Inspection on 01/12/05 for Gatehouse Cottages Care Home

This inspection was carried out on 1st December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found 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 59 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Gatehouse Cottages Care Home 28/01/10

Gatehouse Cottages Care Home 29/09/09

Gatehouse Cottages Care Home 18/01/08

Gatehouse Cottages Care Home 18/01/07

Gatehouse Cottages Care Home 27/06/06

Gatehouse Cottages Care Home 10/06/05

Gatehouse Cottages Care Home 20/12/04

Gatehouse Cottages Care Home 29/04/04

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

CARE HOME ADULTS 18-65 Gatehouse Cottages Care Home Stallingborough Road Immingham Grimsby North East Lincs DN41 8BP Lead Inspector Matun Wawryk Unannounced Inspection 09:30 1 , 2 , 7 , & 15 December 2005 st nd th th Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 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 Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 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. Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Gatehouse Cottages Care Home Address Stallingborough Road Immingham Grimsby North East Lincs DN41 8BP 01469 574010 01469 573058 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) Blair.house@craegmoor.co.uk Health & Care Services (UK) Limited Position Vacant Care Home 27 Category(ies) of Learning disability (27), Physical disability (20) registration, with number of places Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents with physical disability must not reside in The Lodge. Residents with physical disability must not reside on the first foor of the main building. 9th June 2005 Date of last inspection Brief Description of the Service: Gatehouse Cottages is a care home providing personal care with nursing and accommodation for up to 27 adults aged 18-65 with moderate and severe learning disabilities, 20 of these places are for service users who also have physical disabilities. Health and Care Services (UK) Limited/Craegmoor Healthcare own Gatehouse Cottages. The home is situated in the countryside a few miles outside Immingham in a fairly isolated position; there is only one neighbouring property. There is a regular bus service and the home has its own transport. An enclosed garden is to the rear of the building and parking space is provided at the front of the home. The accommodation comprises of 3 separate units; there is a purpose built ground floor main facility, the first floor of this is the Studio flat and there is a separate 3-bedroom house nearby which is the Lodge. There are two shared bedrooms in the main facility and one in the Studio the rest being single. None of the bedrooms have en-suite facilities. A range of aids, adaptations and equipment are provided in the main facility including an Aqua Nova bath and a sensory room. Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and visits were made on the 1st, 2nd, 7th and 15th of December 2005. A second inspector accompanied the lead inspector on the first day on the inspection. The majority of service users who lived in the home had limited verbal communication skills. To find out how the home was run and if the service user’s who lived there were happy with the care they received, one of the inspectors spent time in the dining room at breakfast and lunchtime observing how staff helped service users with their meal and observed staff carrying out their work. The other inspector spoke to two-service users who were in the studio flat. The inspectors spoke to the manager, three nurses, three home support workers, a cook and handyman who were working in the home at the time of the inspection. One of the inspectors also spoke to the mother of one service user. In addition the inspectors looked at a range of paperwork in relation to staff recruitment, induction, supervision, training, rotas, menus, fire records, care plans, activity records, complaints and the servicing of equipment. Since the last inspection changes had been made to the management arrangements for the home. The current manager had only been in post for five weeks. What the service does well: There was a core group of staff that had worked at the home for several years and knew the service users well. Staff spoken to reported they enjoyed working in the home Staff reported that relatives are made to feel welcome when visiting the home, and discussions with the mother of one service user confirmed this, thereby helping service users to maintain family contacts. Staff spoken to commented on the approachability of the current manager. All stated they found her to be friendly and efficient, Staff reported that access to training was good. The home employs an activity coordinator, who provides a good variety of activities to the clients. This means service user’s have opportunities for social stimulation. Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: The home must address the outstanding requirements and the new ones issued from this inspection. Failure to do so may result in enforcement action being taken. Two serious concerns were identified. One concern related to administration of medication. Records showed on some occasions nurses had not recorded administration of some medication. This raises questions about whether medication has been given or not. The second concern related to lack of proper care records for four service users. Some care plans and risk assessments were found to be inaccurate or incomplete. This means staff may not have all the information they need to care for service users properly. An official letter was left at the home for the owners to put this right by 21st December 2005 or enforcement action would be considered. All service users must have their needs properly assessed prior to admission to the home. This is needed to ensure the home is able to provide necessary care and support. Service user care plans must improve; Individual service user plans were available however some records did not have enough information about all the needs of service users. This means the home was not able to show that all aspects of health, personal and social care needs of service user’s are identified and planned for. Staff must be provided with more service specific training for example, in working with people with a learning disability and communicating with people who have difficulties in the area. This is needed to ensure staff have necessary skills and knowledge to meet the changing needs of service users. Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 Page 7 The management and supervisory arrangements for the home must improve to show service users living in the home are safe and well cared for and to ensure staff are provided with necessary guidance, leadership and support. Staff reported that they felt ‘under-valued’ by the company who own the home and that this has affected the morale of some staff working in the home. Regular reviews of aspects of the homes performance through a good programme of self review and consultations, which includes the views of service users, staff, relatives and others for example care managers must be carried out. This is needed to ensure continuous improvements are made. 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. Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 Page 8 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 Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 Page 9 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): 1&2 Information provided to prospective service users and their carers is detailed thereby enabling them to make informed decisions about whether the home can meet their needs. Not all service users have their needs assessed prior to admission to the home. This is needed to ensure the home has the capacity to provide necessary care and support to meet the needs of service user’s. EVIDENCE: The home’s statement of purpose and service user guide, were last examined in April 2004. Because the inspector was aware that some changes had taken place since the document was last looked at and because there was an outstanding requirement from previous inspections, the statement of purpose was examined again as part of this inspection. Required amendments had been made to include recent management and staff changes and more detailed information about the home. The manager was not able to locate a copy of the service user guide. The guide was deemed to have met the standard at the inspection in 2004. The registered person must ensure copies of the service user guide are available and provided or explained to new service users. The guide may need to be amended to reflect the above changes. Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 Page 10 Since the last inspection the home had admitted one service user who had transferred from another Craegmoor home. The responsible local authority had agreed to the move but had not provided the home with a revised needs assessment or care plan. The home had not carried out their own needs assessment nor had they revised any existing assessment information. Staff said they were able to meet the service user’s health and personal care needs. The service user does not meet the age criteria for the home and an application to vary the homes registration had not been made to the Commission prior to his admission. A variation application was submitted to the inspector during the inspection. In future the registered person must not admit any service user who does not fall within the homes registration category unless an application to vary registration has been granted. The registered person must ensure a current needs assessment or summary is obtained for new admissions. In the absence of a local authority assessment the home must complete one. Failure to obtain or complete a needs assessment prior to admission means assurance cannot be provided about the homes capacity to meet the needs of service users. Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 Page 11 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 & 9 Service users do not have care plans and risk assessments that reflects their full range of needs and choices. Without this there is no assurance the service user’s health, personal and social care needs will be met. EVIDENCE: The inspectors examined a sample of three service user care plans and other associated records. The quality and consistency of information varied considerably. Care plans had not always been revised and updated as needs had changed and there was some duplication of information. Records showed care plans were being evaluated but not on a monthly basis. Changes noted on evaluation records had not always resulted in changes to care plans and risk assessments. Records and discussion with the manager showed not all service users had had a review during the past twelve months. As previously indicated care records for the newest admission to the home had transferred with him. Some assessments and care plans were noted to be several months old. Records had not been reviewed and/or updated following Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 Page 12 the service user’s admission to the home. As a result some care records did not reflect the service users current care needs and care provision. One service user had a plethora of care plans and risk assessments, a number of these did not reflect the service users current care needs and care provision. For example the service user’s Water-low and nutritional screening assessments contained inaccurate information. The service users peg-feeding programme did not reflect the existing feeding regime. Some care plans were generic and therefore did not support the delivery of individualised care. The service user had significant communication problems. None of the assessments addressed this fully and a communication plan had not been developed. Care Plans and risk assessments for another service user were again not up to date e.g. for personal care, feeding, continence and behaviour. Discussion with staff and examination of daily records indicated significant changes had taken place for example; the service user had stopped talking and was shouting/making noises for long periods. Staff raised concerns about the impact of this not only for the service user but also for others living in the home. Staff and records indicated the service user exhibited frequent episodes of challenging behaviour. A behaviour management plan linked to risk assessments had not been developed to assist staff in trying to manage the service users behaviours or to minimise the impact of this for others residing in the home. The manager was advised to immediately request a re-assessment of this individual’s needs, which she was observed to do. The registered person must ensure agreed behaviour management plans are in place for all service users who exhibit challenging behaviour. This is needed to ensure the welfare and safety of service users and staff. Although incidents of challenging behaviour were being recorded there was no evidence that these incidents were being monitored and evaluated on a regular basis to ensure lessons can be leant. Again this is needed to ensure the welfare and safety of the service user and staff and to ensure appropriate strategies are in place. This remains on outstanding requirement from the previous inspection and must now happen. The registered person must ensure individual care plans and risk assessments reflect all current identified needs. Regular monthly or more frequent evaluations (where needed) must be completed. Records must be updated to reflect any changes in needs and circumstances as necessary. This is needed to ensure staff have access to sufficient information to provide the right level of care to service users. Without this assurances cannot be given that the care needs of service users are met. Reviews of care plans must be carried out as a minimum of six monthly. Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 Page 13 Care plans are kept in the office. Daily records are maintained by the nursing staff, these described care provided and communication with other parties. Nursing records were being held separately from the main care file as were a number of other records e.g. weight charts. At the last inspection staff did not indicate any particular problems with this system. However following the case tracking exercise and discussions with staff it is now evident care plans are not being used as ‘live’ documents. The inspectors advise firstly that records are located in a more accessible place for staff and secondly that documentation is combined into one ‘holistic system’, which would be more user- friendly for staff and service users. Not all the care plans and risk assessments had been agreed with the service user or their representative(s). This matter was discussed with the manager and the inspector was advised that multi-agency reviews were being arranged for all the service users, agreements to care plans and risk assessments was being sought as part of the review process. This remains an outstanding requirement from the previous inspection and must now happen. Care plans were still being produced in standard written format, this does not assure the accessibility of these for service users. The need to produce care plans in a more accessible format remains an outstanding requirement from previous inspections and must now happen. Staff reported that service users were given choice and supported to make decisions as much as the service user was able to. The majority of service users are reliant on staff and family members recognising and identifying their likes and dislikes. Most service users had significant communication problems. There was no evidence to show Very little information was in alternate formats and staff did not appear to use have specific communication tools with service users. Care plans did not fully and consistently address communication issues. This means the home was not able to fully demonstrate through assessments, care plans and information how service users were supported to make decisions and choices. None of the service users managed their own finances. Health and Care Services UK Limited/Craegmoor Healthcare acts as a corporate appointee for the majority of service users living at the home. The inspector examined financial records relating to four service users. Income and expenditure was being recorded and receipts for expenditures were available in most cases. The inspectors noted that a small number of relatives were being given a regular payment from the service users DLA allowance to assist with transport cost to enable them to visit the home to see their family member. Individual financial plan were in place, however these did not provide a clear audit trail for decision-making. The registered person must ensure service users have a current financial plan. These must provide a clear audit trail for decisionmaking. This is needed so that the home can demonstrate arrangements are in Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 Page 14 place to support effective management of the service users’ finances and to ensure appropriate safeguards are in place. Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 Page 15 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): 11, 13, 16 & 17 Service users social and personal development needs are not well provided for. Service users need to be provided with more structured support. Daily routines observed in the home are flexible and promote choice for the service user’s as far as practicable. The meals in the home are good offering both choice and variety. Arrangements for assessing and monitoring the nutritional needs of service user’s requiring peg feeding were unsatisfactory. EVIDENCE: Staff reported that they helped service users to maintain family contacts by sending cards at significant occasions such as birthdays and Christmas and supported service users on visits where this was needed. This means service users are enabled and supported to maintain family contacts. Feedback from the relative of one service indicated she was very happy with the care and support provided to her son. Staff were described as helpful and friendly. Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 Page 16 The home employs an activity co-ordinator who takes responsibility for organising a weekly programme of activities on an individual and group basis for service users in the main facility. Records of activities were maintained. All staff spoken to stated the provision of activities had improved significantly over the past year. The home has a sensory room, observation and records indicates it is well used. As indicated in the last inspection report the activity co-ordinator had not had any specific training in planning and running activities for people with complex needs. This needs to be an area of future development to enable her to develop new ideas for activities in the home linked to individual needs, preferences and capacities of service users. Three service users in the main facility attend a local authority day centre; records did not evidence any joint planning and recording. Consideration should be given to this. This would promote a more consistent approach and show how activities accessed at the day centre fit in with activities provided in the home. This would possibly address some of the communication concerns and issues highlighted by staff in discussion with the inspector. Service users residing in the Studio and Lodge had more structured opportunities to develop social, communication and independent living skills. Staff reported service users were supported to manage shopping, cooking, cleaning and personal care. Feedback from two service users confirmed this. Service users living in the Lodge and Studio attended a day centre provided by Craegmoor. Attendance provides further opportunities for service users to develop practical life skills and activities of their choosing. Similarly no information was available in the home regarding progress at the day centre and how this fits in with activities provided in the home. Consideration should be given to this to promote a more coordinated approach to personal development of service users. Records and feedback from staff and service users identified that for the last two months, service users in the Lodge and Studio have had their day attendance disrupted due to transport difficulties and staff availability at the day centre. Staff reported this has impacted negatively on the behaviours of some service users. To accommodate the lack of structured day support, service users are spending more time together in the studio flat. The flat is small; the only communal space available is a small sitting room and kitchen/dining room. This arrangement is not satisfactory. A review of current arrangements should be considered with a view to finding an alternative provision. Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 Page 17 The inspectors were advised that service users spiritual needs were assessed on admission and arrangements to meet those needs were put in place where required. There were no service users who were receiving any on-going spiritual support, although one-service user occasionally attended the local church. Service users are provided with three meals a day and a varied menu was available. One of the inspectors spent time in the main facility observing the breakfast and the lunchtime meal. Staff were observed to assist service users to eat in a sensitive manner and service users were not hurried. Nine service users need to be assisted to eat. This is in addition to those who require peg feeding. Staff commented that mealtimes, particularly at weekends were problematic because all the service users were normally in the home. The registered person must keep this matter under review and where necessary staffing levels should be increased to ensure mealtimes are flexible to meet the needs of service users. Service users’ nutritional needs were assessed however records examined identified some assessments were not up to date. In one case the assessment was totally inaccurate. The peg feeding regimes for two service users did not reflect current arrangements. This potentially places service users at risk of not having their nutritional needs fully met. The registered person must ensure individual assessments and care plans are accurate and kept up to date. One service user had been receiving food orally and was also peg fed. Following a chest infection oral food was withdrawn because of a potential risk of choking. There were no records to indicate any review of this arrangement. It was not clear whether a re-introduction of some oral feeding was being considered/planned or whether permanent peg feeding was now needed. Gaps in the service user’s food chart were also noted. The inspector advised that the dietetic nurse or GP is consulted. This is needed to ensure there is an agreed plan of care for this individual. Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 Page 18 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): The arrangements for meeting the health care needs of service users and management of the service users medication are unsatisfactory. This potentially places the service user at risk of not having their health and care needs identified and planned for. Personal support is provided in a way, which respects the service user’s right to privacy and dignity. EVIDENCE: The manger was not able to fully demonstrate through assessment, medication administration records, care planning and evaluation processes that all the service users health needs were being met in a consistent way. All the service users were registered with a GP and records of visits by health care professionals were maintained. The home had risk assessment tools for nutrition, supported by weight charts, falls, Water-low assessments and manual handling. However the process of assessing, recording and monitoring needs in these areas showed inconsistent practice. In some cases records were inaccurate, incomplete or out of date. For example: One recently admitted service user had not had his assessments and care plans updated. For example; the manual handling assessment had last been reviewed in December 2004. Discussion with staff and records indicated the Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 Page 19 service user was now much more dependent and reliant on staff for support. The nutritional screening assessment had last been reviewed in August 2005 (prior to the service users admission to the home); the assessment noted the person was under weight. A re-assessment had not been completed despite records indicating changes had occurred. Staff were recording fluid and food intake but there was no evidence to show how this information was being monitored or used. A Water-low assessment completed in August 2005 identified service user was high risk, a note on the assessment stated the service user did not have a pressure sore. The Water-low assessment had not been updated to reflect changes and there was not care plan for skin integrity/pressure area care. Records indicated the service user was having dressings applied on a weekly basis. There was no evidence the service user had seen his GP since his admission to the home. The Water-low and nutritional screening assessments for another service user were inaccurate and did not reflect the service user current needs. Staff had not picked this up despite the fact that the assessments had been evaluated on several occasions. Records and discussion with staff did not evidence that annual health checks and been sought and provided for all of the service users. This remains an outstanding requirement from the previous inspection and must now happen. This matter was fully discussed with the manager at the visit carried out on the 1st December. At the visit on the 7th December the inspector was handed a written record confirming requests for annual health checks had been made. Health action plans had not been introduced into the home, despite this having been identified as a need in some service users reviews reports. The inspector advised the manager to contact the local authority to progress this matter. At the visit on the 7th December the manager confirmed contact had been made and that a ‘health plan’ implementation plan had been agreed. The manager was asked to confirm these arrangements in writing to the Commission. Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 Page 20 Only qualified nurses administer medication and the home had a range of polices and procedures in place for medication to support staffs practice in this area. No service users were self-medicating. The inspectors examined the medication administration recording sheets and care plans for a number of service users. Records and discussion with staff identified a number of issues. Medication care plans were in place however in some cases these were old and had not been updated to reflect changes. It was noted that some medication supplies were on the floor in one stock room. This practice should cease. Records showed that on occasions nurses had failed to record administration of some medication to some service users. This raises questions about whether medication had been given or not. Advice was given to the manager to consider utilising a different medication record sheet, which would be more user- friendly for staff and encourage better recording practice. At the visit on the 7th December 2005, the inspector was advised that a different Monitored Dosage System was shortly to be introduced into the home. Two service users had been prescribed medication in tablet form and nurses were crushing this up, mixing it with water and then administering via the service user’s peg feed. There was no evidence to indicate this practice had been discussed with and agreed with the prescribing clinician. This is needed to ensure the efficacy of the medication was not being compromised. The manager was advised to seek immediate advice from the GP, which she was observed to do. Observation and discussion with staff identified that a significant number of service user’s in the main facility were having their medication administered in food and drinks. Medication care plans did not support this practice and there was no evidence to indicate agreements for this to happen had been agreed with the service user or their representative(s), thereby demonstrating a clear audit trail of decision-making. Since the last inspection the Commission had received two regulation 37 notices, reporting mal-administration of medication to two service users. Records and discussion with the manager indicates these were genuine errors. In both cases appropriate follow up action had been taken by the home. Records of training and discussion with nursing staff did not evidence any recent medication training. The inspector advises that consideration is given to updating training in this area. The inspector also advises that nursing staff are re-familiarised with the NMC ‘Guidelines for administration of Medication’ as one way of reinforcing their professional responsibilities and accountabilities Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 Page 21 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): The management of complaints is unsatisfactory. The arrangements for reporting allegations or suspicions of adult abuse are satisfactory. The arrangements for dealing with challenging behaviours do not assure the safety and welfare of some service users. EVIDENCE: The complaints log identified three complaints had been made since the last inspection. One had been responded to within timescales set out in the homes complaints procedure, two had not. Both complaints had been received prior to the current manager taking up post. Responses have now been provided. Full investigatory reports were not available. All the complaints were up held. There was no evidence to show why some complaints had not been investigated and dealt with in a timely manner. This is needed so that complainants can be assured their complaints will be listened to and acted upon. The home had an adult protection procedure and a whistle blowing procedure. Records showed staff had been provided with adult abuse training. In discussion with the inspectors staff demonstrated an awareness of the procedures and their responsibilities for reporting allegations and suspicions of abuse. Since the last inspection one referral had been made to the Local Authority under the Multi-Agency Adult Protection Procedures. Findings were inconclusive. The local authority is not taking any further action in response to this matter. Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 Page 22 A small number of service users display challenging behaviours. Records for two-service users were examined. One service user had an agreed behaviour management plan, the other did not. Records showed incidents of challenging behaviour were being recorded. However there was no evidence to indicate incidents were being monitored and used in such a way to ensure lessons were learnt from the handling of an incident and that future interventions were modified as appropriate. This must now happen. Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 Page 23 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): The home was generally clean tidy and free from offensive odours. EVIDENCE: The inspector carried out a tour of the home. Because of ongoing redecoration work and planned works the inspector was not able to fully assess compliance with the relevant Regulations and National Minimum Standards on this occasion. These standards will be fully assessed at the next visit. Since the last inspection a significant amount of work had been undertaken to improve the home in terms of decor and furnishings. The home was notably cleaner. Thereby creating a more comfortable and pleasant environment for service users. Further redecoration and refurbishment works are planned. At the time of the inspection a new floor covering was being fitted to the dining room, new furniture was on order. Corridors were being repainted and new carpets are to be fitted once this is completed. Some requirements concerning the building, detailed in the last inspection report remain outstanding. However it is anticipated these will be fully complied with early in the new-year. Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 Page 24 There are no private areas for visitors and /or meetings and consultations etc. Service users can entertain visitors in any of the communal rooms `or their own bedroom. All bedrooms examined were generally clean and tidy and were furnished and decorated in a homely style. Several of the bedroom carpets are to be replaced within the next four weeks. Bedrooms were equipped with a call bell system. Two-service users share a double room and staff reported the service users were happy with this arrangement. The room meets the minimum space requirements, however the bedroom furniture was very large and there was very little space between the beds. Both service users have manual handling needs requiring the use of a hoist. One bed has to be moved in order to use the hoist safely. The manager was advised to carryout a risk assessment. At the feedback meeting this matter was discussed and it was agreed that new bedroom furniture would be purchased. Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 Page 25 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): The home had sufficient numbers of staff to meet the needs of service users living in the home at the time of the inspection. Some inconsistencies in recruitment practice were noted resulting in service users receiving care from some staff that have not been properly vetted. This potentially leaves service users at risk. Staff must be provided with better supervision and training to ensure they receive necessary guidance and support from managers and to ensure staff are equipped to carryout their role competently and safely. EVIDENCE: The home had a range of job descriptions, these clearly set out roles and responsibilities. Recent proposed changes following the appointment of a manager without a nursing qualification means some roles and areas of responsibility and decision making need to be more clearly defined and communicated. Please refer to comments detailed on page 30 of this report. Since the last inspection the manager had increased the number of care hours provided. Comments from staff indicated that generally staffing levels were reasonable satisfactory when fully staffed. However several staff commented that meals times were problematic due to the high number of service users require who require assistance to eat. Staffing levels must be kept under Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 Page 26 review and must be increased where service users needs indicate this is required. The inspector examined a random sample of four files for staff that had been employed since the last inspection. The reference for one worker indicated a lack of knowledge and skill in some areas, there was no evidence to confirm this had been followed up. One worker had been recruited by an overseas agency. The agency had obtained one ‘to whom it may concern’ reference. A second reference had not been obtained. This practice does not afford adequate protection for service users and must cease. The registered person must ensure all required records are in place before staff commence working in the home. This is needed to ensure the protection of service users. The home had detailed guidance in place for induction, training, development and supervision. The inspector examined the induction records for six staff who had commenced working in the home from May 2005. There were no induction records for one worker who had transferred to the home from another care home owned by Craegmoore. Similarly records for another worker employed in August 2005 showed a very basic induction had been completed. The induction was started and completed on the same day. Structured induction training is needed to ensure staff have necessary basic skills and competencies to meet service user needs. The current manager had ensured corporate induction handbooks had been issued to those staff employed since she took up post in November 2005. The inspector was not able to evidence what induction training had been provided as the induction booklets were not available because the staff kept their own books. The inspector was advised that all staff within the home are to be put through the full corporate induction programme. This was confirmed in discussions held with staff. Some annual appraisals had been carried out. In some cases records did not give clear information on the training and development needs of the worker. This potentially means training plans and priorities may not fully reflect the training and development needs of the whole staff team. Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 Page 27 The home had a good mandatory training programme and individual staff training records evidenced staff were up-to-date in areas of mandatory training such as manual handling, health & safety and first aid etc. There was no evidence to show staff had been provided with more specialist and service user specific training. This is needed ensure staff have the necessary skills and competencies to meet the changing needs of service users. This is an outstanding requirement from the previous inspection and must now happen. Records did not evidence that staff had been provided with equal opportunities and disability awareness training. This must now be provided. An NVQ programme had been implemented; to date four staff had achieved an NVQ, a number of other staff were enrolled on an NVQ programme. The home must continue with its NVQ programme to ensure 50 of care staff achieve an award. This is needed to fully comply with National Minimum Standard 35. A programme of formal supervision had been introduced. However discussions with staff and examination of a sample of staff supervision records showed inconsistent supervision practice. Records indicated the majority of staff had only had one recorded supervision session between May and November 2005. The need to ensure staff are provided with supervision as a minimum of six times a year remains an outstanding requirement from the previous inspections and must now happen. Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 Page 28 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): The current management and supervisory arrangements are not robust. This results in some arrangements and practices that do not promote and safeguard the health, safety and welfare of the service users living in the home and staff. A robust quality monitoring system must be introduced to make sure that everyone is consulted about the running of the home and continuous improvements are made. EVIDENCE: There has been no registered manager for the home for the last 18 months. The current manager had only recently been seconded to the home and is not currently registered with the Commission for Social Care Inspection (CSCI). The inspector was advised that an application was to be submitted. The manager although very experienced does not hold a nursing qualification and is therefore not able to provide necessary clinical oversight of the home. To address this the owners of the home plan to appoint two nurses currently Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 Page 29 employed in the home to act as clinical leads to support the manager. Whilst it was evident that some discussions had taken place with these staff, the manager was not able to confirm how these arrangements would operate in practice. Therefore the manager was not able to demonstrate that robust arrangements were in place to ensure effective clinical supervision and management of the home and a clear audit trail for decision-making. At the inspection feedback session carried out on the 15th December the regional director was advised this matter must be addressed immediately. It was agreed the regional director would identify and communicate to the homes staff the names of appropriately qualified staff who will provide arms length clinical expertise and input by the 16th December 2005. A formal structure for the home must be provided to the commission by Friday 23rd December. The director was advised that unless this is received statutory action will be considered. There were comprehensive health and safety policies in place and a health and safety statement. A fire risk-assessment had been completed. However this needed to be updated to reflect guidance issued following the fire officers visit to the home on the 6th December 2005. Safe working practices were maintained by the provision of training to staff in the form of crisis prevention, moving and handling, basic food hygiene, first aid, COSHH and fire safety. Fire safety checks were up to date, although the inspector was only able to confirm that one fire drill had been completed in 2005. A minimum of two is needed to meet health and safety guidance. Service contracts/certificates were in place for fixed electrical systems and water systems; fire safety equipment and moving and handling equipment. Hot water was monitored regularly and records seen during the inspection were satisfactory. Window restrictors had been provided to first floor windows in the Lodge and studio. Portable appliance testing (PAT) had last been completed in August 2004. The registered person must ensure appliances are re-tested to ensure, as far as practicable these remain safe to use. The home uses calor gas to cook with, there was no evidence to show a maintenance check had been completed, this must now happen. A bathroom in the main facility had exposed pipe-work. The inspector advises these should be boxed in to ensure the safety of service users. The bathroom across from the office had a parker bath fitted. The bath needed repair. The inspector was advised the bath was unsuitable for the current service user group. The bath should therefore be replaced with a more suitable one. Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 Page 30 The sink in the shared bedroom in the Studio needed repair, the tap head was missing and there was an exposed radiator. A radiator cover or thermostat must be fitted. The sink in the bathroom in the Lodge did not have a hot water supply. This matter was discussed with the manager who advised she would take immediate action to resolve this issue. One of the bedrooms also had exposed pipe work, the inspector advised that this is boxed in, whilst this did not pose an immediate danger to the service user there was the potential for the service user or other to pull the pipe from the wall. Individual service user risk assessments were completed. However in some cases records were inaccurate and or incomplete. These matters are outlined in other section of this report. A formal and robust quality monitoring system had not been implemented in the home. However since the last inspection a clinical audit of the home by a manager from the company’s clinical audit team had been completed. The inspector was provided with a copy of the ensuing action plan. It is intended that the auditor will monitor the action plan to ensure agreed actions are carried out and continuous improvements are made. The registered person must ensure that a formal quality assurance programme, which fully meets National Minimum Standard 38, is in place. This remains an outstanding requirement from previous inspections and must now happen. Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 Page 31 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 1 X X X Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 1 2 1 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X 2 2 X X 2 LIFESTYLES Standard No Score 11 2 12 X 13 2 14 X 15 3 16 2 17 Standard No 31 32 33 34 35 36 Score 2 2 1 2 2 1 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Gatehouse Cottages Care Home Score 2 1 1 x Standard No 37 38 39 40 41 42 43 Score X 1 1 X X 2 x DS0000002786.V264112.R01.S.doc Version 5.0 Page 32 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 5 Requirement Timescale for action 31/01/06 2 YA3 3 YA3 4 YA9YA6 5 YA37 The registered person must ensure copies of the service users guide are made available or explained to new service users. The guide must be checked to ensure it contains accurate and up to date information 14(1)b The registered person must Sch.3(1)(a) ensure a current care management needs assessment or summary is obtained for all new admissions. In the absence of one the home must complete an assessment. Timescale of the 31.8.04 and 31.9.05 not met. 14 The registered person must not admit any service user who does not meet the homes registration category unless a variation has been sought and granted by the Commission 15 The registered person must review and update the care plans and risk assessments for SU’s A, B, C & D to ensure these reflect all current care needs and care provision. Immediate requirement notice issued 8 The registered person must DS0000002786.V264112.R01.S.doc 31/12/05 31/12/05 21/12/05 31/12/05 Page 33 Gatehouse Cottages Care Home Version 5.0 6 YA6 15(2) 7 YA6 15 8 YA6 15 9 YA7 12 & 15 10 A9 12 & 13 11 YA8 12 ensure an application to the register the manager is made to the CSCI The registered person must ensure that all service users and their representatives are involved in the development of their individual plan and that the plan is available in an accessible format or explained to them. The individual plan of care must be reviewed with the service user (involving family, friends, advocate and significant professionals as agreed by the service user) at least 6monthly. The timescale of 30/9/04 and 31.7.05 not met. The registered person must audit all care plans for service users to check whether information details all the service users current care needs and care provision. Where necessary care plans must be revised and updated. The registered person must ensure care plans are evaluated on a monthly basis. Changes must be reflected in the care plans. The registered person must ensure each service user has a current financial plan. These must provide a clear audit for decision-making. The registered person must review all current risk assessments Where necessary risk assessments must be revised and update. Management plans must be developed for any new areas of risk The registered person must ensure that service users have opportunities to participate in activities that will enable them DS0000002786.V264112.R01.S.doc 31/01/06 31/01/06 31/12/05 31/01/06 31/01/06 28/02/06 Gatehouse Cottages Care Home Version 5.0 Page 34 12 YA9 13 13 YA19 13 14 YA19 18 15 YA20 13 16 YA20 13 17 YA20 13 to influence decision-making in home and contribute to the development and review of policies and procedures.Timescale of 31/08/04 and 31.6.05 not met The registered person must ensure that risk assessments for service users are agreed to by the service users or their representative and updated regularly.The timescale of 31/3/05 not met The registered person must ensure that all service users are given an annual health check; this must include a medication review. Timescale of Decenber 04 and 31/9/05 not met The registered person must ensure staff responsible for completing service user risk assessments have the necessary skills and knowledge. Where required staff must be provided with risk assessment training relevant to the areas of risk being assessed. The registered person must confirm with the prescribing GP that the practice of crushing and mixing tablets in water is safe. In future nurses must discuss and agree these issues with prescribing clinician at the point of prescribing. The registered person must ensure care plans set out where medication must be administered in service users food/drinks. This practice must be agreed with service user and or their representatives and relevant professional staff to provide a clear audit trail for decision-making. The registered person must ensure medication DS0000002786.V264112.R01.S.doc 31/01/06 31/01/06 31/01/06 07/12/05 31/01/06 07/12/05 Gatehouse Cottages Care Home Version 5.0 Page 35 18 YA23YA9 13 19 YA9YA23 13 & 15 20 YA7 15 & 16 21 YA7YA6 15 & 18 22 YA32 18(1)(c)(i) 23 YA36 18(1)(c)(i) administration records are accurately maintained. Where medication has not been administered the reason for this must be clearly documented. Immediate requirement notice issued The registered person must devise and implement a system in the establishment whereby the recorded episodes of challenging behaviour are reviewed in a way that supports a review of each episode with a view to informing best practice in such circumstances. Timescale of 30/6/05 not met The registered person must ensure where service users exhibit challenging behaviours, a behaviour management plan(s) must be developed. This must be subject to regular review and monitoring. The registered person must ensure assessments, care plans demonstrate how service users are encouraged and enabled to make choices and decisions with regards to their day-to-day lives. The registered person must ensure for those service users with communication difficulties a detailed communication plan is developed. This must include details of any specific communication methods used by the service users. Staff must be provided with communication skills training The registered person must ensure staff are provided with specfic service user training.Timescale of 31/10/05 not met The registered person must ensure staff are provided with DS0000002786.V264112.R01.S.doc 31/12/05 31/12/05 31/01/06 31/12/05 31/01/06 31/01/06 Gatehouse Cottages Care Home Version 5.0 Page 36 24 25 YA32 YA34 18(1)(ii) 19 26 YA32YA17 18 27 YA11 16 28 YA11 23 29 YA20 13 & 18 30 YA22 12(5), formal recorded supervision as a minimum of six times a year. Timescale of 31/9/04 and 30.6.05 not met The registered person must ensure 50 of care staff achieve an NVQ The registered person must obtain a second reference for staff member A. The registered person must ensure workers do not commencing the home until all required records have been obtained. Where poor references are provided with must be followed up. The registered person must carryout an audit to establish whether nurses require pegfeeding training. Where necessary relevant training must be arranged. The registered person must ensure structured daytime support is provided to service users in order to promote and encourage personal development. The registered person must carryout an environmental risk assessment for the lodge to inform decision making about whether space and facilities are sufficient to accommodate up to seven service users and two staff. Where necessary alternative provision must be made. The registered person must ensure nurses are provided with updated medication training. Nurses must re-familiarised with the NMC ‘Guidelines for administration of Medication’ as one way of reinforcing their professional responsibilities and accountabilities. The registered person must DS0000002786.V264112.R01.S.doc 31/12/05 31/12/05 31/12/05 31/01/06 31/12/05 31/01/06 31/12/05 Page 37 Gatehouse Cottages Care Home Version 5.0 18(2) 31 YA24 23 32 YA24 23 33 YA36 18 34 YA35 18(1)(c) 35 YA32YA31 10 & 18 36 YA33YA31 10 & 18 37 38 YA42 YA42 13 & 23 13 & 23 ensure complaint responses are supported by investigatory notes, interview records etc. Agreed complaints processes must be followed. The registered person must have the damaged cuboards in the studio kichen repaired. Timescale of 31/09/05 not met. The registered person must carryout necessary redecoration to the area near the boiler in the lodge. Timescale of 31/09/05 not met. The registered person must ensure annual appraisals give clear information on the training and development needs of the worker to ensure training plans and priorities reflect the training and development needs `of the staff team. The registered person must ensure staff are provided with training on equal opportunities including disability equality, race equality and anti-racism. The registered person must identify and communicate to staff working in the home the names and contact details of a suitably qualified and experienced person(s) who provide clinical expertise and support to staff. The registered person must provide a formal structure for the home. Clear arrangements for effective clinical oversight (management and supervision) of the home must be demonstrated. This must also provide a clear audit trail for decision making The registered person must ensure PAT testing is completed The registered person must ensure a minimum of two fire DS0000002786.V264112.R01.S.doc 31/01/06 31/01/06 31/01/06 28/02/06 16/12/05 23/12/05 31/12/05 31/01/06 Page 38 Gatehouse Cottages Care Home Version 5.0 drills are carried out annually 39 40 YA42 YA42 23 23 The registered person must have maintenance check carried out for the homes gas systems. The registered person must arrange to have exposed pipes in one of the bathrooms in the main facility boxed in The registered person must have the bath in the bathroom across from the main office replaced with a more suitable one The registered person must have the damaged tap in one of the bedrooms in the Studio is repaired. The radiator in the room must be covered with a cover or a thermostat must be fitted The registered person must ensure the sink in the bathroom in the lodge is repaired to ensure hot water is available The registered person must ensure exposed pipe work in one of the bedrooms in the lodge is boxed in The registered person must complete an environmental risk assessment for one of the double rooms in the main facility to ensure manualhandling operations can be carried out safely. Where necessary remedial action must be taken. The registered person must confirm to the CSCI that requirements set by the fire officer, following the inspection carried out on 6th December 2005 have been complied with and/or confirm dates when this will happen. The registered person must ensure health action plans are DS0000002786.V264112.R01.S.doc 31/01/06 31/01/06 41 YA27YA42 23 28/02/05 42 YA26YA42 23 23/12/05 43 YA42YA27 23 23/12/05 44 YA42YA26 23 31/01/06 45 YA42YA26 23 31/12/05 46 YA42YA24 23 31/12/05 47 YA19 13 31/01/06 Gatehouse Cottages Care Home Version 5.0 Page 39 developed for each individual service user. 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 YA6 Good Practice Recommendations The registered person should consider reviewing the current documentation system to provide one current user-friendly system. Consideration should be given to locating care plans in a more accessible place for staff. The registered person should consider utilising a different medication record sheet, which would be more userfriendly for staff and encourage recording better recording practice. The registered person should provide the activity coordinator with training in developing activity programmes for people with complex needs. The registered person should ensure systems are in place, which support joint activity planning and recording for service users attending day services to promote a more coordinated approach. 2 YA20 3 4 YA14 YA13YA11 Gatehouse Cottages Care Home DS0000002786.V264112.R01.S.doc Version 5.0 Page 40 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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. 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