Inspection on 25/07/07 for Gernon Manor

This inspection was carried out on 25th July 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Gernon Manor 09/05/06

Gernon Manor 28/09/05

Gernon Manor 14/06/05

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 Derbyshrie DE45 1EN Lead Inspector Denise Bate Unannounced Inspection 09:30 25th July 2007 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 Gernon Manor DS0000035737.V340603.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Gernon Manor DS0000035737.V340603.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gernon Manor Address Dagnall Gardens Haddon Road Bakewell Derbyshrie DE45 1EN 01629 778411 01629 778419 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) www.derbyshire.gov.uk Derbyshire County Council June Richardson Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Gernon Manor DS0000035737.V340603.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th May 2006 Brief Description of the Service: Gernon Manor was built in 1980 and is a care home with 33 places, registered to accommodate older people. This Derbyshire County Council home provides permanent care, short-term care and day care. It is situated close to the centre of Bakewell and accommodation is provided on one level with 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. Fees are £381.84 per week for permanent residents, but a range of prices for short term care residents. Additional charges, e.g. hairdressing, chiropody, are clearly identified in the home’s Statement of Purpose and Service User Guide. Copies of inspection reports are available in the foyer. Gernon Manor DS0000035737.V340603.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over seven hours. During the inspection six residents, four visitors, two staff members and a visiting health professional were spoken with. A cross section of residents were spoken with, including long stay and short stay residents. The deputy manager and a relief deputy manager were present during the inspection and provided assistance and information as the manager was on leave. In addition a number of telephone conversations took place and there was a meeting with the manager when she returned from leave. Prior to the inspection a number of sources of information were looked at including the home’s service record and previous inspection reports. An Annual Quality Assurance Assessment (AQAA) was completed by the manager prior to the inspection, and information provided has been used in the preparation and presentation of this report. Ten residents completed surveys (some with help from relatives) which provided additional information and comments on the home. A number of records were examined on the day of inspection, including care planning documentation, minutes of staff meetings, regulation 26 visit records, accident records, complaints record, staff files and medication records. Four residents were case tracked and care planning documentation and files for other residents were seen. A tour of part of the building took place and the grounds were seen. What the service does well: Gernon Manor provides a comfortable, homely, and relaxed environment for residents. Residents and friends spoken with made positive comments about the home and staff; ‘staff always do their best’, ‘staff are very kind at all times’, ‘I would not like to move’, ‘no one could be better’. Communal areas of the home are comfortable and provide a range of areas for residents to use. The home was found to be generally well maintained and clean throughout. The food was said to be ‘good’ and quality was praised by residents, although they said there had been catering problems earlier in the year. Staff spoken to were enthusiastic about their work and committed to the welfare of residents. They had undertaken ‘Skills for Care’ training which they felt had prepared them for the job. Over 50 of care staff are trained to NVQ level 2. Gernon Manor DS0000035737.V340603.R01.S.doc Version 5.2 Page 6 There is a robust system for recruiting and training new staff and appropriate checks are carried out. There is a corporate complaints procedure, although most day to day difficulties are dealt with on an informal basis. There is a clear safeguarding adults procedure and most staff have received appropriate training. An independent quality assurance exercise found that the overall quality of care was rated as ‘good’ or ‘excellent’ by most residents and their advocates, but activities were identified as an area for improvement. Although there are a number of areas that need to improve, e.g. staffing levels and consistency, activities, improvements in some aspects of care planning (see below); the manager has a proactive attitude toward improvements. Areas for improvement are clearly set out in the business plan. Team meeting minutes indicate that matters relating to the day to day running of the home are discussed with staff and clear direction provided. What has improved since the last inspection? What they could do better: The home have been experiencing staffing and recruitment difficulties. This has had an impact on the provision of residents’ care and on the availability of activities. A great deal of management time is spent ensuring the staff rota is covered. Some vacancies have now been filled and new staff are expected to begin work when their CRB checks have been received and Skills for Care training completed. Some improvements are needed to the care planning system, including ‘end of life planning’ (see good practice recommendations at the end of the report). Staff supervision needs to take place at the required intervals. On the day of inspection a skylight was leaking, the inspector was informed this was repaired the day after inspection. Gernon Manor DS0000035737.V340603.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Gernon Manor DS0000035737.V340603.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Gernon Manor DS0000035737.V340603.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available to ensure residents can make an informed choice about where they live. EVIDENCE: The inspection report and service user guide are available and were seen in the entrance hall and in residents bedrooms. These documents had recently been updated. The resident surveys indicated that most residents felt they and their relatives had sufficient information about Gernon Manor before they moved in. One resident seen was in for short term care. The home provides both day care and respite care. Gernon Manor DS0000035737.V340603.R01.S.doc Version 5.2 Page 10 The manager explained the home’s policies; ‘The service user is invited to spend a day at the home, a member of the care team will spend time with the Service User introducing them to other residents, show them around, make them feel comfortable and answer any questions. Alternatively if this is not possible a visit to the Service User takes place; families are invited to view the home and talk to staff’. A resident said that ‘the introductory visit was welcoming and informative’. There was evidence on care planning documentation that assessments are carried out prior to residents moving in. The department have recently introduced a new computer system, Framework I, that is being used for care planning assessments, reviews, personal service plans and other documentation. This should speed up the exchange of information between social work professions in relation to the provision of care for residents. Due to staffing difficulties there are only 24 residents at the moment out of possible 33 places. The residents survey indicated that residents had received a contract confirming the arrangements for living at the home. Matters relating to payments are dealt with by a Central Assessments Team who keep copies of short term contracts. Gernon Manor DS0000035737.V340603.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are generally completed and are individualised to demonstrate that residents’ health, personal and social care needs are being met. EVIDENCE: There is a clear system of care planning documentation. Four residents were case tracked. Documentation included front sheets with basic information, photos, personal service plans, original assessments and some reviews, but personal service plans were very brief. There were monthly updates. There were no detailed social histories or end of life plans. Some care plans included likes, dislikes, and other useful personalised information, e.g. night time routines. Detailed daily logs were kept, issues relating to day to day care of Gernon Manor DS0000035737.V340603.R01.S.doc Version 5.2 Page 12 residents was recorded to ensure that information was passed on to staff. There was an individual activities record on residents file. Risk assessments had been undertaken in moving and handling, nutrition and skin integrity. However, one risk assessment had not been updated and one need in relation to mental health did not form part of the personal service plan. Another moving and handling assessment was brief and did not have some relevant information. There was no cross referencing between the personal service plan and risk assessments. The standard of care generally provided by staff, and their knowledge of residents as individuals, was not fully reflected in care planning documentation. Staff sometimes seemed to rely more on verbal communication to ensure the needs of residents were met rather than ensuring a comprehensive written care planning system underpinned all their work. The manager said it is her aim to introduce more team meetings to ensure that the personal service plan is used as a working document, so to reflect on resident’s needs and preferred way of care. The manager keeps an informal record of resident dependancies, but it is recommended that a more formal system is introduced. Although individual ‘end of life’ plans are not yet recorded on care planning doucmentation, the home has a clear intention to support residents in their final days of life. The manager said ‘we seek medical advice and support from nursing staff if required. We offer comfort and support to the families allowing them to spend time with their dying relative at the service users wishes. Care staff or key worker will take on this role if there are no family’. The manager said a key worker system was in place and there is a clear description of their duties which includes promoting residents rights and choices in their care, maintaining contact with residents’ families, ensuring their clothes are kept clean, and ensuring their daily aids are available such as zimmer frames, hearing aids etc, and are in working order. Six residents were spoken with. They felt staff were ‘good’ but residents commented that the home was sometimes short staffed and comments included; ‘the service is not as good as it was’ and ‘sometimes we have to wait for attention’, ‘it is a good place when there are enough staff’, ‘staff are very busy and don’t have time to talk’. However, residents also commented that they liked the staff, who were competent and kind. Visitors said ‘it is a nice home with kind staff’, ’the people I visit are very happy here’. Derbyshire County Council has a clear policy relating to equality. Staff were observed supporting and reassuring residents as they carried out day to day activities. Choices were offered and residents were given plenty of time and encouragement. Residents indicated that they were treated with dignity and Gernon Manor DS0000035737.V340603.R01.S.doc Version 5.2 Page 13 respect. Residents confirm that they are encouraged to be independent and that they generally get the help they need appropriately. Residents have access to local health care facilities. The manager gave details of the working arrangments with local health services. This includes access to the Community Mental Health Team, The Dales Assessment and Rehabilitation Team, physiotherapist and chiropodist. There is generally good support from local GPs and district nurses, who are involved in incontinence assessment, medical support with dressings, blood pressure checks, pressure relief equipment, and nursing assessments as well as providing routine care. The inspector was informed that recently some residents have moved to nursing homes as their needs had changed. One case where there had been a communication issue was discussed with the manager. A visiting health professional said ‘‘there is a nice atmosphere are this home’ ‘staff talk with people not at them’. He also gave examples where the home had co-operated with special regimes to improve residents health care. The home consulted appropriately where there were problems. The home have a room where medication is kept. The home use a Monitored Dose System. The medication administration record for case tracked residents was found to be correct. There was a record of staff signatures. Eye drops had the date of opening clearly marked. Fridge temperatures were taken regularly. There were systems in place for the safe storage and administration of controlled drugs. The local pharmacist can be consulted for advice and support and completes 6 monthly audits. No residents adminster their own medication at present. Lockable drawers are provided to ensure medication is locked away for residents who choose to self medicate or part medicate, following a risk assessment. The inspector was told that all managers have recently undergone training and are accredited to a NVQ3 in Medication. Derbyshire Council Council have recently reviewed their medication policy which complies with the Royal Pharmaceutical Society of Great Britain and The Administration and Control of Medication in Care Homes. Managers follow these procedures and refer to this document for guidance. Gernon Manor DS0000035737.V340603.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is planning to provide suitable activities to enhance the well being of residents. The quality of catering is good which contributes to the overall levels of satisfaction for residents. EVIDENCE: Over the past few month activities have sometimes had to be cancelled if there are staff shortages so it has not been possible to maintain a consistent programme. An improvement in activities was identified as a major concern by last year’s resident survey. Comments from residents included; ‘I am sometime bored’, ‘we don’t do as many activities as we used to’, ‘there’s not enough to do, although activities have just started again’, ‘activities have declined – I would like a return of them’, ‘more stimulating activities are required’. A member of staff is now responsible for organising activities and she was spoken with on the day of inspection. Activities are now being planned Gernon Manor DS0000035737.V340603.R01.S.doc Version 5.2 Page 15 she has undertaken appropriate training, e.g. chair based exercises. There is now a system in place for planning activities and recording which take place. Better use could be made of notice boards to publicise activities and outings. Some outings are now taking place and these are very popular. There are records of activities undertaken on residents care planning documentation. Although staff said that it was sometimes difficult to motivate residents, residents meeting minutes clearly record what residents want, but it is not always clear how suggestions are followed up, e.g. ‘more one to one time’, new television, more board games, cushions for garden, ‘chair based activities, trips’. It is very good that regular residents meetings are taking place, but feedback could be improved by writing down what action is being taken and making the minutes of meetings available to residents. An outside visitor was doing reminiscence therapy on the day of inspection and residents appeared to enjoy this. Residents can get their hair done and several hairdressers visit regularly. Residents also told the inspector that they sometimes get their nails done, which they enjoyed. Four visitors were spoken with. They said they were always made welcome and that the home had a good reputation. No relatives were visiting on the day of inspection, but some residents said their relatives visited regularly and were made welcome. Contacts with the local community are encouraged and local shops, pubs, etc are close by. Feedback regarding catering was positive, although for a while there had been no cook and the standards had dropped; ‘for a while there was no cook and the standard of food was poor, but it’s very good now’, ‘the food is very good’, ‘I enjoy my meals’, ‘special diets can be given’, ‘there is a suitable selection’, ‘very complimentary about the meals’. One resident did say they would like more vegetarian meals. Special occasions like Christmas, Easter and birthdays are celebrated. Menus are discussed with residents and likes and dislikes taken into consideration, and special arrangements made where necessary, e.g. for residents who may prefer to take their meals alone. Sample menus are included in the service users guide. The manager said ‘We have reviewed the cook rota; this has enabled us to provide more choice on the menu at tea time’. Drinks and snacks are available throughout the day, and fresh fruit was available in the lounge. There is an area where residents or their visitors can make drinks and snacks. A water machine has been installed in the entrance area, so to improve the access of cool drinking water. Gernon Manor DS0000035737.V340603.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clear and accessible complaints and safeguarding adults procedures are in place to ensure residents can be confident that any issues raised would be acted on effectively and promptly. EVIDENCE: CSCI has not received any complaints about the home. There is a formal Derbyshire County Council complaints procedure and details are displayed, are contained in a leaflet and made available in the service user guide. The manager said that residents and relatives are reminded of the formal complaints procedures at reviews. There is also a complaints, comments and suggestions box. The manager said they generally receive positive feedback from residents and their families on the service they receive. Residents spoken to indicated that they would raise issues with the manager or other members of staff. There comments included; ‘I have no complaints’ ‘my daughter knows how to make a complaint’. Gernon Manor DS0000035737.V340603.R01.S.doc Version 5.2 Page 17 One complaint had been made, and a record of the home’s response given in complaints book indicated it had been dealt with satisfactorily. Derbyshire County Council has a Safeguarding Adults policy that is followed by the home. Staff and managers said that they had undertaken safeguarding adults training and felt that their understood their responsibilities and would be supported by their policies and procedures and their management hierarchy. Gernon Manor DS0000035737.V340603.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home generally provides residents with an attractive and homely place to live. EVIDENCE: The home provides a homely, relaxed environment for residents. There are a variety of lounge and dining areas available so residents have a choice of where they spend their time. Gernon Manor DS0000035737.V340603.R01.S.doc Version 5.2 Page 19 The home have done a lot of decoration since the last inspection, including some corridors, bedrooms, lounge areas, sluice areas and the laundry. The conservatory area has been refurbished. Residents spoken with on the day of inspection were satisfied with their bedrooms. Four bedrooms were seen and were satisfactory (apart from wardrobes, see below) and had been personalised. There were a number of comments from residents about the ‘built in’ wardrobes which are shabby and difficult for residents to use. The placement of some of the hanging rails makes it difficult for residents to hang up their clothes themselves. The inspector was informed there is a plan to replace some wardrobes in the coming year, but this could be expensive because all the wardrobes are of the same design but a different size. A recommendation has been made in relation to this issue because residents who can still do so should be able to use the wardrobes as part of maintaining their choice and independence. There were also some comments regarding the decoration of bedrooms which the inspector passed on to the manager. Toilets and bathrooms were satisfactory, although the home are planning to raise the height of some toilet seats. A new shower room had been built, as required at the last inspection. One the day of inspection a skylight was leaking. This was repaired and it is understood that further maintenance work needs to be carried out on the roof. The inspector was informed that a request had been made to the home’s maintenance services to investigate the heating system, as some areas of the home were sometimes very hot, while other areas were not warm enough. It is anticipated that this will be done in the next few weeks. The home were also looking at ways of improving ventilation in the corridors. There is access to the garden so that residents can enjoy sitting outside in fine weather. Areas of the home seen on the day of inspection were clean and tidy. Four visitors spoken with said that the home was ‘always clean’, and ‘regularly decorated’. A resident said; ‘the home is always spotless’. The manager said that the COSSH risk assessment had been updated. Some staff have had training in infection control. Residents spoken with were satisfied with the laundry service; ‘the laundry is good’. Gernon Manor DS0000035737.V340603.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A trained and competent workforce are in place which generally meet the dependency needs of residents currently accommodated within the home. EVIDENCE: At the time of inspection the home had a number of staffing problems relating to recruitment and to sickness. There were several vacancies including 2 night care, 2 day care and a domestic vacancy. Staff have been recruited to these vacancies, but will not be able to start until they have completed their CRB checks and ‘Skills for Care’ training. In addition several staff had been off long term sick. In addition, on the day of inspection two staff had been taken ill. The home have done their best to recruit effectively but there are sometimes delays and there currently appears to be insufficient relief staff to cover at short notice. Current staff do their best to cover the shortfall; We encourage staff to be more flexible with their shifts, so we can meet the needs of the service. Managers spend a great deal of time ‘juggling’ staff rotas try to ensure Gernon Manor DS0000035737.V340603.R01.S.doc Version 5.2 Page 21 sufficient staff are on duty. This means they have less time for other management responsibilities. The rotas were made available to the inspector. Normally there are four care staff on in the mornings and three care staff on in the afternoons. In addition there is always a manager on duty. At weekends there are three care staff on in the mornings and two care staff on in the afternoons plus one short shift. On the day of inspection there were only two members of staff on duty in the afternoon. On the previous day emergency cover had been brought in with shifts being covered by staff employed at other homes. At the time of inspection, because of the staffing difficulties outlined above, the home had only admitted 24 residents rather that their full registered numbers of 33. At the time of the inspector’s meeting with the manager, two members of staff who had been off long term sick had returned to work. The manager has introduced regular team meetings for all groups of staff and the minutes were seen by the inspector. Matters relating to day to day care for residents are discussed and ideas sought for improvement, e.g. improving communication. Future developments are also discussed, e.g. staff taking specific responsibilities for newsletter, sensory impairment and short term care. Staff spoken with confirmed that training opportunities are good. Both staff were new and keen to do NVQ2. Other comments included, ‘I enjoy my work’, ‘people have helped me settle in and always offer to help’, ’shadowing other staff is part of the training’, ‘ the skills for care training prepared me for the work’. The manager also confirmed that training is given a high priority; ‘over 50 percent of the care staff have achieved their NVQ 2 and two of our deputy managers are working towards their NVQ4 in Care’. Some training needs have been identified including dementia care training, and safeguarding adults (for some staff who have not had it through ‘Skills for Care’). The manager hopes too open up NVQ training to all staff including domestic staff and cooks. Recruitment procedures are robust. Two staff files were seen and had evidence of CRB checks having been carried out, copies of application forms, and references. Staff supervision is taking place and some records were seen. There are some gaps where supervision is not taking place within the recommended timescales, and there are plans to address this shortfall. Gernon Manor DS0000035737.V340603.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is suitably qualified and experienced and staff demonstrate an awareness of their roles and responsibilities, thus ensuring the home is generally run in the best interests of residents. EVIDENCE: The manager has the required qualifications and experience to fulfil the responsibilities of her role. There is a management team and individual Gernon Manor DS0000035737.V340603.R01.S.doc Version 5.2 Page 23 deputies take responsibility for various aspects of the day to day running of the home and for staff supervision. Regular team meetings take place for all groups of staff, the minutes were seen and provided evidence that matters relating to day to day running of the home are addressed. e.g. cleanliness, staffing, activities, getting ideas from staff. The home have an equal opportunities policy, and staff told the inspector that dignity and equality are covered in Skills for Care training. A quality assurance exercise was held last and found that residents felt the quality of service they received was good or excellent and there was generally positive feedback, apart from the amount and quality of activities. The quality assurance exercise is due again soon. In addition the home have their own questionnaires about choices in the service provided e.g. frequency and times of baths. Regulation 26 visits are carried out by the registered providers representative and the records were seen. A number of issues were discussed with the manager that had not been reflected in the regulation 26 visits. The inspector was informed that the home use a computer system for personal finance records and this works well. Information supplied by manager in the AQAA indicated that safe working practices are in place and equipment maintained. Gernon Manor DS0000035737.V340603.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X 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 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X X 3 X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Gernon Manor DS0000035737.V340603.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? no 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 OP19 Regulation 23 (2) (b) Requirement The roof area, including skylights, must be maintained at all times to ensure residents comfort and safety. There must be sufficient staff on at all times to meet residents assessed needs. Timescale for action 30/10/07 2 OP27 18 (1) (a) 30/09/07 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 OP7 Good Practice Recommendations Care planning documentation should cover in detail all aspects of the health, personal and social care needs of the resident and include a social history and ‘end of life’ plan. Personal service plans should be improved further by cross referencing them with risk assessments and other detailed information. Resident dependency levels should be formally monitored to ensure that staffing levels are sufficient to meet residents needs at all times. DS0000035737.V340603.R01.S.doc Version 5.2 Page 26 2 3 OP7 OP7 Gernon Manor 4 5 OP12 OP24 6 7 8 9 OP25 OP27 OP27 OP30 The activities, entertainment and outings programme should be developed further to meet residents needs for social and recreational activity. Improvements should be made to the wardrobes in residents’ bedrooms to ensure they are easily accessible for residents to encourage choice and maintaining independence. Heating arrangements should enable all residents to adjust their radiators in their bedrooms to a temperature that is safe and comfortable for them. Arrangements should be made to speed up the recruitment and selection process to ensure vacancies are filled promptly. More relief staff should be recruited to ensure staffing levels remain appropriate to meet service users needs. All staff should have up to date training in dementia care and safeguarding adults. Gernon Manor DS0000035737.V340603.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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