Inspection on 14/06/05 for Gernon Manor

This inspection was carried out on 14th June 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Gernon Manor 25/07/07

Gernon Manor 09/05/06

Gernon Manor 28/09/05

Gernon Manor 25/01/05

Gernon Manor 11/05/04

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

CARE HOMES FOR OLDER PEOPLE Gernon Manor Dagnall Gardens Haddon Road Bakewell De45 1EN Lead Inspector Andrew Bailey Unannounced 14 June 2005 10.00am 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 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Gernon Manor C52-C02 S35737 Gernon Manor V230974 140605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Gernon Manor Address Dagnall Gardens Haddon Road Bakewell Derbyshire DE45 1EN 01629 580000 01629 778419 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Derbyshire County Council June Richardson CRH - Care Home 33 Category(ies) of OP Old age - 33 places registration, with number of places Gernon Manor C52-C02 S35737 Gernon Manor V230974 140605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None stated Date of last inspection 25 January 2005 Brief Description of the Service: Gernon Manor was built in 1980 and is a 33 bed care home registered to accommodate older people. This Derbyshire County Council home provides permanent care, short-term care and day care. Gernon Manor is situated close to the centre of Bakewell. Accommodation is provided on one level and there are 33 single occupancy bedrooms. All bedrooms are equipped with washbasin, built in wardrobe, TV point and a link to the call system. There are several lounge and dining areas. The home is set around a pleasant enclosed garden area, which is easily accessible. Services include personal laundry, meals, and personal care designed to meet individual needs. A range of leisure and social events are organised. Gernon Manor C52-C02 S35737 Gernon Manor V230974 140605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and the duration of the inspection was approximately 5.5 hours. A tour of the building took place. Discussions were held with three service users and with four staff. There was one visitor spoken with during the inspection. A number of records were examined, including care plans (as part of the case tracking process, which is used to facilitate assessment of the home from the service users perspective). An assessment was also made of progress by the registered persons to address requirements made at previous inspections of this service. What the service does well: What has improved since the last inspection? The current manager commenced at the home last year and is steadily making progress towards ensuring that National Minimum Standards are met. The training programme has been brought further up to date, health and safety audits and risk assessments have commenced, and the standard of care planning has improved. The home is well run and there is clear leadership evident. Gernon Manor C52-C02 S35737 Gernon Manor V230974 140605 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Gernon Manor C52-C02 S35737 Gernon Manor V230974 140605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Gernon Manor C52-C02 S35737 Gernon Manor V230974 140605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 & 5 There is comprehensive written information available to service users to assist them in making decisions about this home as a place for them to live. Pre-admission procedures are in place to ensure that new service users are admitted on the basis of a full assessment of their needs. EVIDENCE: The Statement of Purpose, Service User Guide and associated written information was examined. The information in total comprises of an information pack and has been reviewed since the last inspection of this service, with several of the information leaflets updated. The information is informative and detailed and provides a good resource for prospective and current service users to refer to. Community care workers undertake the initial assessment of service users. The manager also assesses prospective service users before admission to the home. There was documentation confirming this in the care plan files examined at this inspection. This provides increased assurance that the home will provide a suitable placement for service users. Gernon Manor C52-C02 S35737 Gernon Manor V230974 140605 Stage 4.doc Version 1.30 Page 9 There are arrangements made for prospective service users to have trial visits to the home for day assessment, or short-stay placements, prior to making a decision to stay at the home in the longer term. Some of the service users spoken with were able to confirm that these arrangements had taken place. Gernon Manor C52-C02 S35737 Gernon Manor V230974 140605 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10 The care plan documentation is generally of a satisfactory standard. Further monitoring by management should ensure that all reviews and written entries are signed and dated. There are systems in place to promote the safe administration of medicines. Service users report that staff respect their privacy and dignity. EVIDENCE: There was written evidence in the care plan files examined to support that service users had been involved in the formulation of the care plans. Service users also stated that they had been consulted. This demonstrates a partnership in care between care staff and service users. There had been significant progress in improving the standard of the care planning documentation since the last inspection. However, further monitoring and intervention by the manager should ensure that care plan entries and reviews (including risk assessments) are unambiguous, and dated and signed consistently. There were some examples found where these details had not been recorded and such omissions lessen the value of these documents in legal terms. An example was where a service user had signed in respect of the custody and administration of medicines, but it was unclear from the Gernon Manor C52-C02 S35737 Gernon Manor V230974 140605 Stage 4.doc Version 1.30 Page 11 documentation what the outcome was i.e. self-administration or responsibility for medication administration resting with staff. The medication systems were satisfactory and had been assessed by a CSCI pharmacist within the last few months. All staff with medication responsibilities had received training. There were service user photographs included with the medication administration records and this provided increased assurance that the identity of the service user was established when medications were administered. Service users spoken with confirmed that staff are respectful of their privacy and dignity in their daily interaction with the service users. Gernon Manor C52-C02 S35737 Gernon Manor V230974 140605 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15 The activities programme is well organised, providing stimulating and interesting opportunities for the service users. The meals are reported by service users to be of a satisfactory standard, with a choice available and regular changes made to the menus. EVIDENCE: Open visiting is encouraged for visitors to the home and service users reported that their visitors are made welcome. There was corroboration from service users that the home is run along informal lines, with an emphasis on personal choice for the service users. Therefore, service users are able to exercise as much control over their lives as possible. Service users expressed general satisfaction about the quality of the catering, with most very complimentary about the service. The menus are seasonal and changed regularly. There was a church service taking occurring on the morning of the inspection. A celebration of 25 years of opening of the home was due to take place a few days after this inspection. Activities and events are well publicised and records are kept of events, with individual activity sheets present in the care plan files. Efforts are made by staff to provide a varied social & leisure programme. Gernon Manor C52-C02 S35737 Gernon Manor V230974 140605 Stage 4.doc Version 1.30 Page 13 Service users spoken with acknowledged this, whilst exercising personal choice over which elements of the programme they wanted to be involved with. Gernon Manor C52-C02 S35737 Gernon Manor V230974 140605 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 There is a complaints procedure in place, with confirmation that any concerns are investigated and acted upon, where appropriate. The adult protection systems in place at the home and the training received by staff promote the protection of service users from abuse and neglect. EVIDENCE: The complaints procedure was examined at this inspection and was contained in the Statement of Purpose, Service User Guide and was also on display in the home. There had been a previous complaint involving an allegation of abuse. This had been thoroughly investigated by the management, in conjunction with the relevant bodies. The way in which this allegation was handled confirms that the systems in place offer assurance that the welfare and protection of service users is taken very seriously and acted upon where appropriate. Gernon Manor C52-C02 S35737 Gernon Manor V230974 140605 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 21 & 26 Service users live in a safe environment, which is generally kept in a satisfactory condition structurally and decoratively, with high standards of hygiene and cleanliness maintained in the home. EVIDENCE: A tour of the building was undertaken during the inspection. The building is maintained to a good standard overall, which makes it visually pleasing to the service users and visitors, and also provides assurance that there is regard to the safety and welfare of the service users. At the last inspection there was a requirement made to upgrade the bathroom on Lathkill wing. The timescale has not yet expired for this requirement. Whilst the work has not yet been undertaken, the manager has asked for this to be included in the current year budget for estates works at the home. Service users expressed satisfaction with their rooms. The level of cleanliness within the home received praise and those spoken with also appreciated the standards met by the laundry personnel. Gernon Manor C52-C02 S35737 Gernon Manor V230974 140605 Stage 4.doc Version 1.30 Page 16 The wall finish in the laundry has peeled paint in some areas. This makes effective cleaning of the wall difficult. The manager has asked for this to be addressed with the annual maintenance for the home. A requirement has been made in this report. Whilst the subject of infection control is included within training such as Basic Food Hygiene and Working Safely, there is no confirmation that specifically dedicated training for staff is organised on the subject of infection control. A recommendation has been made to arrange this, given the high profile that infections such as MRSA now have within health care settings. There are policies and procedures in place to cover infectious diseases and dealing with waste. Gernon Manor C52-C02 S35737 Gernon Manor V230974 140605 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 28 A skilled and knowledgeable team of staff cares for service users. Staffing levels require continued monitoring to ensure that sufficient numbers of staff are always available to meet the needs of service users. EVIDENCE: Feedback from service users indicated staff to be friendly, professional and competent. The staffing levels were the subject of a requirement at the last inspection, to ensure that adequate levels were maintained. This remains relevant, since the ‘investment hours’ (additional hours granted by the registered persons) were not sustained consistently, with minimum hours prevailing on many occasions. Examination of the staffing rotas confirmed this. Some of the staff working at the home are usually based at another local authority home, currently closed whilst works are being carried out. Some of the service users had noted that staffing levels fluctuated and seemed low to them at times, but nonetheless praised the efforts of staff and considered them as a group to be very hard working. Approximately 45 of the staff currently working at the home have undertaken (or are undertaking) National Vocational Qualification (NVQ) Level 2 training (50 required this year to meet the National Minimum Standard). This figure includes staff temporarily based at this home, which indicates that there is still scope to increase the numbers of staff with this qualification. Gernon Manor C52-C02 S35737 Gernon Manor V230974 140605 Stage 4.doc Version 1.30 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 36 & 38 The financial and safe working practices systems in place promote the protection of service users from health, safety and best interest perspectives. There is effective management of this care home and management is accessible and responsive to service users needs. EVIDENCE: The manager has completed Registered Manager Award training and is therefore able to demonstrate that appropriate training has been undertaken in order to manage the establishment. There was verification that the home is run in an open and transparent manner, with records examined at this inspection that demonstrated the involvement and consultation with staff and service users. Minutes of residents’ meetings were made available and examined at this inspection. Gernon Manor C52-C02 S35737 Gernon Manor V230974 140605 Stage 4.doc Version 1.30 Page 19 Service users spoken with confirmed that management relate well to them and ‘get things done’, quoted one service user. Visits to the home in accordance with regulatory requirements are made (Regulation 26) and these visits provide evidence that there is on-going monitoring of the quality of the service from the registered persons, at a level of management not concerned with the day-to-day running of the home. This affords some assurance that there is assessment of the service that is less prone to subjectivity than might be the case if self-assessment alone were relied upon. In-house auditing includes audits of cleanliness, the environment and hygiene levels. A service user satisfaction survey had been undertaken recently and the results were being in a format appropriate to publicise within the home. Examination of the preliminary results bares general comparison with the overall findings from this inspection, in that the majority of the respondents were satisfied with the service provided at Gernon Manor. The system for the accounting of service users personal monies and expenses was examined at this inspection. The standard of the accounting provides an auditable system. Staff supervision was not examined in detail at this inspection, but it was established that there is a system in operation, with identified supervision groups and documentary evidence of supervision sessions that have taken place. Staff had received training in safe working practices, with updates arranged periodically. The manager confirmed that there had not been training that was singularly focussed on infection control issues, although components of this can be found within other safe working practices training and as a part of National Vocational Training (for those staff undertaking this). Training in safe working practices is on-going and dates had been set for update training. There was confirmation that gas, electrical and water services had been appropriately monitored and serviced, with certification available at inspection. Health and safety audits and risk assessments were in the process of being updated. The systems promote the safety and welfare of the service users. Gernon Manor C52-C02 S35737 Gernon Manor V230974 140605 Stage 4.doc Version 1.30 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x 2 x x x x 2 STAFFING Standard No Score 27 2 28 2 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x 3 3 x 3 Gernon Manor C52-C02 S35737 Gernon Manor V230974 140605 Stage 4.doc Version 1.30 Page 21 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 7 Regulation 14, 15 Requirement All care plan entries, including reviews and risk assessments must be unambiguous (e.g. responsibility for medication) and be dated and signed The second bathroom on Lathkill wing must be upgraded (previous requirement timescale of 30 July 2005) The wall finish in the laundry must be readily cleanable (washable paint peeling) The home must continue to monitor staffing levels to ensure that they are maintained (previous requirement timescale of 28 February 2005 remains relevant) A minimum of 50 trained members of staff (NVQ2 or equivalent) must be achieved by 2005 (previous requirement not yet met) Timescale for action 31 July 2005 2. 21 23 (2) 31 August 2005 31 August 2005 31 August 2005 3. 4. 26 27 13 (3) 18 (1) 5. 28 18 (1) 31 December 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Gernon Manor C52-C02 S35737 Gernon Manor V230974 140605 Stage 4.doc Version 1.30 Page 22 No. 1. Refer to Standard 38 Good Practice Recommendations There should be training dedicated to the subject of infection control, including MRSA prevention and containment measures Gernon Manor C52-C02 S35737 Gernon Manor V230974 140605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Couth Point Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Gernon Manor C52-C02 S35737 Gernon Manor V230974 140605 Stage 4.doc Version 1.30 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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