Inspection on 22/07/04 for Gattison House

Care Home For Older PeopleGattison HouseGattison Lane Rossington Doncaster DN11 0NQUnannounced Inspection22nd July 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Gattison House Address Gattison Lane, Rossington, Doncaster, DN11 0NQ Email address Name of registered provider(s)/company (if applicable) Doncaster Metropolitan Borough Council Name of registered manager (if applicable) Mrs Norma Cooke Type of registration Care Home No. of places registered (if applicable) 36 Tel No: 01302 864993 Fax No: 01302 866520Category(ies) of registration, with (number of places) Dementia - over 65 years of age (18), Old age, not falling within any other category (18) Registration number J070000099 Date first registered 1st April 2003 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 10th March 2004 YES NO 12/03/04 If Yes refer to Part CGattison HousePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 322nd July 2004 09:00 am Ian HallID Code074214Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMs Diane GriceGattison HousePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementGattison HousePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Gattison House. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Gattison HousePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Gattison House is a care home offering personal care and accommodation for thirty-six older people including eighteen who have mental health needs, including dementia. Doncaster Metropolitan Borough Council owns the home. The home is located in Rossington, which is approximately 6 miles from Doncaster. It is accessed by a frequent bus service. There are shops post office, and public houses nearby. The home is a single storey modern building set within its own grounds with a car park at the front. All residents are accommodated in single bedrooms. The home is divided into two distinct areas providing care for elderly persons with residential care needs and mental health needs. There is a choice of both lounge and dining areas. The home has safe gardens with lawned areas shrubs and flowers.Gattison HousePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This unannounced Inspection took place on 22nd July 2004. A number of the National Minimum Standards had been met or partially met and in spite of an ongoing shortage of staff, the overall quality of care was good. Choice of Home (Standards 1-6) 5 of these 6 standards were met 1 did not apply The Service Users Guide/Statement of Purpose did not contain service users comments. The home provides a contract for service users that contained the required information. Full needs assessments were undertaken, but service users and their representatives were not fully included in assessments. Trial visits to the home took place. Health and personal Care (Standards 7-11) 3 of these 4 standards were met Care plans were of a good standard and covered the majority of required information. Service users and their representatives were not fully involved with them. Monthly updates of reviews, both formal, and written take place. Service users spoken to all expressed satisfaction with the personal and healthcare provided. Medication storage was satisfactory. Staff had no accredited medication training although this has commenced. Staff interacted very well with service users, being cheerful and respectful. Service users all had keys to their rooms. Daily Life and Social Activities (Standards 12-15) 2 of these 4 standards were met Service users said that daily routines were flexible and varied. The home offered a range of activities but not on a regular basis due to staff shortages. Religious needs were catered for. The home did not employ an activities co-ordinator. Food served was well balanced and wholesome. Complaints and Protection (Standards 16-18) 2 of these 3 standards were metThe home had a complaints procedure in place and service users spoken to, stated that they Gattison House Page 6 would know how to make a complaint if necessary. The Adult Protection Policy was in the process of revision to include Whistle Blowing and the Department of Health No Secrets guidance. Environment (Standards 19-26) 4 of these 8 standards were met The location and layout of the home was suitable for the service user group. Furnishings and decoration were in reasonable condition and the home clean and smelt fresh. Some service users rooms did not have all the required furnishings and fittings and the manager must assess service users wishes in this matter. Room sizes were those provided on 31st March 2002. Double electric power sockets were lacking in some rooms. The home did not have risk assessments in relation to radiators and service user safety. Some areas of the home had fluorescent lighting. The washing machine had no disinfecting programme. Staff spoken to said they had not received formal training on infection control. The homes gardens were generally of a good standard but in need of some maintenance. The home has had gas central heating installed; this has not been 100 reliable since installation. Staffing (Standards 27-30) 0 of these 4 standards were met The home had a number of vacancies for care staff, domestics and cooks. Some staff were undertaking NVQ2 training and the manager had begun NVQ4 in Care and Management. Mandatory training had not taken place. The induction programme had been revised. Management and Administration (Standards 31-38) 3 of these 8 standards were met Service users and staff spoke highly of the manager and the home had an open environment. There were several records which the inspector was unable to access including staff personal files, development plans, maintenance plans, and financial plans which were held at Doncaster Metropolitan Borough Council. Service users meeting were irregular and there was no formal system of consultation such as service users surveys. Regulation 26 visits took place. Staff had no formal supervision or appraisal. Mandatory training had not taken place.Gattison HousePage 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action 1 15(2) OP7 The Registered Person must ensure that the care plan is agreed and signed by the service user or their representative 30/06/04216(2)mOP12The home must employ dedicated staff to 30/06/04 develop and implement a regular programme of activities, which reflect the interests, and needs of the service user group. Information about activities must be circulated to all service users in formats suited to their capabilities The home must employ sufficient numbers of cooks to ensure that domestic and care staff are able to carry out their own tasks in relation to their job description and service users needs. The Registered Person must review the provision of the call bell system within the lounge areas 30/06/04323(2)OP19416(2)cOP2030/06/04516(2)cOP24The Registered Person must provide minimum 30/06/04 furnishings and fittings for service users rooms. This should include two comfortable chairs and a table to sit at. All service users who do not wish for the required furnishings and fittings in their rooms must be consulted and an assessment made. Decisions made must be placed on their files. Two double electric sockets must be fitted in all service users bedrooms. 30/06/0430/06/04Gattison HousePage 8 613OP25The Registered Person must ensure as far as reasonably practicable the Health, Safety and Welfare of service users and staff. -Undertake and document risk assessments -provide adequate storage space -provide a trained designated first-aider throughout the 24 hour day.30/06/0430/06/04 30/06/04 30/06/04 30/06/04718OP30Staff members must have an individual training and development assessment and profile undertaken. Annual mandatory training must be provided for all staff, including prevention of abuse, moving & handling, fire prevention and first aid and administration of medication. The home must provide core foundation training to NTO specifications,.30/06/0430/06/04 30/06/04824(1)a,b.OP33The Registered Person must provide an annual development plan, which is based on a system of planning- action- review, and reflects aims and outcomes for service users. Service users views on the home must be sought by service user surveys and regular meetings and discussions.30/06/04925OP34Records demonstrating annual business plan, financial viability and staff files must be available for inspection30/06/04Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements.Gattison HousePage 9 RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard 1 2 3 OP28 OP31 OP18 Minimum of 50 of care staff achieve NVQ 2 by 2005 The registered manager achieves an NVQ 4 or equivalent qualification by 2005 Review the system for staff interview, and appointment to prevent excessive time lapse (approx. 3 months) this is causing potential employees to seek alternative employment before the homes manager can make an employment offer.CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No) NOGattison HousePage 10 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standar Requirement Timescale d* for action The Registered Person must ensure that the care plan is agreed and signed by the service user or their representative The home must employ dedicated staff to develop and implement a regular programme of activities, which reflect the interests, and needs of the service user group. Information about activities must be circulated to all service users in formats suited to their capabilities The home must employ sufficient numbers of cooks to ensure that domestic and care staff are able to carry out their own tasks in relation to their job description and service users needs. The Registered Person must review the provision of the call bell system within the lounge areas. Submit written proposals to CSCI. All service users who do not wish for the required furnishings and fittings in their rooms must be consulted and an assessment made. Decisions made must be placed on their files. Two double electric sockets must be fitted in all service users bedrooms. 1st November 2004115(2)OP7216(2)mOP121st November 2004323(2)OP191st November 2004 1st November 2004416(2)cOP20516(2)cOP241st November 2004Gattison HousePage 11 The Registered Person must ensure as far as reasonably practicable the Health, Safety and Welfare of service users and staff. 6 13 OP25 -Undertake and document risk assessments -provide adequate storage space -provide a trained designated first-aider throughout the 24 hour day. Staff members must have an individual training and development assessment and profile undertaken. OP30 7 18 . Annual mandatory training must be provided for 1st all staff, including prevention of abuse, moving & November handling, fire prevention and first aid and 2004 administration of medication. The home must provide core foundation training to NTO specifications The Registered Person must provide an annual development plan, which is based on a system of planning- action- review, and reflects aims and outcomes for service users. Service users views on the home must be sought by service user surveys and regular meetings and discussions. 9 25 OP34 1st November 2004824(1)a,b,cOP331st November 2004Records demonstrating annual business plan, 1st financial viability and staff files must be available November for inspection 2004 The joint sluicing/laundry arrangements must be reviewed in accordance with guidance for prevention of infection. The home must provide red dissolvo bags to reduce the handling of foul linen and reduce risk of cross infection / contamination. Extractor fans must be serviced, cleansed and functional The joint sluicing/laundry arrangements must be reviewed in accordance with guidance for prevention of infection. Advise the CSCI in writing of the proposals.1023(2)OP191st November 20041123(2)OP211st November 2004 1st November 2004 Page 121223(2)OP26Gattison House RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 1 2 OP28 OP31 Minimum of 50 of care staff achieve NVQ 2 by 2005 The registered manager achieves an NVQ 4 or equivalent qualification by 2005 Review the system for staff interview, and appointment to prevent excessive time lapse (approx. 3 months) this is causing potential employees to seek alternative employment before the homes manager can make an employment offer.3OP18* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Gattison HousePage 13 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES NO YES YES YES YES NO YES YES YES YES YES YES NO YES YES YES YES YES 14 7 X YES YES YES YES 21 X 22/07/04 O8.30 7.15Gattison HousePage 14 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Gattison HousePage 15 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) 330.00 To (£) 490.00Any charges for extrasYEShairdressing, chiropody, papers, activities, and extra toiletries.If yes, please state what the extras are: 3 Key findings/Evidence Standard met? The inspector checked the homes Statement of Purpose/Service Users Guide. This contained the information required. The inspector saw copies of the Statement of Purpose/Service Users Guide in service users rooms.Gattison HousePage 16 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? The manager confirmed that each service user is provided with a contract/statement of terms and conditions when they move into the home. The inspector saw a blank contract and contracts in service users plans. These contained the required informationStandard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? The manager, and staff spoken to, confirmed that full needs assessments were completed prior to service users admission. The inspector saw full needs assessments completed by social workers as well as the homes own assessments on the care plans checked. These covered the required information and the plan of care was generated from the Care Management assessment. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The service users interviewed stated that their needs were met and that they were happy with the service provided. The manager staff and service users confirmed that specialist health services were available, including District Nurse, Chiropody, Psychiatric Care and Hospital appointments with specialists. There was evidence that religious needs had been assessed and catered for. Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? The manager, staff spoken to and service users confirmed that service users were able to visit the home prior to admission. The manager confirmed that visits were made by her to prospective users homes or hospital where necessary On occasion service users have been admitted urgently due to a crisis situation.Gattison HousePage 17 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? The home did not provide intermediate care. Day care and short- term care were provided. This service is not registered by the CSCI, the home is required and does provide additional staff and facilities to meet their particular needs.Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 2 Key findings/Evidence Standard met? The inspector checked three service users plans. These included a range of required information. Three of the plans checked had details of health care needs which were not dated. The inspector noted evidence of review and monthly updates of care plans. The manager stated that the majority of service users had been formally reviewed and that the majority of service users information was regularly updated. The inspector noted that in discussions with staff there was some variation as to the level of service user involvement with care plans. There were a number of service users who were unable to contribute to their care plans because of their mental condition. Service users had not yet signed their care plans.Gattison HousePage 18 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) 15 23 Key findings/Evidence Standard met? Service users spoken to confirmed their satisfaction with the health care they received. Staff interviewed stated what assistance service users needed with personal care. Individual case records checked demonstrated that residents had regular access to their G.P. Dentist, Chiropodist and other specialist healthcare professional as required. A visiting health care professional confirmed that staff were aware of individual service users needs and acted promptly to engage with the relevant professionals. Assessments of service users nutritional needs were made. Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 3 Key findings/Evidence Standard Met? Records were kept of medication received administered and disposed of. The manager stated that following the previous inspection the home now had a metal cupboard with separation of internal and external preparations. A register and facility for storing controlled drugs was available, although the home did not have any controlled drugs on the day of the inspection. Accredited training for the administration of medicines has been provided for staff involved in medication administration. Service users care plans checked showed evidence of medication review. Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? The service users spoken to all said that all their personal care needs were met and that staff; are kind and considerate. The inspector observed staff knocking on doors and closing them for personal care tasks. Staff, were also observed talking gently and encouragingly to service users. Service users clothes were clean and they looked well cared for. There was a telephone for service users. Service users had keys to their rooms and could see their visitors and health professionals in private.Gattison HousePage 19 Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? Service users wishes are recorded in event of their death. Community and McMillan nurses are involved in management of terminal illness. Staff, were aware of the homes policies and procedures for last offices.Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 2 Key findings/Evidence Standard met? The service users interviewed said that daily routines were flexible and varied and they could choose how to spend their day. There were a number of lounge and sitting areas in the home and service users could move freely between them. The home provided an area with computers, and a range of activities including music, bingo, card games and dominoes. The home did not employ an activities co-ordinator, and activities were not planned. Staff spoken to said; that they would like to spend more time with service users but were unable to because of staff shortages. Religious needs were assessed and the manager stated that there was a regular church service and different denominational ministers visited the home if requested by service usersGattison HousePage 20 Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 3 Key findings/Evidence Standard met? The manager, service users and staff interviewed stated that visiting times were flexible and that service users could see their visitors in private. Service users confirmed that staff helped to maintain contact with friends and family by being welcoming and friendly. The manager confirmed that visitors were only restricted access to the home at the service users request. Service users were encouraged to go out to the local shops if they were able. Relatives and friends also took service users out. Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? Service users rooms checked were personalised with photographs, memorabilia and a variety of possessions from their homes. The majority of service users or their relatives manage service users finances.Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 2 Key findings/Evidence Standard met? Service users spoken to, said that the food was good. The inspector observed lunch being served in the dining room. The food was well cooked, attractively served, and nutritious. Service users were consulted as to portion size and preferences, and special diets (soft diets) were attractively served. Service users who needed it were given help discreetly and care staff sat down with them. The meal was unhurried and service users were given time to eat. Menus seen by the inspector offered a variety of foods and were seen to be wholesome and nutritious. However, there was no choice of main meal shown on the menus although on the day of the inspection a choice was offered. There were three full meals offered each day. The manager stated that the home was short of one full time and one half time cook as well as one 21-hour vacancy for a domestic staff and one domestic off sick. The previous reports drew attention to the shortage of domestic staff.Gattison HousePage 21 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days X X X X X X X 3 Key findings/Evidence Standard met? The home had a complaints policy and procedure. Any complaints/concerns were documented, monitored and responded to within the required timescale. The management team monitored any complaints to discover trends or patterns. A copy of the complaints policy/procedure was provided for each resident and their advocate on arrival at the home.Gattison HousePage 22 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 3 Key findings/Evidence Standard met? Advocacy services are available for persons requiring this facility. Postal votes are utilised to enable service users to exercise their right to voteStandard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES X2 Key findings/Evidence Standard met? The home had a procedure and policy on adult protection (DMBC), which the inspector saw. The manager stated that the policy was in the process of revision to include the Department of Health Guidance No Secrets. The policy did not include Whistle Blowing. Staff interviewed said they had not had training in Adult Protection procedures, although they could state what actions they would take if an incident was seen or suspected.Gattison HousePage 23 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 2 Key findings/Evidence Standard met? The inspector checked a proportion of the environment, and the home was clean, fresh smelling and reasonably decorated and furnished. The grounds were, in the main, tidy safe and attractive. The manager stated that the home did not have a copy of the maintenance and renewal programme (as defined by DMBC), and the majority of records in relation to repairs, etc were kept at DMBC. There is a lack of storage space at the home with the hairdressing room being used for this purpose. The room would not be accessible for its designated use without considerable effort and movement of boxes/equipment. The laundry and sluice areas are combined in one area. Clean and foul linen are stored within the same area. The waste disposal facility is of the open slop hopper type. This facility must be reviewed / upgraded in the light of changes to infection control management. Red dissolvo bags must be provided in the interim to reduce the manual handling of foul linen and reduce the spread/risk of cross infection. Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 2 Key findings/Evidence Standard met? The home had an appropriate amount of sitting recreational and dining space. There were sufficient rooms for a variety of activities to take place. There were smoke free sitting rooms. Outdoor space and all areas of the home were accessible to people in wheelchairs. The home provided the same communal space as it provided on 31st March 2002. The manager stated that a solution had not yet been discovered to address the problem of immobile service users accessing the call system in lounge areas.Gattison HousePage 24 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 2 Key findings/Evidence Standard met? The home had sufficient numbers of baths showers and toilets. They were close to bedrooms lounges and dining areas. Doors were labelled. There were appropriate aids and adaptations, i.e. hoist, grip rails, seat raisers, etc. There were en-suite facilities in two bedrooms. A number of extractor fans in these areas were found to not work or be in need of cleaning. The home had sluicing facilities Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 2 Key findings/Evidence Standard met? Individual service users needs are assessed by occupational and physiotherapists. The home has not been the subject of this process. Toilets are equipped with a range of aids and adaptations to assist service users to maintain their mobility and independenceGattison HousePage 25 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite NO YES NO 36 2 1 X 33 3X X 1 X3 Key findings/Evidence Standard met? The home provided the same amount of space in service users rooms as was provided on 31st March 2002.Gattison HousePage 26 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 2 Key findings/Evidence Standard met? Three bedrooms were checked in detail and several other bedrooms were briefly checked. All seen were clean and smelled fresh. All had a suitable bed with clean bed linen, curtains, overhead lighting, lockable facility and wardrobe. Some furnishings were not provided including seating for two people and a table. The manager stated that service users did not want these items in their rooms and also some service users wanted beds placed against the wall. The manager stated that not all rooms had two double electric power sockets. Service users had keys to their bedrooms. Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 3 Key findings/Evidence Standard met? Service users bedrooms checked all had opening windows. Temperatures of radiators were not controlled locally but within the boiler house. Records were kept at DMBC. Lighting in residents accommodation was mainly domestic in character, and lighting levels were sufficient. The lounge, dining area and corridors had fluorescent lighting. Emergency lighting was provided at the home.Gattison HousePage 27 Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 2 Key findings/Evidence Standard met? The building was clean and free from offensive odours on the day of the inspection. Laundry facilities were sited away from food preparation and storage areas. The laundry provision must be reviewed and risk assessment undertaken and recorded.StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence Gattison House X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X XX 21 14 Standard met? 2 Page 28 The staff duty rota corresponded to the members of staff on duty. The manager, staff and service users spoken to said there was a shortage of staff. On the day of the inspection vacancies were: Care staff - 1 x 37 hours 1x 32 hours 1x 29.5 hours 1x 20.5 hours. Domestic staff ­ 1x 18.5 hours 1x 21 hours. There was a vacancy for 1x 37 hours cook and 1x part time cook. The manager stated that the home was awaiting the start of one domestic. The manager was not always supernumerary and worked shifts with staff to cover at times. The night care team was complete. Care staff spoken to said that staff shortages meant they could not spend time with service users as much as they would like to and that they had to prioritise jobs. They said however, that there was good will within the staff team and they were not pressurised to work extra shifts. The staff said that staff shortages meant that staff did not receive appropriate training. The inspector noted that although staff, were busy they conducted interactions with service users cheerfully, appropriately and with empathy. The previous inspection noted that care staff were required to undertake domestic duties within their working day; therefore reducing time available for personal care. The manager stated that discussions had taken taken place in relation to care assistant job descriptions but no changes had been made. A laundry assistant was provided. The home had not re-assessed the laundry hours needed. A professional visitor to the home who felt that in general the quality of care was maintained in spite of the persistent and ongoing staff shortages. Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 2 10 2 Key findings/Evidence Standard met? A number of care staff are undertaking NVQ 2 training at present. The manager is aware that 50 of staff need to achieve NVQ 2 by 2005.Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2 Key findings/Evidence Standard met? The inspector was unable to examine any staff files on the day of the inspection, as staff records were kept at DMBC. The home follows the DMBC policies and procedures for staff recruitment. The manager confirmed that all staff CRB checks were completed.Gattison HousePage 29 Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 2 Key findings/Evidence Standard met? The inspector saw the revised Induction Programme that included NTO specifications. The manager and staff interviewed confirmed that mandatory training had not been undertaken on a regular basis this year. The manager stated that getting training up to date had been a problem because of shortage of staff. The homes staff members did not have an individual training and development assessment and profile, although the home had a general DMBC training programme.Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 2 Key findings/Evidence Standard met? The manager was an experienced residential care manager with nursing qualifications. She had begun NVQ4 in Care and Management and was aware of the need to complete it by 2005.Gattison HousePage 30 Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? Service users and care staff interviewed spoke highly of the manager and said that she was approachable and supportive. She is responsible only for Gattison House. Staff interviewed said they could ask her about any problems within the home and that an open environment was encouraged. Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 2 Key findings/Evidence Standard met? The homes manager undertook an in-house audit of documentation and the homes environment. The home had no annual development plan and any records were kept at DMBC. Service users meetings took place on an irregular basis and there was no formal mechanism such as service users surveys to record service users views, although it was apparent that service users were consulted on matters such as menus. Regulation 26 visits took place and copies were sent to the CSCI. Service users and staff were notified when inspections took place. Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 2 Key findings/Evidence Standard met? All information relating to this standard was held at DMBC and was not available for inspection.Gattison HousePage 31 Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders 12 9 93 Key findings/Evidence Standard met? Service users finances were individually recorded and stored. The home staff was not responsible for management of individuals financial affairs but limited amounts of personal monies.Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 2 Key findings/Evidence Standard met? The inspector checked a sample of the records the home was required to keep. Service users spoken to were not aware that they could have access to their records. There was a lack of information for the inspector to access, including staff files, business and financial information developmental information and maintenance information. The manager stated these were all maintained centrally at DMBC The manager and care staff interviewed confirmed that formal supervision did not take place within the home. Supervision was carried out on a daily ongoing basis. Appraisals did not take place. The home had no volunteers.Gattison HousePage 32 Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 2 Key findings/Evidence Standard met? The inspector checked a sample of the records the home was required to keep. Service users spoken to were not aware that they could have access to their records. There was a lack of information for the inspector to access, including staff files, business and financial information developmental information and maintenance information. The manager stated these were all maintained centrally at DMBCStandard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? The manager and staff interviewed indicated that mandatory training in Health & Safety at Work, Food Hygiene, First Aid, Fire Prevention, Infection Control and Adult Protection had not taken place this year. There had been a moving and handling course in 2001. The home had no designated first aider and staff, are being trained in first aid. Accredited Medication training had commenced. The manager and staff believed that the lack of training was due to shortage of staff. Staff interviewed said they knew where the homes policies were but had not read them. The home had two hoists to assist moving residents with mobility problems. No fire exits were blocked. Radiators and hot water outlets must have risk assessments and ongoing recording of measurements as required by Health & Safety Legislation. The home provided a DMBC Health & Safety Policy Statement, risk assessments and working practices.Gattison HousePage 33 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceRegulatory Inspector Second Inspector Regulation Manager DateIan HallSignature SignatureAnn MicklethwaiteSignaturePublic reports It should be noted that all CSCI inspection reports are public documents. Gattison House Page 34 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 22nd July 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleGattison HousePage 35 Action taken by the CSCI in response to provider comments: Amendments to the report were necessaryComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurate Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationNOAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planOther: enter details here Gattison HousePage 36 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I Sarah Rogerson of Gattison House confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on 22nd July 2004 and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I Sarah Rogerson of Gattison House am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on 22nd July 2004 for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Gattison HousePage 37 - 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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