Inspection on 04/08/05 for Gillibrand Hall Nursing Home

This inspection was carried out on 4th August 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

Gillibrand Hall Nursing Home 11/03/10

Gillibrand Hall Nursing Home 18/01/10

Gillibrand Hall Nursing Home 02/06/09

Gillibrand Hall Nursing Home 02/07/07

Gillibrand Hall Nursing Home 03/05/06

Gillibrand Hall Nursing Home 03/02/06

Gillibrand Hall Nursing Home 31/01/05

Gillibrand Hall Nursing Home 19/08/04

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

CARE HOMES FOR OLDER PEOPLE Gillibrand Hall Nursing Home Grosvenor Road Chorley Lancashire PR7 2PL Lead Inspector Anne Taylor Announced 04 August 2005 09.15 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. Gillibrand Hall Nursing Home F57 F08 S25560 Gillibrand Hall V232407 040805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Gillibrand Hall Nursing Home Address Grosvenor Road Chorley Lancashire PR7 2PL 01257 270586 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) Century Healthcare Ltd Care Home 60 Category(ies) of DE - Dementia over 65 (31) registration, with number OP - Old Age (31) of places PD - Physcial Disability (5) Gillibrand Hall Nursing Home F57 F08 S25560 Gillibrand Hall V232407 040805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 31 service users in the category of OP (Old age not falling in any other category). 2. Up to 31 service users in the category of DE (E) (Dementia aged over 65 years of age. 3.Up to 4 service users in the category PD (Physical Disablilty aged over 60 years of age). 4. One named female service user in the category PD (Physical Disability aged 54 years and above) may be accommodated within the overall number of registered places. 5. The serive should, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 6. Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidelines which may be issued through the Commission for Social Care Inspection regarding staffing levels in care homes. Date of last inspection 31 January 2005 Brief Description of the Service: Gillibrand Hall is a listed building, set in its own grounds, within a residential area close to Chorley town centre. Public transport does serve the area nearby, however, a public right of way and a driveway leading to the home reach Gillibrand Hall. The home is privately owned by Century Healthcare Ltd. A new manager has recently been appointed and registered with the Commission for Social Care Inspection. The home is registered to care for 60 service users with a variety of needs, including nursing and personal care and service users suffering from dementia. The home accommodates people of either sex. At the time of inspection forty people were living at the home. The accommodation is set on two floors. The first floor is served by a passenger lift or can be reached via a sweeping stairway, an original feature of the old house. Gillibrand Hall Nursing Home F57 F08 S25560 Gillibrand Hall V232407 040805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection that took place over one full day in August 2005. Two inspectors carried out the inspection and both were involved in the production of this report. The inspection involved discussion with the people who lived and worked at the home and visitors, examination of records, policies and procedures and a tour of the premises. Comment cards received from residents, relatives and other health care professionals and the pre inspection questionnaire completed by the registered manager have also been used. As part of the inspection process the inspector used “case tracking” as a means of assessing some of the National Minimum Standards. This process allows the inspector to focus on a small group of people living at the home. All records relating to these people are inspected along with the rooms they occupy in the home. They are invited to discuss their experience of the home with the inspector, however this is not to the exclusion of other people living at the home. What the service does well: What has improved since the last inspection? The improved recruitment process took into account the need to protect residents and made sure employees were suitable to work with vulnerable adults. Gillibrand Hall Nursing Home F57 F08 S25560 Gillibrand Hall V232407 040805 Stage 4.doc Version 1.30 Page 6 A lower staff turnover and less use of agency staff had improved continuity and consistency of care for people living at the home. 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. Gillibrand Hall Nursing Home F57 F08 S25560 Gillibrand Hall V232407 040805 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 Gillibrand Hall Nursing Home F57 F08 S25560 Gillibrand Hall V232407 040805 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) 3 & 4 The pre admission procedure was not thorough enough to ensure that prospective residents were involved in the process and their individual wants and needs properly assessed. EVIDENCE: Care records seen showed that pre admission assessments carried out by the home did not involve prospective residents and or their relatives. This meant that residents could not be sure what sort of care they should expect to receive when they came to live at the home or that all their individual needs could be met by the home. The registered manager said that she usually carried out pre admission assessments or delegated the task to another trained nurse to make sure someone with the right skills and experience did the assessments. This should have ensured the assessments were done properly but not all the assessments seen had been completed in full. One file seen for a resident in the dementia care was not dated or signed and provided very little information, some of which conflicted with information in the assessment done by the social worker. Gillibrand Hall Nursing Home F57 F08 S25560 Gillibrand Hall V232407 040805 Stage 4.doc Version 1.30 Page 9 This meant that there was no clear picture of this person’s individual needs and so no one could be certain that the home would be able to meet his or her needs. Residents spoken to could not remember the pre admission assessment process in any detail but thought someone from the home had been to see them before they came to live there and had probably spoken to their relatives. Gillibrand Hall Nursing Home F57 F08 S25560 Gillibrand Hall V232407 040805 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 The care planning process was not thorough enough to ensure the needs of residents were consistently met. Risk assessments were not detailed enough to ensure the safety of residents. EVIDENCE: Care records seen showed that each resident had a plan of care but the plan had not been agreed with him or her or a relative. This meant that residents or their relatives could not be sure what care they should expect to receive whilst living at the home. It also meant that they had not been given the opportunity to discuss any concerns and identify any specific needs or preferences. When asked the registered manager said that care plans were drawn up by trained nurses after consultation with the resident or relative whenever possible. And they used information from pre admission assessments undertaken by the home, social worker or nurse from the hospital. Although staff were able to discuss individual needs and how the home met those needs this was not reflected in the care records. Care plans were Gillibrand Hall Nursing Home F57 F08 S25560 Gillibrand Hall V232407 040805 Stage 4.doc Version 1.30 Page 11 sometimes too brief, did not cover all assessed needs, particularly health needs and instructions for staff were not always not specific enough to help the care process and promote the welfare of residents. A number of risk assessments had been carried out by the home in relation to health care needs. However, some assessments, specifically relating to the risk of falling and a wound assessment relating to a pressure sore were not in place so the home was not able to show that the risks to residents were being effectively managed. Records showed that people living at the home generally had access to health care services according to individual need so that specialist advice and treatment could be provided. However, professional advice had not been sought in relation to tissue viability or continence care for a resident in the dementia care unit to ensure adequate health care was being provided. Comment cards from residents and relatives showed that they were satisfied with the overall standard of care provided. One resident stated ‘I have no concerns, I am quite comfortable’ and a relative said ‘the staff are lovely, they are very helpful’. Gillibrand Hall Nursing Home F57 F08 S25560 Gillibrand Hall V232407 040805 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 & 15 Daily routines were flexible so that residents were able to make choices and exercise some control over their daily lives. Poor record keeping meant that the home could not show that the dietary needs of residents were consistently met despite residents being offered a well balanced diet and given a choice about what they ate. EVIDENCE: Residents spoken to said that they were able to exercise choice about what time they got up and went to bed and what clothes they wore, giving them some control over their lifestyle. For residents unable to make such choices, personal preferences were recorded in care plans. Care records seen showed that people living at the home had been asked about their preferences in relation to food, leisure activities, routines of daily living and religious observance, showing that individual preferences had been taken into consideration. However, the plans of care did not show how the home was going to support residents to continue their leisure interests and make sure their lifestyle expectations were met. (see assessment of standard 7 of this report). Gillibrand Hall Nursing Home F57 F08 S25560 Gillibrand Hall V232407 040805 Stage 4.doc Version 1.30 Page 13 Comment cards from residents showed that they felt the home provided suitable activities and that they liked the food provided. When asked about activities comments from residents included, “ I enjoy living here. I like playing games and doing quizzes” and “it is OK living here, there is always something going on”. The pre inspection questionnaire completed by the registered manager showed that residents had a choice of menu and that special diets were catered for. The menu was varied and balanced so that residents were offered a healthy diet that took into account any specific dietary needs. A list of meals requested by residents for teatime was kept in the kitchen so that the cook could make sure residents had they meal they wanted. The lunchtime meal was relaxed and unhurried so that residents could enjoy their food and eat at a pace suitable to them. Independent eating was encouraged with staff providing assistance as required. Staff were consistent in their approach to encourage adequate dietary intake. Catering records kept by staff were not up to date so it was not possible to determine what residents had actually eaten or drunk and on some occasions if they had eaten or drank anything at all. Gillibrand Hall Nursing Home F57 F08 S25560 Gillibrand Hall V232407 040805 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 The home had a complaints procedure that ensured residents knew how and who to complain to. EVIDENCE: A complaints procedure was in place. The procedure was included in the service user guide and on display in reception so residents and visitors had access to information about how and who to complain to. Comment cards from residents showed that if they were unhappy with their care they knew who to speak to. Resident’s spoken to felt that they were encouraged to raise any concerns they might have about the home, that they would be listened to and action would be taken on any issues raised. Staff were able to discuss how they would respond if a resident complained to them and realised how important it was to make sure residents felt able to raise concerns and be sure they were listened to. Gillibrand Hall Nursing Home F57 F08 S25560 Gillibrand Hall V232407 040805 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) EVIDENCE: The environmental standards were not assessed at this inspection However, a brief tour of the premises was undertaken and the following items needed attention. 1. The carpet covering on the corridor near the cupboard labelled ‘shop’ had been repaired with tape in several places, which in time could create a potential trip hazard. This carpet should now be replaced to prevent any possible injuries resulting from residents or staff tripping and falling. 2. A ceiling tile on the service corridor was missing and in need of replacing as the heat from the exposed pipes in this area was excessive. Gillibrand Hall Nursing Home F57 F08 S25560 Gillibrand Hall V232407 040805 Stage 4.doc Version 1.30 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 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, 29 & 30 The skill mix of and number of staff on duty was sufficient to ensure the needs of residents were met. The recruitment process was thorough enough to ensure the continued protection of residents. The management of training was not good enough to ensure that staff were fully trained and kept up to date with current good practice. EVIDENCE: Staff rotas showed the number and skill mix of staff on duty at any time and that enough staff were on duty to ensure the needs of residents could be met. Comment cards completed by relatives also confirmed that there was always sufficient numbers of staff on duty so that residents could be looked after and attended to properly. When asked about staff residents said, “the staff are good, they do what they can and I have no grumbles”. Staff spoken to felt that there was usually enough staff on duty so that they were able to provide a good standard of care to residents. Records showed that the recruitment process was thorough and took into account the need to protect residents. Discussion with the personnel manager and registered manager showed that they were aware of their responsibility to Gillibrand Hall Nursing Home F57 F08 S25560 Gillibrand Hall V232407 040805 Stage 4.doc Version 1.30 Page 17 appoint suitable staff that would be able to provide good care and the continuing need to protect people living at the home. The training programme lacked co-ordination and records showed that some staff had not received updated training in areas such as abuse and dementia. However, staff on duty in the dementia care unit were able to discuss the needs of the people they cared for and felt confident to provide the specific care that these people required. The quality and training manager said that a training matrix had recently been introduced that showed all compulsory and specialised training planned for the following months. This system should improve the training and development of staff as it showed when training had been completed and when it was due for updating. The quality and training manager also said that an updated appraisal system had been developed that would include a training needs assessment for each member of staff. The system had not been introduced at the time of inspection so it was not possible to determine whether it was effective. The home was not able to provide any induction training records that would show how new staff had been trained and assessed to make sure they had the knowledge and skills to carry out their duties. Gillibrand Hall Nursing Home F57 F08 S25560 Gillibrand Hall V232407 040805 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) 38 The current management processes did not make sure that all equipment used by the home was properly maintained so that the health, safety and welfare of residents and staff was not fully protected. EVIDENCE: Certificates to confirm that systems and equipment used by the home were mainly up to date. However, portable electrical appliance testing was out of date so the home was not able to show that the appliances were safe to use. Records showed that hot water temperatures in resident’s bedrooms had not been checked for a significant period of time so there was an increased risk to anyone using the sinks in those rooms. Records showed that health and safety training was not provided regularly so staff were not kept up to date with current good practice. Gillibrand Hall Nursing Home F57 F08 S25560 Gillibrand Hall V232407 040805 Stage 4.doc Version 1.30 Page 19 Discussion with the management team and examination of records showed that fire safety training and regular maintenance of fire safety equipment had been carried out. However, a fire risk assessment was not in place so areas of higher risk and information about how to manage any risk had not been identified. Staff spoken to said that they had received some training about safe working practices so they felt able to carry out their duties safely but some of it was due for updating. Gillibrand Hall Nursing Home F57 F08 S25560 Gillibrand Hall V232407 040805 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 x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 2 COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 3 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x x x x x x 2 Gillibrand Hall Nursing Home F57 F08 S25560 Gillibrand Hall V232407 040805 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 3 Regulation 14(1) (c) Requirement A full preadmission assessment must be undertaken prior to any resident coming to live at the home. Residents or a representative must be involved in the assessement. (Timescale of 31st March 2005 not met). Residents must receive written confirmation that the home is able to meet their assessed needs. (Timescale of 31st March 2005 not met). A written plan of care as to how a residents needs are to be met by the home must be drawn up with the involvement of the resident or a relative. (Timescale of 31st March 2005 not met) Risk assessments in relation to the management of healthcare needs must be carried out and reviewed regularly. Arrangements must be in place for residents to receive, where necessary treatment, advice and any other services from any healthcare professional. The home must keep up to date records of the food provided to residents in sufficient detail to ensure that anyone inspecting Timescale for action 30th September 2005 2. 4 14(1)(d) 31st October 2005 30th September 2005. 3. 7 15(1) 4. 8 13(4)(c) 30th September 2005 30th September 2005. 30th September 2005 Page 22 5. 8 13(1)(b) 6. 15 17(2) Schedule 4 Gillibrand Hall Nursing Home F57 F08 S25560 Gillibrand Hall V232407 040805 Stage 4.doc Version 1.30 7. 19 23(2)(b) 13(4)(c 8. 19 23(2)(b) 13(4)(c) 9. 30 38 18(1)(c) the record is able to determine whether the diet is satisfactory in relation to nutrition and otherwise. The worn corridor carpet identified at inspection must be replaced as it present a trip hazard. The missing ceiling tile identifed at inspection must be replacedas the heat from the exposed pipes in this area was excessive. Induction training must be provided for new staff and records kept. Training must be updated regularly so that staf are kept up to date with current good practice and maintain their skills and knowledge. Portable electrical appliances must be tested to ensure that they are safe to use. 31st October 2005 31st August 2005 31st October 2005 10. 38 23(2)(c 30th September 2005 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. 2. Refer to Standard 3 7 Good Practice Recommendations Pre admission forms should be completed in full and be dated and signed. Care plans and assessments should be reviewed monthly. Gillibrand Hall Nursing Home F57 F08 S25560 Gillibrand Hall V232407 040805 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Levens House Ackhurst Business Park Foxhole Road Chorley PR7 1NW 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 Gillibrand Hall Nursing Home F57 F08 S25560 Gillibrand Hall V232407 040805 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. 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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