th February 2006 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, but is within striking distance of the town centres of Plumstead and Woolwich with their thriving and multi-ethnic 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 care for people suffering from dementia. All the rooms are single occupancy, with hand washbasins and shared bathroom and toilet facilities. The site is attractively landscaped, with gardens adjacent to each unit, and 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 £547.75 - £795 per week. This does not include additional charges such as chiropody, hairdressing, newspapers and toiletries. This information was supplied to the commission on 24.07.06. Gallions View Nursing Home DS0000006761.V291537.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on 24.07.06, between 09:30am–18:00pm and on 25.07.06, between 08:45am –12:00 midday. Some of the information received about the service was used to determine which issues were assessed during the visit. On day one of the inspection one inspector spent the day on Hutton House and one inspector spent the day on Benn House. The inspectors spoke with residents, staff and visitors and observed care practices. Five sets of care records were examined and the management of medication was assessed on Benn House. All of the communal areas and a selection of bedrooms were examined on both units. On day two of the inspection health and safety, quality assurance and staff records were assessed. Comment cards requesting feedback about the service were sent to a random selection of residents, relatives and health care professionals. Twenty-seven cards were returned to the commission, five from residents, one from a health care professional and twenty-one from relatives. What the service does well: Feedback from relatives and residents was mostly good. Twenty out of twenty one relatives were satisfied with the overall standard of care provided in the home. Residents said that staff were “helpful” and listened and acted on what they said. Staff on Squires House were “commended for their constant care and kindness”. Staff carried out their work in a professional manner and made sure that residents dignity and privacy was maintained. The arrangements for admitting new residents into the home were satisfactory. The home received regular support from a local GP and staff were able to contact other health care professionals for advice when required. Residents said that the food provided in the home was usually good and that they were able to choose what they ate from the menu. Resident’s friends and family were able to visit the home when they wanted and were welcomed by staff. Good records were maintained about money or valuable items that residents or relatives handed to staff for safekeeping. The manager carried out additional checks to ensure that staff had followed the correct procedure. Staff were encouraged to undertake relevant training and were supported to attain recognised qualifications. New staff attended an induction training day and spent time working alongside other more experienced staff. Staff had a Gallions View Nursing Home DS0000006761.V291537.R01.S.doc Version 5.1 Page 6 good understanding of abuse and were clear about the action they should take if they witnessed or were told about an allegation of abuse. What has improved since the last inspection? What they could do better: This home has made good progress with the requirements set during the previous inspection but further work is required to meet some standards. Staff must ensure that all residents are supplied with a copy of the Service User Guide. All of the files seen included a care plan but plans were often similar in appearance and included little information about the resident’s personal preferences or routines. Care plans included more information about resident’s personal interests and hobbies. But there was little evidence that staff used this information to provide meaningful occupation for residents. Residents said they enjoyed the activities that took place in the home but wanted more activities and they wanted to be able to go out every so often. The practice of labelling medication bottles with room numbers had stopped. Medication was administered as prescribed but records of receipt were not always properly maintained and the temperature in the medication room was unsuitable for the storage of medicines. Although the home was clean and comfortable some parts of the home and some of the furnishings were worn and chipped. The flooring in the shower Gallions View Nursing Home DS0000006761.V291537.R01.S.doc Version 5.1 Page 7 room on Hutton House was coming away from the floor. This could create a tripping hazard. Complaints and concerns were investigated or referred to other professionals promptly. Staff dealt with complaints according to company procedure but it was not always clear from the records if the complainant was told about the findings. Equipment was serviced at regular intervals and fire safety equipment was located at suitable points around the home. The records showed that fire drills were not carried out regularly on one unit and that some staff required further guidance or training. It was not clear if any action had been taken to address the concerns in the mains electricity installation report 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. Gallions View Nursing Home DS0000006761.V291537.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Gallions View Nursing Home DS0000006761.V291537.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 5. (Standard 6 does not apply to this home). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for admitting new residents into the home were good. New residents did not always receive adequate information about the service once they had moved into the home. EVIDENCE: There was no evidence that resident’s had received a copy of the Service User Guide. Three residents on Hutton said they did not recall receiving a copy of this document. See requirement 1. Senior staff were responsible for assessing residents needs, prior to agreeing for the resident to be admitted into the home. Staff recorded information about prospective residents needs and preferences and obtained additional information from the placing authority. Residents that were admitted to the home from Hospital were usually given a transfer letter and list of medication to pass onto the staff. Gallions View Nursing Home DS0000006761.V291537.R01.S.doc Version 5.1 Page 10 Residents were encouraged to view the home prior to making a decision to move in but were often too frail or unwell to do this. Some residents said that their family members visited several homes including Gallions and helped them to make a decision about the type of home that might suit them. Comments made by residents and relatives indicated that they had received adequate information about the service before they made a decision to move into the home. “We went to see the home without an appointment and were very impressed with the staff and facilities”, my “relatives visited homes in the neighbourhood and were reassured by what they saw/heard and by how they were greeted in Gallions View”. Gallions View Nursing Home DS0000006761.V291537.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff had developed a plan of care for each resident. Care plans provided adequate information for staff to meet resident’s basic needs but there was little evidence that personal preference or routines were considered. Staff worked in partnership with other professionals to ensure that resident’s health care needs were met. Medication was administered as prescribed but it was not possible to account for all medicines, as some records were not properly maintained. Staff carried out their work in a professional manner. Care was taken to maintain resident’s privacy and dignity. EVIDENCE: Five sets of care records were assessed. The records viewed showed that staff assessed resident’s needs on admission to the home and used the information they obtained during the assessment to develop a care plan. Some residents and relatives had agreed and signed the care plan and there was evidence in some of the files that staff had discussed other assessments such as the use of bedrails with relatives. Care plans were mostly satisfactory but frequently Gallions View Nursing Home DS0000006761.V291537.R01.S.doc Version 5.1 Page 12 lacked specific information about resident’s social needs and personal preferences. See requirement 3. Staff assessed resident’s risk of developing pressure sores and took action to reduce risks where possible. Staff said that pressure relieving mattresses and cushions could be obtained. Nutritional assessments were undertaken to identify residents that that were at risk of weight loss and residents were weighed regularly. It was noted that a new resident whose health was rapidly deteriorating had been referred to the Palliative Care team. Access to community health care services was satisfactory. Records indicated that some residents had seen a GP, Tissue Viability Nurse, Optician, Physiotherapist, Dentist and other health care professionals in recent months. Appointments were recorded in the diary and outcomes noted in daily care notes. Feedback from one health care professional that was in regular contact with the home was good. The respondent said that staff communicated clearly, demonstrated a clear understanding of residents needs and were “cooperative and polite”. The majority of relatives that provided written feedback about the service said that they were kept informed about important matters affecting their relative. The management of medication was assessed on Benn House. Medicines were stored appropriately but the temperature in the clinical room was unsuitable. Records of receipt of medicines were variable. It was not clear when some medicines particularly liquid preparations and creams were supplied to the home. One discrepancy was noted where a resident was prescribed pain relief tablets three times a day but was receiving this medication four times a day. Records of administration and disposal of medication were good. See requirement 2. Several staff members were observed carrying out their duties thoroughly throughout the inspection. Staff responded to residents in a caring and professional manner. Comments made by residents during the inspection and in written feedback indicated that staff were kind, treated them with respect and maintained their privacy. Residents said that they always or usually received the care and support they required, that staff listened to what they had to say and were always or usually available when they required assistance. All of the rooms in the home are single occupancy. The manager said that she was considering providing training for senior nursing staff so that they could verify the death of a resident in certain circumstances. This issue was discussed with the inspector and a copy of the policy relating to this issue was assessed. Gallions View Nursing Home DS0000006761.V291537.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides regular activities but the current range and frequency of activities did not always meet resident’s needs. Residents were able to maintain contact with their friends and family and were able to choose how and where they spent their time. Residents were satisfied with the choice and quality of food provided in the home. EVIDENCE: Residents stated that their routines of daily living were flexible and they could choose whether to join in with activities or pursue their own interests. There was however a general consensus amongst residents spoken to on the day of the inspection that there was not enough to do during the day so they sometimes felt “bored”. Some residents said they had taken part in bingo sessions and quizzes but none of the residents had been on any trips or outings. Staff on Hutton had identified resident’s personal interests and prepared a care plan to meet their individual needs. There was little evidence in the key Worker diary or daily care notes that residents interests such as football and walks in the garden were taking place. The records maintained by activity staff for July 2006 were examined. One resident had not received any support with activities, one resident had spent one to one time with the activity Gallions View Nursing Home DS0000006761.V291537.R01.S.doc Version 5.1 Page 14 coordinator on two occasions and one resident had taken part in six activity sessions during the month. The manager advised the inspectors that the vacant activity post had been advertised and said she wanted to encourage care staff to become more involved with activities. For this to be achieved care staff must have access to adequate information about resident’s social needs and activity and care staff must receive training. See requirement 3. Residents stated that they were able to receive visitors in private and there were no restrictions imposed by the home. Most relatives said they were made to feel welcome when they visited the home. Residents were able to choose when they got up and went to bed and how they spent their time during day. From interviews with residents and staff and general observation of care practices it was evident that residents were encouraged to make their own choices, where possible. One resident ate his meals in his own room through choice and this was recorded in his care notes. Another resident was seen escorting a visitor to his room for a private chat. Residents were aware that staff maintained records about the care they received and that they could access these on request. None of the residents spoken with expressed a wish to do so. Meals were served at set times during the day but individual requests for variations could be accommodated in order to facilitate outings or appointments. Lunch was served in the dining area and tables were appropriately laid out. Residents said that they usually liked the food provided, were offered a choice and meals were “appetising and well presented”. This inspection took place on a hot day, jugs of water and squash were provided in the lounge and individual rooms, occupied by residents. Residents stated that they could choose to eat in their own rooms or in the dining area and that snacks were available, on request. Each dining area had an adjacent kitchen area to facilitate this. Laminated menus were provided and staff said that special diets were provided. Gallions View Nursing Home DS0000006761.V291537.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints and concerns were investigated or referred to other professionals promptly. It was not always clear from the records whether complainants had received adequate feedback or were advised about the action the home had taken to address their concerns. EVIDENCE: The home had a complaints procedure, which included a timescale for acknowledging and responding to complaints. Most relatives and residents said they had seen the procedure displayed in the home and knew who to speak to if they had any concerns. One relative said that her concerns had been “dealt with promptly and with minimum fuss” another relative said that staff had addressed her complaint but she had never “heard the result”. Records were maintained about complaints and findings from investigations. Since the last inspection the home had received twelve complaints. Some of the concerns recorded were investigated as adult protection issues. The records seen indicated that complaints were thoroughly investigated and appropriate action was taken where staff had not followed company procedure. It was not always clear from the records if staff had advised the complainant about the outcome of their investigation and about the action they had taken. A significant number of the complaints received in the home related to one unit. The manager was aware of this issue and had recently recruited some new senior staff to provide additional support for staff and to monitor care practices. See requirement 4. Gallions View Nursing Home DS0000006761.V291537.R01.S.doc Version 5.1 Page 16 The home had an adult protection procedure. Staff were aware of the need to report allegations of abuse or misconduct to senior staff and some staff had attended protection of vulnerable adults training during the past year. In view of the number of concerns raised about care practices during the night, the manager should carry out regular unannounced night visits to the home. See recommendation 1. Gallions View Nursing Home DS0000006761.V291537.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean and comfortable. Some redecoration and repairs were required but these issues did not pose a significant risk to resident’s health or safety. EVIDENCE: The inspection team viewed all of the communal areas and a selection of bedrooms on Benn and Hutton House. All parts of the home were clean and odour free. One relative and two residents said that there had been occasions when the standard of cleanliness had dropped and visitors had felt it necessary to clean the resident’s room. Toilets and bathrooms were fitted with appropriate aids to assist residents with poor mobility. Gallions View Nursing Home DS0000006761.V291537.R01.S.doc Version 5.1 Page 18 The home employs a full time maintenance employee and there were good systems in place for reporting or requesting work or repairs. The flooring in the walk in shower room (29) on Benn was lifting in several areas and some of the built in units and bedside cabinets in bedrooms were damaged and looked unsightly. See requirement 5. Overall both units were decorated to a reasonable standard but there were scuffmarks on some of the walls and doors. Water temperatures were regulated and lighting and ventilation were good. Hand washing facilities were provided where clinical waste or infected material was handled. Domestic staff were aware of procedures for handling hazardous substances and cleaning materials were stored securely. Gallions View Nursing Home DS0000006761.V291537.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although there were a number of staff vacancies the home tried to maintain good continuity of care for residents where possible. Through checks were carried out on new staff. Staff were supported to attend relevant training courses. EVIDENCE: Samples of staffing rosters were examined for each of the units visited. All of the units had similar staffing levels. The duty rosters indicated that there were at least two nurses and five care staff on duty during the morning shift, two nurses and three care staff on duty during the evening shift and one nurse and two care staff on duty overnight. The rosters were easy to follow but it was not always apparent if temporary staff were nurses or carers. This information should be clearly recorded on the roster. All of the units were using temporary staff to cover vacant posts or staff absence. Agency staff were requested from a ”known list” where possible to ensure continuity. One third of the relatives questioned said there were times when they felt there were not sufficient staff on duty and some concerns were expressed about the use of agency staff. A number of relatives said that staff were helpful and kind and the staff on Squires House were “commended for their constant care and kindness”. Fifty percent of care staff had attained a vocational qualification in care at level 2 or above. Gallions View Nursing Home DS0000006761.V291537.R01.S.doc Version 5.1 Page 20 Four staff recruitment files were viewed. The files viewed contained all of the documents and information required by legislation. Some photographs were photocopied from other documents. This could make it difficult to identify the staff member, because the quality of the picture, once photocopied was often poor. The manager was advised to use original photographs where possible. Each member of staff had a personal training record. The records seen indicated that new staff had attended a induction training day that included health and safety, adult protection, food hygiene, infection control, fire safety and moving and handling. A new training matrix had been introduced to provide senior staff with up to date information about training that staff had undertaken or required. Gallions View Nursing Home DS0000006761.V291537.R01.S.doc Version 5.1 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The new manager was committed to improving standards of care and supporting staff. Regular audits were carried out to check how the home was performing and to identify areas for improvement. The arrangements for safeguarding resident’s money were satisfactory. Health and safety issues were mostly well managed but some issues of concern were identified. EVIDENCE: Since the last inspection a new manager had been appointed. The manager had undertaken a significant amount of work since her appointment to familiarise herself with the home, residents and staff. Staff said the manager kept them informed about significant issues and made a point of visiting all of Gallions View Nursing Home DS0000006761.V291537.R01.S.doc Version 5.1 Page 22 the units each day to monitor care and support staff. Two relatives commented that there had been a number of “problems” in the home over recent months but “efforts were being made to overcome them” and changes were having a “beneficial effect”. The manager said that she had submitted an application for registration but this was returned, as it did not include all of the information required. A new application must be submitted to the Central Registration Team. The home had systems in place for monitoring the quality of care provided in the home. Unannounced visits to the home were taking place regularly and monthly audits were carried out. The system for dealing with residents’ ‘ money was examined and was found to be satisfactory. Residents’ money was pooled in a bank account but individualised to ensure that each resident received an appropriate amount of interest. Records were maintained on a computer but printouts were made available to residents or their relatives, on request. Printed copies were retained in the administrative office with accompanying receipts to evidence any credits or debits. The safe was used to store any valuables deposited and a list was maintained of any items deposited for safekeeping. Most residents have their finances and valuables managed by their relatives and the home recommends this. When necessary the home does provide the above service with the assistance of the local social services department, solicitors or relatives. The Inspector examined the records for three residents chosen at random. Credits and debits tallied with receipts and balances and a good audit trail was maintained. The home had a comprehensive programme of health and safety checks that included wheelchairs, bed rails and hot water temperatures. A sample of health and safety and fire safety records were examined. Most of the certificates and records seen were satisfactory. The exceptions to this were the fire risk assessment, which was dated 2004, the mains electrical installation, which was inspected in 2004 and was assessed as “unsatisfactory” and the frequency of fire drills. The fire drill log for Hutton stated that “some improvement” was required but did not state if any action had been taken to address this issue. Following the inspection the manager prepared an annual programme of fire drills for all of the units. See requirement 6. Accident records for May and June 2006 were assessed on Benn House. Most of the records viewed provided the reader with a clear picture of what had happened, the circumstances of the incident, any treatment given to the resident and any action that was taken to try to avoid a reoccurrence. There was conflicting guidance in some care plans and moving and handling assessments about how residents should be moved. For instance one care plan said a resident could be transferred manually with the assistance of two Gallions View Nursing Home DS0000006761.V291537.R01.S.doc Version 5.1 Page 23 staff, the moving and handling assessment for the same resident stated the resident should be moved with the use of a standing hoist. See requirement 6. Gallions View Nursing Home DS0000006761.V291537.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X 3 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 2 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Gallions View Nursing Home DS0000006761.V291537.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 5 Requirement Timescale for action 18/12/06 2. OP9 13 3. OP12 18 4. OP16 22 The Registered Person must ensure that each resident receives a copy of the Service User Guide. The Registered Person must 20/11/06 ensure that: • Medicines are stored at a suitable temperature • Information on the MAR sheet correspond with the instructions on the prescription • A record of receipt is maintained for all medicines received in the home The Registered Person must 18/12/06 ensure that appropriate training and supervision is available for all staff including activity organisers. (The previous timescale of 13/04/06 was not met). The Registered Person must 20/11/06 ensure that the complaints file includes a copy of the response to the complainant. The response must state what action, if any has been taken in respect DS0000006761.V291537.R01.S.doc Version 5.1 Gallions View Nursing Home Page 26 5. OP19 23 6. OP38 13 of their concerns. The Registered Person must: • Replace the flooring in the shower room (29) on Benn House • Prepare a programme of work that includes repairing /replacing damaged furniture and built in cupboard units. The Registered Person must: • Advise the commission in writing about the action that was taken to address the findings in the mains electrical installation inspection report • Review and update the homes fire risk assessment • Ensure that moving and handling guidance is reviewed regularly and kept up to date • Ensure that regular fire drills are undertaken (some of which must involve night staff) 18/12/06 20/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP18 Good Practice Recommendations The Registered Person should ensure that regular unannounced visits are undertaken to the home of a night. Gallions View Nursing Home DS0000006761.V291537.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Gallions View Nursing Home DS0000006761.V291537.R01.S.doc Version 5.1 Page 28 - 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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