Inspection on 28/09/05 for Gernon Manor

This inspection was carried out on 28th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 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 Brian Marks Unannounced Inspection 28th September 2005 01:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Gernon Manor DS0000035737.V254529.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V254529.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Gernon Manor Address Dagnall Gardens Haddon Road Bakewell Derbyshrie DE45 1EN 01629 580000 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) 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.V254529.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th June 2005 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. Gernon Manor DS0000035737.V254529.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit that took place at the home over an afternoon. Additionally, time was spent in preparation for the visit, looking at previous reports and other documents. Apart from examining documents, care files and records, time was spent looking around the building and speaking to the staff on duty and to the manager. Additionally 7 residents were spoken to, either as individuals or in a small group; they were also observed throughout the visit working with and being cared for by staff. The most important activity of inspection is the careful examination of residents’ individual care records (case tracking) and 2 were selected for this purpose. The residents themselves were both spoken to at length. The aim of inspection activity during the current inspection year is to assess a service against the ‘key’ National Minimum Standards and these are identified at the beginning of each section of the report. The majority of these keys standards were examined at the last inspection so, for a more complete picture of this service, this report should be read in conjunction with the report dated 14th June 2005. What the service does well: Service users spoke highly of the home and the results of a recent satisfaction survey support this. ‘We have a lot of fun here and all like to have a bit of a laugh’ ‘I can’t fault anything’ Care staff are skilled and knowledgeable and display a clear commitment to their roles; levels of training are good and the provider organisation has a policy of supporting staff to seek a care qualification soon after they start work. They also operate a very extensive and careful approach to staff recruitment and make sure that the staff employed are right for the job Service users live in a safe and supportive environment and they report that they are well looked after. The facilities and private accommodation provided are generally well maintained and there are systems in place to promote service users safety and wellbeing. The management of the care home are accessible and responsive to service users needs and are committed to providing a personalised service. ‘If I have a problem I go to one of the staff and they sort things out for us’ Gernon Manor DS0000035737.V254529.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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 DS0000035737.V254529.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Gernon Manor DS0000035737.V254529.R01.S.doc Version 5.0 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 the following standard(s): 3 and 6 People do not come to live at the home without their needs being assessed and the services they need from the home being identified. This makes sure that they get the right care as soon as they move in. EVIDENCE: All people who come to this home have their care arranged by an officer of the Social Services and it is usually a community care worker who undertakes an initial assessment of a resident’s needs. From all the files looked at, this is carried out to a good standard and a number of formal assessments are carried out as well: tissue viability, moving and handling and nutrition. These all help the completion of a detailed care plan (see next section) that indicates how staff would provide help consistently and safely on a day-to-day basis. This is written in an easy-to-follow style that ensures all areas of care needed by each individual are described, including health and personal care needs. This provides increased assurance that the home will provide a suitable placement. Gernon Manor DS0000035737.V254529.R01.S.doc Version 5.0 Page 9 The home does not provide an intermediate care service so Standard 6 does not apply. Gernon Manor DS0000035737.V254529.R01.S.doc Version 5.0 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 the following standard(s): 7 and 10 The care of all residents, including health care, was planned and given in a way that respected individuality and privacy. EVIDENCE: The records of 2 residents were closely examined and the residents themselves were asked about how they were cared for and about life at the home. The care plans are drawn up using information from the assessments prior to admission, observations made by staff after admission, and from consultation with the residents and their relatives and are arranged to a standard Social Services format, with a number of important areas to reflect personal and health needs. Additionally, some of the assessments referred to previously identified areas of risk affecting the residents’ lives, and these created a practical guide for staff to care for residents consistently and safely. The care plans examined contained a monthly evaluation of the resident’s life at the home; general reviews of care are held with families and outside professionals at least every six months. This makes sure that all the people involved were given accurate information about how care was being given and progress that was being made. Gernon Manor DS0000035737.V254529.R01.S.doc Version 5.0 Page 11 One of the care plans examined had not been signed and dated by the resident; this would confirm that a partnership in care between care staff and service users. The same file did not document the basic information about the resident that is required by the law. Residents spoken to confirmed that staff are respectful of their privacy and dignity in their daily interaction with the service users. They reported that staff worked well for them and that ‘they are all very kind and straightforward in the way they work’. A number of written protocols are in place to guide staff in the right ways of working and this is included in the training they receive when they start work at the home. For the assessment of the other key standards see the inspection report dated 14 June 2005. Gernon Manor DS0000035737.V254529.R01.S.doc Version 5.0 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 the following standard(s): EVIDENCE: These standards were not specifically looked at at this inspection, other than in conversation with residents who were very satisfied with the lifestyles and levels of independence they enjoyed at the home. For the full assessment of the key standards see the inspection report dated 14 June 2005. Gernon Manor DS0000035737.V254529.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not specifically looked at at this inspection; for the assessment of the key standards see the inspection report dated 14 June 2005. Gernon Manor DS0000035737.V254529.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 and 26 The home is clean, hygienic and offers good standards of comfort to residents in bedroom, garden and communal areas, and this had led to high levels of satisfaction. EVIDENCE: On immediate entry, the pleasantness of the home’s atmosphere is apparent with a variety of communal spaces situated in the front area of the building, offering a choice of seating arrangements for residents. The building has continued to be maintained to a good standard overall, and the final stages of decoration of the lounge and dining areas were being completed at the time of the inspection. This has improved the visual impact of the home’s environment and the residents spoken to were satisfied with the improvements made. At the last two inspections there was a requirement made to upgrade the bathroom on Lathkill wing. The timescale has expired for this requirement but, whilst the work has not yet been undertaken, the manager reported that the plans for work had been prepared and was to be carried out by the Estates Department within the current financial year. Gernon Manor DS0000035737.V254529.R01.S.doc Version 5.0 Page 15 The level of cleanliness within the home was good and 1 resident described the bathrooms and toilets as ‘spotless’; additionally those spoken to praised the laundry service. 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 was made in respect of this at the last inspection. Gernon Manor DS0000035737.V254529.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The home recruits staff using well-established and safe procedures and provides them with the training they need to do their jobs properly. Staffing numbers are not always at a level that ensures the needs of residents are met. EVIDENCE: Feedback from service users indicated staff to be friendly, professional and competent. ‘ We’re treated with respect and as individuals’ ‘We have a lot of fun in here’. The staffing levels were the subject of a requirement at previous inspection, and all spoken to – staff, manager and residents – reported this was a regular problem area. Examination of the staffing rotas and discussion with staff indicated that minimum hours continue to be the norm on many occasions and the manager reported that the ‘investment hours’ (additional hours granted by the registered persons) had not been applied. However the manager did report a successful recruitment drive recently and new staff are due to start at the home imminently, to finally resolve this problem and return the home to safer working. Some of the staff working at the home are usually based at another local authority home, currently closed whilst works are being carried out. Not all of the staff currently working at the home have undertaken (or are undertaking) National Vocational Qualification (NVQ) Level 2 training. However the Local Authority will only take on new staff on the understanding that they will commence this qualification within 18 months of starting and the manager was confident that the target would be met. The home operates the Gernon Manor DS0000035737.V254529.R01.S.doc Version 5.0 Page 17 provider’s well-established recruitment and selection process for staff and the files for 2 staff were examined. Most of the documents required by law were seen to be in place, the rest being retained at the area personnel office. The staff spoken to stated that they enjoyed regular access to training and development opportunities and information from staff files also showed this. Development opportunities were made available to them throughout the past year, and they have had regular ‘top-ups’ of the core health and safety training recently. Not all recent starters had completed the key areas however, including how to ensure service users are protected from being abused. Individual records and overall achievements were recorded so that easy monitoring can take place. The Social Services Department requires all new staff to complete an induction and foundation training at the start of their employment and staff described how this involved a period of ‘shadowing’ an experienced member of staff. This helps them to work safely and confidently and to get to know the residents better. Gernon Manor DS0000035737.V254529.R01.S.doc Version 5.0 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not specifically looked at at this inspection; for the assessment of the key standards see the inspection report dated 14 June 2005. The examination of staff training records identified areas of weakness in some areas of health and safety training. Gernon Manor DS0000035737.V254529.R01.S.doc Version 5.0 Page 19 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 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 3 X 2 X X X X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 2 Gernon Manor DS0000035737.V254529.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 14, 15 Requirement The registered person must ensure that all care plan entries, are dated and signed by the people involved with their development, including the resident. All of the elements described in the schedule must be included in the front sheet of the active care records of all residents. The registered person must ensure that all staff receive training or instruction in their responsibilities in relation to the protection of vulnerable adults. The second bathroom on Lathkill wing must be upgraded (Previous timescale of 31/08/05 not met). The wall finish in the laundry must be readily cleanable (washable paint peeling). (Previous timescale of 31/08/05 not met). The home must continue to monitor staffing numbers to ensure that they are maintained at the appropriate level. (Previous timescale of DS0000035737.V254529.R01.S.doc Timescale for action 31/12/05 2 OP7OP37 17(1) Schedule 3 13(4), 18(1) 31/12/05 3 OP18 31/12/05 4 OP21 13(3) 28/02/06 5 OP26 13(3) 28/02/06 6 OP27 18(1) 30/11/05 Gernon Manor Version 5.0 Page 21 7 OP28 18(1) 8 OP38 13(4), 18(1) 31/08/05 not met). A minimum of 50 trained members of staff (NVQ2 or equivalent) must be achieved by the due date. The registered person must ensure that all staff receive training or instruction in the core subjects of emergency first aid and safe food hygiene. 31/12/05 31/12/05 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 OP38 Good Practice Recommendations There should be training dedicated to the subject of infection control, including MRSA prevention and containment measures. Gernon Manor DS0000035737.V254529.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Derbyshire Area Office 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 DS0000035737.V254529.R01.S.doc Version 5.0 Page 23 - 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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