Inspection on 02/05/07 for Goatacre Manor Care Centre

This inspection was carried out on 2nd May 2007.

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

The inspector 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 12/05/06

Goatacre Manor Care Centre 11/11/05

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 Manor Care Centre Goatacre Lane Goatacre Wiltshire SN11 9JA Lead Inspector Tim Goadby Unannounced Inspection 2nd May 2007 09:30 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 DS0000015911.V337493.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000015911.V337493.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Goatacre Manor Care Centre 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 info@goatacre.com Mr John O`Dea Mrs Margaret O`Dea Mrs Kathryn Jane Swainson 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 DS0000015911.V337493.R01.S.doc Version 5.2 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 12th May 2006 Date of last inspection Brief Description of the Service: Goatacre Manor Care Centre 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 three 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 home consists of an original property with a purpose built extension. Service user accommodation is on two floors. There is a lift that operates between these. There are 28 single bedrooms, and seven which may be shared. En-suite toilets and handbasins are provided in the majority of these. There are four bathrooms and two showers. There are two 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. Fees charged to service users range between £550 per week, which is a rate only available for people not in receipt of any nursing care; and a maximum figure of £680 per week. A range of information for service users and other visitors is displayed in the entrance hall. People are informed about CSCI inspection reports on the home, and are often directed to the Commission’s website. Goatacre Manor also has its own website, along with a brochure about its services. Prospective service users can telephone or visit the home for further information. DS0000015911.V337493.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was completed in May 2007. The service’s previous main inspection was in May 2006. A joint visit with the Health & Safety Executive (HSE) took place in October 2006, to follow up specific issues of concern. Both agencies then visited the home separately in December 2006, at which point the CSCI carried out a random inspection. This key inspection followed up on areas identified at all of these earlier visits. Findings from the December inspection are also restated in this report, where they remain relevant. As well as reviewing contact with the service over the months before this inspection, we also considered written information supplied by the service. Five survey forms were completed by staff of the home. Survey forms were also provided for the home to distribute to service users or their families, and one of these was returned. Fieldwork took place via an unannounced visit to the home, which lasted 7.25 hours. During this visit we looked at records, toured the home, observed care practices, sampled an activity session and a cooked meal, and spoke with service users, staff and management. What the service does well: Service users can be confident that their needs are fully assessed, from the pre-admission stage onwards. Care is regularly monitored and reviewed. Other relevant health professionals are involved when necessary. A wide range of health care needs are supported, with the home providing a valuable local resource which is able to cater for people with complex needs and high levels of dependency. Feedback from staff consistently refers to the care provided to service users as a particular strength of this service. Staffing levels are good, and reflect the identified care needs of the home’s service users. This means that there are enough people on duty to support service users when they need help. Goatacre Manor provides a pleasant and comfortable environment for service users. The home is in an attractive situation. It is well furnished and maintained and there are ongoing refurbishments and improvements. DS0000015911.V337493.R01.S.doc Version 5.2 Page 6 Food provided in the home has been of consistently good quality over a number of inspections. Choice is available. Special dietary needs can be catered for. Practice in this area enhances quality of life for service users. Visitors are made welcome, and are a regular feature of life in the home. Contact for service users with their family and friends is positively promoted, ensuring that key relationships can be maintained. Staff display appropriate attitudes towards service users, with warm, friendly, respectful interactions being observed. This creates an open and positive atmosphere from which service users can benefit. Staff themselves appreciate the support received from colleagues, and speak of how much they enjoy working at the home. Service users benefit from the support of a skilled and knowledgeable staff team. Systems are in place to ensure that all staff undertake a range of relevant training. This includes all mandatory topics, and also a variety of areas which are directly relevant to the service users’ care needs. Employees have the opportunity to take courses in areas they are particularly interested in, and to develop expertise which they can then pass on to other colleagues. Over 50 of the home’s care staff have achieved a nationally recognised qualification which supports their work with service users. What has improved since the last inspection? Significant progress has been made to reduce risks to service users from hot surfaces and water temperatures. An extensive programme has been undertaken to cover most radiators and exposed pipework throughout the building. Alternative risk management strategies have been implemented for the few areas where this has not been possible. An improvement notice issued by the HSE during 2006 has been complied with. Action has been taken to regulate hot water temperatures to the recognised safe level. A water softener has been installed to help the building’s plumbing and heating systems work more effectively. Work also continues on trying to identify a suitable long-term solution for replacement of the home’s boiler. Service users can be more confident that any use of bed rails in the home is supported by evidence of the reasons for this, and a proper decision making process. Since the random inspection, the home has provided the CSCI with evidence that suitable documentation is in place for all service users that this issue applies to. More progress could still be made in enhancing the quality and consistency of these records. The home has reviewed its approach to the provision of activities. Care staff are now becoming more involved in this part of what the home offers. This helps staff to get more variety and interest in their job roles, and also gives service users access to a wider range of possible opportunities. This DS0000015911.V337493.R01.S.doc Version 5.2 Page 7 development is also being supported by continuing use of some external entertainment and occasional outings. Further progress is anticipated as care planning in this area develops. 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. The summary of this inspection report can be made available in other formats on request. DS0000015911.V337493.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000015911.V337493.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have their needs assessed before a decision is made to offer them a place in the home. Standard 6 is not applicable to this service. EVIDENCE: DS0000015911.V337493.R01.S.doc Version 5.2 Page 10 The home’s senior nursing staff undertake assessments of potential service users. This is done with the person directly, where possible; or by telephone if they live 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. Goatacre Manor’s assessment format covers the expected range of topics. Two files were sampled of service users who had been admitted within the previous two months. Both showed that the assessment process had been carried out in detail, and fully recorded. DS0000015911.V337493.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have their abilities, needs and goals reflected in their individual plans. Service users receive effective support with their health and care needs. Service users are protected by most of the home’s policies and procedures for dealing with medicines. But clearer guidance is needed on the use of some prescriptions, to ensure these are given consistently and safely. Service users have their privacy and dignity respected. EVIDENCE: DS0000015911.V337493.R01.S.doc Version 5.2 Page 12 Four sets of service user records were checked in detail. All contained evidence of assessment across a range of relevant areas, including pressure care, activities of daily living, behaviour, mobility and handling. Plans had been drawn up for relevant health care needs. The home has produced some plans on common topics in a standard format, and adapts these slightly to particular service users. Additional and more specific plans are also drawn up for any other needs that a person may have. The plans seen contained clear instructions about care to be given, and there was evidence that they are kept under regular review. Plans are supported by daily notes, which provide a detailed ongoing record of care. The home has also begun extending care planning to other areas, such as communication and activities. At the moment, these areas are covered in less detail, and the instructions for staff support are much more general. This issue was discussed with the manager, who recognises the benefits of developing practice in this area, and has already set this as a target. Evidence of health care support is good. There is assessment of all relevant areas, and this is kept under regular review. Identified risks are linked to suitable plans of care. Key indicators of health are monitored and recorded. The actions of the home’s own nursing and care team are clearly shown. It is also apparent that there is regular input from GPs and other relevant health professionals. Reviews and evaluations of care show progress being made by service users in overcoming some health problems, and in effective management of long term issues. Medication is managed safely. Administration of drugs to service users is performed by nursing staff, and is carried out appropriately. Records are maintained in line with required criteria. Medication is booked into the home, and a record is also kept of medicines which are disposed of. Individual medication charts show what drugs have been administered to each service user, and also any reasons for non-administration. One member of staff has lead responsibility for the ordering of prescriptions. The home has links with a number of local GP surgeries, and there is evidence of reviews of medication for individual service users. Further information is needed to support the safe use of medicines which have been prescribed to be given ‘as required’. Individual care plans need to set out the criteria which must be used to make this judgement. This was not in place on the records sampled. For instance, one service user is prescribed ‘as required’ medication to help in the management of verbal and physical abuse towards staff. They had been given this on two occasions within the previous six weeks. Daily notes for the relevant dates showed that the service user had been abusive and agitated on each occasion. However, notes also referred to other occasions when similar behaviours had been exhibited, and medication DS0000015911.V337493.R01.S.doc Version 5.2 Page 13 had not been found necessary at these times. Care records did not make clear how staff would ensure that decisions about the use of this prescription are made consistently. Staff provide personal care to users sensitively and respectfully. There is warm and friendly interaction amongst people. Intimate care tasks are always carried out with due regard for privacy. Staff ensure that they gain the permission of service users, and then take them to their own room, or another suitable location. DS0000015911.V337493.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to exercise choice and control in their daily lives. Service users are provided with a range of activities and opportunities, but would benefit from further development of practice in this area. Service users are able to maintain and develop appropriate relationships with family and friends. Service users are offered healthy, nutritious and enjoyable meals, in line with individual needs and preferences. EVIDENCE: DS0000015911.V337493.R01.S.doc Version 5.2 Page 15 Over a number of inspections, a relaxed and friendly atmosphere has consistently been found at Goatacre Manor. On the day of this unannounced visit service users were sat finishing breakfasts until around 10 a.m. There was an unhurried approach from staff, giving service users time and space to have a pleasant start to the day. Goatacre Manor has been reviewing its approach to the provision of activities. Having allocated staff to lead on this did not seem to be working. So the home is now putting extra carers on duty each morning, and enabling two of these to get involved in leading sessions. Across the team, because of their different skills and interests, this leads to a wide range of possible opportunities for service users. Staff confirmed that they are enjoying this aspect of their work. External entertainment is also provided on occasions. A music and movement session is being held once a fortnight, by a trainee dance therapist. This activity was held during the inspection visit. It took place in the main lounge, with around 20 service users present. The session leader and the staff on duty were successful in encouraging most of these to engage with at least part of the activity. There were some very positive reactions, with service users getting obvious pleasure out of the session. Trips out for groups of service users, enabled by hiring a specially adapted coach, are held at least twice a year. One such outing, to Weston-Super-Mare, was due to take place in the week following this inspection, and people were looking forward to it. As discussed in the previous section, the home is hoping to extend the range of information in care plans relating to activities, to support it developing practice in this area. As more sessions are tried with more service users, staff will be able to gain a clearer appreciation of each individual’s preferences. There are no restrictions on visiting, unless requested by the service user. Most people have contact with family or friends. Visitors come and go regularly. People can choose whether to receive guests in communal areas, or in their own rooms. Arrangements for meals are good. As at previous inspections, a sampled meal was well presented. Portion sizes are 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. Menus have recently been reviewed, based on the evidence seen of service users’ preferences. Special dietary needs can be catered for. This includes caring for service users who need to use special equipment. One staff member was observed supporting a service user with such needs. This was carried out discreetly and DS0000015911.V337493.R01.S.doc Version 5.2 Page 16 respectfully. The service user was given an appropriate amount of time and attention, and the intervention was also used as an opportunity to chat with them and give social contact. DS0000015911.V337493.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are safeguarded by the home’s policies and procedures for complaints and protection. EVIDENCE: A suitable complaints procedure is in place. It is prominently displayed in the entrance hallway, and includes contact details for the CSCI. No formal complaints about the home have been received since the last inspection. The service is devising a system for logging any informal issues or concerns which are brought up, and showing how these are resolved. There is also a suggestion box which can be used by anyone wishing to make comments. Suitable procedures are also in place regarding abuse and adult protection, with information about local multi-agency processes for responding to any concerns. All staff receive training in this topic. It is included as a key part of the home’s induction process, and this has been reviewed to ensure that it is covered in greater depth. Recently appointed staff confirmed that they have received information and training about it. DS0000015911.V337493.R01.S.doc Version 5.2 Page 18 Since the last key inspection a service user raised an allegation relating to the possible theft of money. The issue was referred to the local adult protection process, as appropriate, and those investigations remained open at the time of this inspection. The home has reimbursed the service user with the sum of money in question. There have been no further concerns raised. DS0000015911.V337493.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a comfortable, clean and safe environment, suitable to their needs. EVIDENCE: Goatacre Manor’s service user accommodation is spread over two 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. DS0000015911.V337493.R01.S.doc Version 5.2 Page 20 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. Bedrooms are usually redecorated whilst they are vacant. 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. There are plans to extend and improve the accommodation offered by the home. This will include upgrading bath and shower facilities, an area highlighted as needing attention in some staff feedback. No date has yet been set for starting this work. It is also hoped to be able to extend the home’s lift shaft, so that service users can access the top floor of the building. This additional space could then be used for activity sessions. The home was clean and hygienic in all areas seen during the inspection. This included the laundry, kitchen and food storage areas, bathrooms, showers and toilets, communal lounges and dining rooms, and a few bedrooms. Levels of heating and hot water are being maintained suitably, after a period when the home experienced problems with these. A water softener has been installed, which should help to reduce the difficulties caused by limescale. The home is also continuing to research suitable long-term options for the replacement of its current boiler. DS0000015911.V337493.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported by suitable numbers of appropriately trained staff. The home is unable to provide full evidence that appropriate recruitment processes are in place, to ensure the protection of service users. EVIDENCE: Goatacre Manor is registered to provide nursing care, so qualified nursing staff must be on duty at all times. They are supported by carers working with them to deliver care to service users. Numbers on duty can vary slightly, depending on the service user occupancy. Ratios of staff to service users tend to be high, reflecting the dependency levels of the people living in the home. Overnight cover is provided by waking staff. DS0000015911.V337493.R01.S.doc Version 5.2 Page 22 Staff are deployed to various sections of the home. A nurse oversees each group. A senior carer will allocate carers to service users. Carers usually work in pairs, because most service user need two people for support with personal care. People may also be assigned to work one to one, if an individual has specific needs. Staff work across the different parts of the home, so they get to know all the service users. Some qualified nurses are recruited from overseas. Where necessary, they undertake adaptation training so that their qualifications are recognised in the UK. Such nurses work as carers until this process has been completed. The home generally has stable staffing, with relatively low turnover. The core team is well established. Relief and agency workers are used as necessary. The home also employs people for various other key tasks. These include activities, administration, catering, cleaning, and maintenance. Some staff commented on the need to have better communication between day and night teams. This was passed on to the manager during the inspection. She indicated that she would discuss this further with the staff group, to see if they could identify ways of making improvements. Most staff comments were positive about the atmosphere in the home. They feel that there is good communication amongst team members. They also find the manager and other senior staff approachable. Staff are able to contribute comments and suggestions. They have regular one-to-one sessions at which they can review their own performance. Staff meetings are also held, although these take place less frequently. A member of the nursing team acts as training co-ordinator. 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. Induction of new staff involves working through a booklet, which links to relevant national training standards for the social care workforce. New starters are allocated a senior carer as a mentor. A recently appointed member of staff confirmed the support they had received during their introduction to the home. A new staff handbook is being developed, which can be distributed to employees. This will cover lots of the relevant information which they need, and provide them with a source of reference. More than 50 of care workers have National Vocational Qualifications (NVQs) in care at Level 2 or above. Most of the assessing for NVQs is done by an external training provider but there are also some trained NVQ assessors amongst the home’s own team. DS0000015911.V337493.R01.S.doc Version 5.2 Page 23 Staff confirmed the range of training which they undertake. This includes practical instructions in the use of equipment, alongside courses and in-house sessions on various relevant topics. Training opportunities are displayed on a noticeboard in the home, and staff can put their name forward for any they are interested in. People also have the opportunity to develop particular areas of expertise. For instance, carers can become approved manual handling trainers, who can then give instruction to other colleagues. Recruitment is usually ongoing, as it is recognised that there is always likely to be a certain level of turnover. Four sets of staff records were checked. These were for people appointed in the last year, and in most cases for staff recruited from January 2007 onwards. In two of these four cases, staff had started working in the home for initial induction before they had received clearance against the national list of people deemed unsuitable to work with vulnerable adults, known as the ‘POVA list’. They had not had any unsupervised access to service users, or involvement in direct care giving, until this clearance had been obtained. But this is still in breach of what is permitted. Records are not fully available to evidence all appropriate recruitment checks. Some of the information about POVA list checks was not on file for one employee, and had to be obtained during the inspection once this was noted. Proof of identity, including a recent photograph, is not kept on any of the files. In discussion, the manager acknowledged that all staff files need attention to ensure that they contain all the required information. The home has taken appropriate steps to address issues arising in relation to individual employees. Decisions and risk assessments are clearly documented. DS0000015911.V337493.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good overall; however, quality in the area of quality assurance is only adequate. This judgement has been made using available evidence including a visit to this service. The registered manager is suitably qualified, competent and experienced, so that service users benefit from a well run home. 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’ financial interests are safeguarded by the systems operated. Service users’ health and safety are protected by the systems in place. DS0000015911.V337493.R01.S.doc Version 5.2 Page 25 EVIDENCE: The registered manager for Goatacre Manor is Mrs Jane Swainson. She has worked at the home for a number of years, and was deputy matron prior to the retirement of the previous manager. Staff confirmed that they find the manager and senior colleagues approachable and helpful. Goatacre Manor has not yet fully implemented a quality assurance (QA) system. Various audits 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. This requirement has been unmet over a number of inspections. At the random inspection of December 2006, the manager explained that she had not been able to focus on the issue, due to prioritising action on complying with the HSE’s improvement notice. She indicated that quality assurance would be her next priority, and that she intended to have evidence of progress by the end of February 2007. However, this had not been achieved. It is now the service’s intention to develop a system in line with the guidance issued to providers by the CSCI about the Annual Quality Assurance Assessment (AQAA). This is a new statutory requirement for all registered care homes, following a recent amendment to Regulations. Goatacre Manor will have to provide this information to the Commission by the anniversary of this key inspection. Failure to do so will result in enforcement action. 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. Goatacre Manor 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 Manor 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. DS0000015911.V337493.R01.S.doc Version 5.2 Page 26 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. 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. There are systems for recording and reporting any problems that are noted. The home has its own maintenance team, who can give prompt attention to many tasks. Staff confirmed that they receive regular training and updates on various health and safety issues. An HSE improvement notice relating to reduction of risks from hot surfaces has been complied with. In most cases, this has been achieved by fitting suitable covers to radiators and exposed pipework. There are a few exceptions. Some radiators in corridors are positioned where fitting covers may reduce width and impede access for service users. These radiators have been isolated from the central heating system, and the plan is to remove them altogether. In a bathroom and two shower rooms radiators have not yet been covered. The alternative means of controlling the risk is to ensure that no service user accesses these areas unsupervised. The doors to the rooms have been fitted with bolts, and signs are in place to remind staff of the need for these to be closed every time the room is not in use. Risk assessments have been documented to cover these exceptions, and were updated following some feedback during this inspection. The home has now indicated that covers will be fitted in the bathroom and shower rooms to reduce risk still further. Decisions relating to the use of bed rails with service users are supported by relevant information in individual records. The home supplied evidence relating to 17 service users following a requirement of the random inspection in December 2006. All of these contained the minimum amount of information necessary to demonstrate reasons for the use of bed rails, and who had been involved in reaching the decision. Practice could be developed further, in line with relevant guidance from the Medicines & Healthcare Products Regulatory Agency (MHRA). Care should be taken to ensure consistent detail in documents for different service users. Examples of relevant content include when and how bed rails are to be used. Information about such issues varies in the records provided. Once assessment of a service user has identified the need for bed rails, documentation should also cover the suitability of the type used. Where DS0000015911.V337493.R01.S.doc Version 5.2 Page 27 possible, signatures should be obtained as evidence of consent or decision making. This includes any nurses involved in taking a collective decision. DS0000015911.V337493.R01.S.doc Version 5.2 Page 28 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 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 DS0000015911.V337493.R01.S.doc Version 5.2 Page 29 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 OP9 Regulation 12-1 13-2 Requirement Clear and objective guidelines must be available for the use of all ‘as required’ medications, to promote their consistent use. Timescale for action 02/05/07 2 OP29 19-9,10 Sch2-7 New employees must not 02/05/07 commence work in care positions until a satisfactory result has been received from a POVA First check. The persons registered must devise and implement an effective quality assurance system. (Timescale of 31/12/05 not met) COMMENT: This timescale has been extended to reflect that a new system is now available to the home, by which they can demonstrate compliance at their next regulatory contact. 02/05/08 3 OP33 24 4 OP29 7; 9; 19 Sch 2 Staff records must contain evidence that all required recruitment checks have been completed for all employees. 02/05/07 DS0000015911.V337493.R01.S.doc Version 5.2 Page 30 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 OP12 Good Practice Recommendations The content of the activities section of care plans should be developed, to support the provision of opportunities likely to be of benefit to each individual service user. Records relating to the use of bed rails should be reviewed and updated in line with the relevant good practice guidance of the MHRA. 2 OP38 DS0000015911.V337493.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000015911.V337493.R01.S.doc Version 5.2 Page 32 - 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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