Inspection on 11/11/05 for Goatacre Manor Care Centre

This inspection was carried out on 11th November 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

Goatacre Manor Care Centre 05/11/09

Goatacre Manor Care Centre 01/05/09

Goatacre Manor Care Centre 02/05/07

Goatacre Manor Care Centre 12/05/06

Goatacre Manor Care Centre 26/05/05

Goatacre Manor Care Centre 02/12/04

Goatacre Manor Care Centre 22/04/04

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

CARE HOMES FOR OLDER PEOPLE Goatacre House Goatacre Lane Goatacre Wiltshire SN11 9JA Lead Inspector Tim Goadby Unannounced Inspection 11th & 18th November 2005 09:45 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 Goatacre House DS0000015911.V266134.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. Goatacre House DS0000015911.V266134.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Goatacre House Address Goatacre Lane Goatacre Wiltshire SN11 9JA 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) 01249 760464/454 01249 760252 Mr John O`Dea Mrs Margaret O`Dea Vacant Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42), Physical disability (3), Terminally ill (3) of places Goatacre House DS0000015911.V266134.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. No more than 3 persons in receipt of terminal care at any one time No more than 3 physically disabled residents in the age range 18 - 64 years at any one time No more than 42 persons over the age of 65 years requiring nursing care 26th May 2005 Date of last inspection Brief Description of the Service: Goatacre House Nursing Home provides accommodation, and care with nursing, for up to 42 service users. The majority of these will be people aged 65 and over. The service may also care for up to 3 adults in the 18 to 64 age range, if they need care due to a physical disability, or because of a terminal illness. Both short and long-term placements can be offered. The home is privately owned. It is in the small village of Goatacre, near Lyneham, Wiltshire. The market towns of Calne and Wootton Bassett are within a few minutes drive. The larger town of Swindon is also only a short distance away. This offers a full range of amenities. The nursing home consists of an original property which has had a purpose built extension added to it. Service user accommodation spreads over two floors. There is a lift that operates between these. There are 28 single bedrooms, and 7 which may be shared. En-suite toilets and handbasins are provided in the majority of these. There are 4 bathrooms, and 1 shower. There are 2 main lounge and dining areas, both on the ground floor. The home has wheelchair accessible corridors, bedrooms and communal rooms. Grab rails are provided in corridors, bathrooms and toilets. Lifting aids and equipment are available. Externally there are pleasant, accessible gardens and adequate parking spaces. Goatacre House DS0000015911.V266134.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two visits in November 2005. The first visit was unannounced. A shorter return visit took place, by appointment, to conclude the inspection and give initial feedback. The registered provider was present on the second occasion. A total of 8.75 hours were spent in the home. The following inspection methods have been used in the production of this report: indirect observation; pre-inspection questionnaire, completed by the provider; sampling of records, with case tracking; sampling a meal; sampling activities; discussions with service users, staff and management; tour of the premises. What the service does well: What has improved since the last inspection? 2 requirements of the previous inspection had been met. Arrangements for activities are running more effectively, reflecting some changes in personnel. One longstanding employee continues to offer a number of sessions each week. Another recently appointed carer has expressed an interest in this area, and is to undertake training to enable them to also participate in the provision of activities. Service users were engaging with and enjoying the session taking place on the first day of this inspection visit. A number also spoke positively about recent and forthcoming outings. Goatacre House DS0000015911.V266134.R01.S.doc Version 5.0 Page 6 Information displayed in the home showed that a range of opportunities are being offered, helping to meet the needs and aspirations of service users. Medication records are now being stored securely, away from communal areas, when they are not in use. This upholds the privacy of service users. What they could do better: 6 requirements were unmet from the previous inspection, whilst 6 further requirements arose as a result of these visits. A sampled service user file showed significant deficits, failing to evidence that all necessary steps had been taken to assess, plan, monitor and review care for all the individual’s key health needs. This placed the individual at risk that their welfare may not be upheld. Immediate requirements were issued at the close of the inspection, specifying that these issues must be addressed in respect of the individual considered within a short period. The home will also need to ensure that practice is audited, and rectified for all service users, from this point forward. Some health and safety topics need attention to ensure that service users are not placed at risk of harm. These too were made the subject of immediate requirements. Firstly, action is required on hot water and radiator surface temperatures. The home currently has a risk assessment process which relies mainly on weekly checks. But, although these are conducted, records show that some temperatures can be too high. There is no evidence that effective action can then be taken to address any such problems. As a first step, the home needs to ensure that full risk assessments are in place for all hot surfaces, and hot water outlets which are accessible to service users. Where issues of concern are identified, a suitable risk management plan must be put in place. In the longer term, action must then be taken to resolve any problems which are contributing to the current situation of unsafe temperatures being recorded regularly. Secondly, use of bed sides with any service user must be supported by a documented risk assessment, addressing all relevant issues; and by evidence of consent. Whilst cleanliness and décor are generally good, 2 areas are in need of attention, to ensure that no infection control risks develop. The laundry room floor and walls must have impermeable surfaces, so that they are easily cleanable. The kitchen flooring needs to be fully sealed, ensuring that it too can be cleaned effectively. Goatacre House DS0000015911.V266134.R01.S.doc Version 5.0 Page 7 To ensure the further protection of service users and staff from all infection control risks, there must be suitable personal protective equipment available for use for all intimate care tasks. At present, staff report that some items,, such as gloves, are not kept in sufficient stock to be available each time they are required. Another outstanding requirement is for implementation of a quality assurance system. Work is ongoing towards this, but no evidence has yet been generated. An annual development plan must be produced as the outcome of a suitable quality audit, so that service users can be confident that their views underpin a process of continuous improvement for the service. The home’s procedures for the protection of service users from abuse must be linked to Wiltshire’s multi-agency process for this. This will ensure that referrals to those arrangements are made if it is appropriate to do so, and that the welfare of service users is upheld in line with national and local procedures. The post of registered manager for the home is currently vacant, following the retirement of the previous postholder. The deputy manager is acting in the role of matron for the interim period. Once an appointment has been made, this person will need to apply without delay for registration with the CSCI. Filling of this vacancy will ensure that service users once more have the benefit of a suitable person who is accountable for their care and welfare. 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. Goatacre House DS0000015911.V266134.R01.S.doc Version 5.0 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 Goatacre House DS0000015911.V266134.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Prospective service users have their needs assessed before a decision is made to offer them a place in the home. EVIDENCE: The home’s senior nursing staff undertake assessments of potential service users. This is done in person, where possible; or by telephone, if the prospective admission lives some distance away. The initial assessment is recorded on a form devised for this purpose. When applicable, relevant information is also obtained from other sources. In the example seen during this inspection, a service user had been admitted after spending some time in another specialist health facility. A detailed report had been obtained, in addition to the home’s own pre-admission assessment. There was also evidence of consultation with the individual’s family. Goatacre House DS0000015911.V266134.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&8 A service user did not have appropriate guidance in place to ensure effective personal and health care support. This placed them at risk of harm. EVIDENCE: A sampled service user file showed a number of significant deficits. Although the individual had been admitted 6 weeks before the first inspection visit, not all assessments had been completed and linked to care plans. A moving & handling risk assessment had been started, but was unfinished. A wound care plan was also incomplete, and not clearly linked to other quoted sources of guidance. There was an incomplete record regarding catheter care. A number of health care needs identified in the same person’s assessment for nursing care funding had not been incorporated into their plan. For instance, no guidance or monitoring was evident for areas such as epilepsy, bowel management, and pressure relief. Care plans sometimes lack an appropriate level of detail about the actions to be taken to support areas of need. For instance, a plan for personal care simply stated that the service user was to be assisted with washing and Goatacre House DS0000015911.V266134.R01.S.doc Version 5.0 Page 11 dressing, without describing how. Some plans are pre-printed, with the person’s name then inserted, so they do not fully reflect the individual needs. Goatacre House DS0000015911.V266134.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): 12 & 15 Service users’ expectations and preferences in social and recreational needs are being met. Service users are offered healthy, nutritious and enjoyable meals, in line with individual needs and preferences. EVIDENCE: The home employs one person, who works for 3 sessions each week, to lead on the provision of activities. Another carer has expressed an interest in this area, and is to attend some training which will enable them to contribute to the home’s programme as well. Relevant celebrations are marked, and outside entertainment is also brought into the home on some other occasions. Trips out for groups of service users, enabled by hiring a specially adapted coach, are held at least once a year. A visit to Weston-Super-Mare had been a successful excursion during the summer. People were now looking forward to a forthcoming Christmas shopping trip to Bristol. At Goatacre itself, a weekly programme of activities is drawn up. The sessions provided include carpet bowls, bingo, quizzes, art and craft, and cooking. On Goatacre House DS0000015911.V266134.R01.S.doc Version 5.0 Page 13 the first day of this inspection visit, games were taking place in the larger of the home’s two lounges. A quiz proved particularly successful in engaging the participation of a number of service users, and was a starting point for a number of conversations and reminiscences. As well as small group activities, staff also spend time in one to one conversation with service users. Naturally occurring situations when people may need support, such as when having a drink, are used to engage in interaction, and provide a good point of social contact. The majority of service users were out of bed, and in communal areas, so they were able to be involved to varying degrees in the daily life of the home. Arrangements for meals were seen to be of a continuing good standard. As at previous inspections, a sampled meal was tasty and well presented. Portion sizes were appropriate to the needs of individuals. The home has a menu, based on a four week rotation. Dishes provided are varied and nutritious. There is a focus on the use of fresh ingredients. Choice is available. If people do not wish to have the main option, an alternative dish will be prepared in line with their request. Goatacre House DS0000015911.V266134.R01.S.doc Version 5.0 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 the following standard(s): 18 The home’s policies and procedures for adult protection need to be clearly linked to local multi-agency arrangements, to ensure that the welfare of service users is safeguarded. EVIDENCE: Goatacre House has policies and procedures relating to abuse and adult protection. These have been produced at a national level, by the nursing home association of which the home is a member. They need updating to reflect the change of regulatory body, from the NCSC to the CSCI, which occurred in April 2004. The policies also fail to link clearly to the Wiltshire & Swindon multi-agency procedure for adult protection. As a registered care provider within the county, the home is required to operate within this framework. Therefore, it is important that internal procedures clearly link to the referral process, and the circumstances in which an alert would need to be made. Staff have had training and talks on abuse and protection issues in the past, and the training co-ordinator reported that it is hoped to set up further sessions in the near future. There is a policy in place on how staff may raise concerns about issues of practice, commonly known as whistle blowing. Currently this document refers only to internal routes for doing so. It would benefit from review and Goatacre House DS0000015911.V266134.R01.S.doc Version 5.0 Page 15 expansion, to make clear that there are various other routes which employees might use to make disclosures. Goatacre House DS0000015911.V266134.R01.S.doc Version 5.0 Page 16 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, 20, 22 & 26 Service users’ individual and communal accommodation is homely and comfortable. The environment is safe, clean and well maintained in the majority of areas. Issues of cleanliness and décor in the kitchen and laundry need resolving, to ensure that service users are not placed at risk of harm. The protection of service users and staff from infection risks is compromised by a failure to use suitable personal protective equipment on all occasions. EVIDENCE: Goatacre’s service user accommodation is spread over 2 floors. The main communal areas are on the ground floor. There are large, accessible grounds. Car parking space is available at the front of the home. Goatacre House DS0000015911.V266134.R01.S.doc Version 5.0 Page 17 Care has been taken to create a homely environment. Furniture, fixtures and fittings are of a good standard. The property appears to be well maintained. There is an ongoing refurbishment programme. Office space is mainly found on the first floor. The matron’s office is relatively small, and also in an area used as a thoroughfare. It is hoped to provide a more suitable office. Ideally, this would be on the ground floor, making the matron more readily accessible to service users and visitors. It is also hoped to create a more suitable nurses’ station. At present, a small area off the entrance hallway is utilised. This has limited space. It is also away from the main parts of the building where service users spend their time. Both of these issues are due to be addressed by a plan to extend the property. But there is no date set for this work as yet. Adaptations and equipment, such as grab rails and toilet seat raisers, have been provided where necessary. Assisted baths are also available. All beds are of a hospital type. Individual service users have also been provided with adapted seating and adjustable tables. Staff receive manual handling training, which includes instruction in how to use the various equipment available. Hoists were observed being used appropriately during this inspection visit. The laundry room has been redecorated over the past year, but some issues remain in need of attention. Part of the floor surface is bare concrete, and therefore not impermeable. The wall surface has areas of flaking paintwork, exposing plaster. There is also no seal between the floor and wall behind pipe work. The kitchen floor covering is noticeably stained and scratched in places. Substantial efforts have been made to clean the area, with some success. But it remains discoloured, and on the first visit of this inspection was noticeably less clean than on the previous occasion. The provider reported that a recent environmental health officer’s inspection had passed the floor as not presenting any hygiene risks. Evidence of this is to be produced for the CSCI. Staff are provided with personal protective equipment to use when carrying out intimate care tasks. However, they report that there are occasions when there are insufficient supplies of such items available. Infection control risks are then heightened by the necessity to perform such tasks without the appropriate protection. Goatacre House DS0000015911.V266134.R01.S.doc Version 5.0 Page 18 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): 28 & 30 Service users are supported by appropriately trained staff. EVIDENCE: The home has a member of the nursing team who acts as training coordinator. She ensures that all staff attend all necessary courses, and that refresher sessions are provided when these become due. Both nurses and carers undertake various training, appropriate to their roles. Recent sessions have included wound care, nutrition, and infection control. A record is kept during the induction period for new starters. The approach used by the home reflects the previous set of national induction standards for the social care workforce. As these have recently been reviewed, the home should also update its own approach accordingly. NVQ training for care staff is well established, and the home comfortably exceeds the minimum 50 target for carers with at least a Level 2 qualification. At the time of this inspection, 11 of 15 employees had completed this award, or were just about to do so. 2 people were now working towards the Level 3 award. Domestic and catering staff also have the opportunity to undertake NVQ training in their own subjects. Goatacre House DS0000015911.V266134.R01.S.doc Version 5.0 Page 19 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): 33, 35, 37 & 38 Quality assurance measures need to be implemented, to ensure the home is conducted and developed in line with service users’ needs and preferences. Service users’ best interests could be better upheld by some improvements in the required areas of record keeping. The health, safety and welfare of service users are placed at risk by a failure to take all required protective measures for the regulation of hot surface and water temperatures; and for the appropriate use of bed sides. EVIDENCE: Since the previous inspection, the home’s former matron has retired. So Goatacre is currently without a registered manager. A recruitment search for a new manager is ongoing, but had not been successful at the time of this inspection. In the interim, the home’s deputy manager is acting in the role of Goatacre House DS0000015911.V266134.R01.S.doc Version 5.0 Page 20 matron. She is also having to cover various areas of administrative responsibility, due to the absence of another employee. Goatacre House has not yet fully implemented a quality assurance system. A management consultant has been assisting in work towards this. The approach taken is based on existing systems, such as the one devised by the Registered Nursing Home Association. Various audits already take place on a range of topics. Feedback is also obtained from service users, visitors and others in a number of ways. But no evidence is yet available to demonstrate how these sources are collated, to produce a quality audit report, and a service development plan. One of the home’s administrative staff is responsible for any involvement that the service has with service users’ money. Most have their affairs managed by relatives, or legal representatives. Often these people live some distance away. So Goatacre House provides a facility that enables more convenient access to cash for service users. Money can be paid into a residents’ account that the home maintains with a local bank. This does not accrue any interest. There is also a rigorous system of checks to prove appropriate operation of the account. Each individual resident can only have funds drawn on their behalf if they are in credit. Monies are not pooled in the sense that an individual could be in deficit. Care home regulations mean it is generally not permitted for services to pay money belonging to users into an account, other than one in their own name. But this rule does not apply if the money is paid in respect of services provided by the home. It has been agreed that the arrangement at Goatacre House falls under this latter category. Therefore, it is appropriate for it to continue. The service provides clear information about this facility, to assist people in deciding whether they wish to make use of it. Where possible, service users are enabled to retain some control over amounts of their own money. It is recognised that this is an important way of people maintaining a sense of independence and self-esteem. Key records relating to service users were not all clearly signed and dated. These good practice principles are important in ensuring that current care guidance can be readily identified, and that there is clear accountability for the care planning process. Health and safety risk assessments are in place, addressing all areas of the building, and key topics such as hazardous substances and infection control. A review schedule ensures that each one is looked at annually. Staff also receive regular training and updates on various health and safety issues. Goatacre House DS0000015911.V266134.R01.S.doc Version 5.0 Page 21 Hot water for the home is provided by an oil fired boiler. Problems have been experienced in the past with this being able to provide a sufficient supply of hot water to all parts of the building at all times of day. It is reportedly difficult to regulate the system to ensure an appropriate temperature at each of the outlets which is supplied. Central heating is provided by radiators. As noted at previous inspections, not all of these have low temperature surfaces, or covers. These help to reduce the risk of burns, should a service user fall against one. All radiators can be individually temperature controlled by a thermostatic valve. The home’s current risk assessment process for both hot water and radiator surface temperatures relies mainly on weekly checks. But, although these are conducted, records show that some temperatures can be too high. The maximum safe level is 43°C. Records for the week of the first visit of this inspection showed that 15 hot water outlets had exceeded this by more than 10 , with the highest recorded temperature being 65.9°C, at the sink in a service user’s bedroom. Records for the 7 weeks up to and including that of the first inspection visit showed that 45 radiator surface temperatures had exceeded the safe level by more than 10 , with the highest recorded figure being 66.3°C, in a service user’s bedroom. Certain radiators were consistently shown as being well above the required safe temperature. An example was the appliance in an ensuite toilet. This was checked on both days of this inspection, and on each occasion was too hot to touch. There is no current evidence that effective action can then be taken to address any such problems. The home needs to ensure that full risk assessments are in place for all hot surfaces, and hot water outlets which are accessible to service users. These must be individual documented risk assessments for each location. They must take into account environmental factors, such as position; and relevant service user factors, such as the needs and preferences of a room’s occupant. Where issues of concern are identified, a suitable risk management plan must be put in place. In the longer term, action must then be taken to resolve any systemic problems which are contributing to the current situation of unsafe temperatures being recorded as a regular occurrence. 4 files were checked in relation to service users who have bed sides in place. None had full risk assessments to support their use, or documented evidence of consent. Where reference is made to the issue, it is insufficient. For instance, in one case, staff are instructed to ensure that an individual is not at risk of hurting themselves. But it is not made clear how this is to be achieved. Goatacre House DS0000015911.V266134.R01.S.doc Version 5.0 Page 22 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 N/A 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 3 3 X 3 X X X 2 STAFFING Standard No Score 27 X 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score N/A X 2 X 3 X 3 1 Goatacre House DS0000015911.V266134.R01.S.doc Version 5.0 Page 23 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 12-1;15 Requirement The persons registered must ensure that there is a full plan of care for each service user, generated from a comprehensive assessment. COMMENT: The timescale quoted relates to the individual considered during this inspection. The persons registered must ensure that there is evidence of appropriate assessment, planning, monitoring and review for all health care needs of each service user. COMMENT: The timescale quoted relates to the individual considered during this inspection. Policies and procedures for adult protection must be linked to the local multi-agency arrangements for this topic. Laundry floor and wall finishes must be impermeable and readily cleanable. (Timescale from 29/04/04 partly met) DS0000015911.V266134.R01.S.doc Timescale for action 09/12/05 2 OP8 12-1;131;15 09/12/05 3 OP18 12-1a;136 13-3;162j;23-2d 31/12/05 4 OP26 13/01/06 Goatacre House Version 5.0 Page 24 5 OP26 13-3;162j;23-2d 12-1a;133 6 OP26 7 OP31 8-1 8 OP33 24 COMMENT: The area has been redecorated since this requirement was originally set. But problems remain in part of the room. The kitchen floor must be kept clean at all times, and have an intact surface. (Timescale from 03/12/04 not met) Suitable personal protective equipment for staff carrying out intimate care tasks must be available, and be used at all appropriate times, to minimise infection control risks. A person must be appointed to manage the home, and that individual must apply to the CSCI for registration as manager. The persons registered must devise and implement an effective quality assurance system. (Timescale of 31/03/05 not met) COMMENT: The timescale relates to production of an annual development plan, as evidence of an outcome from various quality audits. The persons registered must ensure that documented risk assessments, and written evidence of consent, are in place for any use of bed sides. (Timescale from 26/05/05 not met) There must be an individual documented risk assessment, and risk management plan, for all remaining uncovered radiators. (Timescale of 31/07/05 not met) There must be an individual documented risk assessment, and risk management plan, on DS0000015911.V266134.R01.S.doc 13/01/06 18/11/05 31/01/06 31/12/05 9 OP38 121,2&3;137&8 09/12/05 10 OP38 13-4 09/12/05 11 OP38 13-4 09/12/05 Goatacre House Version 5.0 Page 25 12 OP38 13-4 all hot water outlets which are accessible to service users. Following risk assessment of uncovered radiators, and hot water temperatures, suitable actions must be taken where identified as necessary. COMMENT: Immediate action is required to protect service users from identified risk. The timescale quoted is for the full completion of any remedial works which may then be needed. 31/03/06 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 3 4 Refer to Standard OP7 OP9 OP18 OP19 Good Practice Recommendations Care plans should include appropriate detail about the actions necessary to support the assessed needs of service users. Consideration should be given to storing of drugs away from communal areas for service users. The whistle blowing policy should be reviewed and expanded, to include information on all possible avenues of disclosure. Consideration should be given to identifying more suitable locations for the nurses station, and matrons office. COMMENT: Proposals for a future extension of the property will include steps to address this. The approach to induction of new care staff should be reviewed and updated, to reflect changes in national standards for the social care workforce. All records relating to service users should be clearly signed and dated. 5 6 OP30 OP37 Goatacre House DS0000015911.V266134.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Goatacre House DS0000015911.V266134.R01.S.doc Version 5.0 Page 27 - 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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