Inspection on 26/05/05 for Goatacre Manor Care Centre

This inspection was carried out on 26th May 2005.

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 02/05/07

Goatacre Manor Care Centre 12/05/06

Goatacre Manor Care Centre 11/11/05

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 26th May 2005 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. Goatacre House D51_S15911_GOATACRE_v210488_260505_Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Goatacre House Address Goatacre Lane Goatacre Wiltshire SN11 9JA 01249 760464/454 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) Mr John ODea Mrs Marion Georgina Stanford-Mepstead Care Home 42 Category(ies) of OP Old age (42) registration, with number PD Physical Disability (3) of places TI Terminally Ill (3) Goatacre House D51_S15911_GOATACRE_v210488_260505_Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. No more than 3 persons in receipt of terminal care at any one time 2. No more than 3 physically disabled residents in the age range 18-64years at any one time 3. No more than 42 persons over the age of 65 years requiring nursing care Date of last inspection 2nd December 2004 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 D51_S15911_GOATACRE_v210488_260505_Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in May 2005. The lead inspector was accompanied for part of the day by the pharmacist inspector, who checked medication systems and practice. A total of 7 hours were spent in the home. The following inspection methods have been used in the production of this report: indirect observation; sampling of records, with case tracking; sampling a meal; discussions with service users, visitors, staff and management; tour of the premises. What the service does well: The needs of service users are assessed and planned for, from the preadmission stage onwards. Systems ensure that all required areas are considered. Arrangements for health care are particularly effective. People can be supported with all such needs, including during terminal illness. The home works well on the key topic of moving and handling. There are detailed risk assessments and guidance for staff, and a range of suitable equipment. Some team members are the lead specialists for this issue, and arrange the training for their colleagues. Goatacre provides a pleasant environment. The home is in an attractive situation. Internally, it is well furnished and maintained. There is an ongoing programme of refurbishments and improvements. For instance, some bedrooms and shower facilities were being upgraded around the time of this inspection. Food provided in the home has been seen to be of consistently good quality over a number of inspections. Choice is available. Special dietary needs can be catered for. 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. There is a stable staff team, with a well established core of people, providing consistency and continuity. A range of posts ensure that all the various aspects of the day-to-day running of the service are covered. Staff display appropriate attitudes towards service users, with warm, friendly, respectful interactions being observed. Goatacre House D51_S15911_GOATACRE_v210488_260505_Stage4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: 3 requirements were unmet from the previous inspection. 2 of these related to areas of cleanliness and décor. The laundry room floor and walls need attention, to ensure that surfaces are impermeable and easily cleanable. The kitchen floor needs to be made good, ensuring that it too can be effectively cleaned. Both measures need addressing, to ensure that no infection control risks develop. The other outstanding requirement was for implementation of a quality assurance system. Work is ongoing towards this, but no evidence has yet been generated. It was recommended that the home should begin implementation of some sections of the overall system, to demonstrate initial compliance, rather than continuing to delay whilst trying to devise the overall approach. Activities staff are provided, but the home needs to give a further commitment to developing practice in this area. More resources, equipment and training would help to support such development. Goatacre House D51_S15911_GOATACRE_v210488_260505_Stage4.doc Version 1.30 Page 7 Some health and safety topics need attention. 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. Uncovered radiators, which are not of a guaranteed low surface temperature design, must be risk assessed, and, if necessary, replaced or covered in order of priority. Medication records need to be stored securely, to ensure that appropriate confidentiality is maintained. Some service user care plan areas should be developed to include more specific detail about the actual support that staff are required to give. 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 D51_S15911_GOATACRE_v210488_260505_Stage4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Goatacre House D51_S15911_GOATACRE_v210488_260505_Stage4.doc Version 1.30 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 standard(s) 1, 3 & 4 Information for prospective service users is in place. Some further attention to the relevant documents should assist people in making an informed choice about the home. Prospective service users have their needs assessed, and can enter the home knowing that these will be met. EVIDENCE: The Statement of Purpose and Service User Guide have been reviewed, and made more specific to the home. All required pieces of information are included. But there could be greater detail about the arrangements for consultation with service users. Developing this aspect would also help with inclusion of their views in the Guide. Goatacre House D51_S15911_GOATACRE_v210488_260505_Stage4.doc Version 1.30 Page 10 The matron or one of her nursing colleagues 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. If applicable, relevant information is also obtained from other sources. Goatacre provides for a wide range of needs amongst its service user group. Staff have a variety of knowledge and experience. They continue to receive further relevant training. Advice and support is accessed from various local health professionals, as required. The home also has a range of equipment suitable to the needs of its users. Goatacre House D51_S15911_GOATACRE_v210488_260505_Stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 & 11 Service users’ assessed needs are clearly documented in their care plans, and kept under review. Some records need more detail about required actions from staff, to ensure that those needs are supported effectively. Service users’ health care needs are assessed, monitored, treated and reviewed. The systems for the safe handling of medication in the home are good. Service users’ medication needs are met. Medication records were not stored securely, creating a risk that visitors may have inappropriate access to confidential information. Service users have their privacy and dignity respected. Care for terminally ill service users is delivered appropriately and respectfully. EVIDENCE: Goatacre House D51_S15911_GOATACRE_v210488_260505_Stage4.doc Version 1.30 Page 12 Sampled care plans covered all required areas. Recording systems enabled clear tracking of any issues arising, so it could be seen that appropriate steps were taken in response to these. There was clear evidence of regular and meaningful review of care. The sampled plans varied in the level of detail about the actions to be taken to support areas of need. Some were of good quality, setting out clear instructions, along with the reasons for these. Others gave no specific information. For instance, a plan for personal care simply stated that the service user was to be assisted with washing and dressing, without describing how. Some plans had been pre-printed, with the person’s name then inserted. So the individual relevance was not fully established. Evidence of health care support was good. The actions of the home’s own nursing and care team were clearly shown. It was also apparent that there is regular input from GPs and other relevant health professionals. The medication is all kept in secure locked storage. Medical information was readily available to nurses when administering the drugs. All relevant records were maintained. Medication administration charts were clear, with photographs to aid recognition. But some creams were not regularly recorded as used. The drug trolleys are positioned in public areas, and although the medicines are secure, the records were not. It was observed that staff provided personal care to users sensitively and respectfully. There was warm and friendly interaction amongst people. Service users’ spiritual needs are highlighted in their records. Church services are held in the home. People with particular religious views are enabled to express these in line with their own preferences. Care for frail and terminally ill service users is clearly set out. Records showed evidence of frequent and appropriate input from GPs. People’s own wishes about care at this time were also documented and observed. Goatacre House D51_S15911_GOATACRE_v210488_260505_Stage4.doc Version 1.30 Page 13 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, 13, 14 & 15 Service users’ expectations and preferences in social and recreational needs are not being fully met. Service users are able to maintain important relationships and community contacts. Service users can exercise choice and control in various aspects of their daily lives. Service users are provided with meals of appropriate quality and variety. EVIDENCE: The home employs 2 staff to lead on the provision of activities. A recent celebration had been held to mark VE day, and outside entertainment had been brought into the home on some other occasions. Trips out for groups of service users, enabled by hiring a specially adapted coach, are held once a year. At Goatacre itself, a weekly programme of activities is drawn up. Service users confirmed that the sessions provided include carpet bowls, bingo, Goatacre House D51_S15911_GOATACRE_v210488_260505_Stage4.doc Version 1.30 Page 14 quizzes, art and craft, and cooking. As well as small group activities, the relevant staff spend time in one to one conversation with some individuals. But on the day of this inspection no meaningful activity was observed to be taking place. Instead, service users and staff expressed frustration that progress is held back by a lack of suitable resources. The difficulty of engaging some people in any kind of activity indicates the need for the relevant staff to have specific training. Appropriate equipment should be provided. A suitable space in which to carry out some group sessions would also be an advantage. Overall, a deeper commitment to this area would make better use of the staff hours allocated to it. There are no restrictions on visiting, unless requested by the service user. Most people have some contact with family or friends. Visitors were coming and going regularly on the day of this inspection. People could choose whether to receive guests in communal areas, or in their own rooms. One relative was present during mealtime, to assist their family member. The home was just implementing a new computerised system for visitors to log in and out of the building, via a touch screen facility. Service users are able to choose how to spend their time. They were seen to be confident in expressing their wishes. Staff took note of these, and acted accordingly. Individual needs and preferences were set out in sampled records, with a focus on issues of particular importance to each person. Formal arrangements for consultation were also being addressed, with the reinstatement of a residents’ group. 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 set 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. Goatacre House D51_S15911_GOATACRE_v210488_260505_Stage4.doc Version 1.30 Page 15 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 & 17 Suitable procedures and systems are in place to respond to any complaints received. There is a documented commitment to the upholding of service users’ rights. EVIDENCE: A suitable complaints procedure is in place. It is prominently displayed in the entrance hallway, and includes contact details for the CSCI. No complaints about the home have been received over the period since the last inspection. There is also a suggestion box which can be used by anyone wishing to make comments. Service users are registered on the electoral roll. Most exercise the option to have a postal vote. Many individuals are supported by family or legal representatives in the management of their affairs. Goatacre House D51_S15911_GOATACRE_v210488_260505_Stage4.doc Version 1.30 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 standard(s) 19, 20, 21, 22, 23, 24 & 26 Service users’ individual and communal accommodation is homely and comfortable. Service users have suitable adaptations and equipment to promote their independence and quality of life. 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. EVIDENCE: Goatacre House D51_S15911_GOATACRE_v210488_260505_Stage4.doc Version 1.30 Page 17 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. 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. An ongoing refurbishment programme was continuing around the time of this inspection. Some new curtains had just been fitted. Some bedrooms were being upgraded, and some bathrooms converted into showers. 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. Space is limited. 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. Records demonstrated that relevant professionals are involved in assessments to identify suitable equipment. 2 carers lead on manual handling training. This includes teaching people how to use the various equipment available. Hoists were observed being used appropriately during this inspection visit. Sampled records showed that service users have detailed individual risk assessments for moving and handling. The laundry room has been redecorated over the past year, but some issues remained in need of attention. Part of the floor surface was bare concrete, and therefore not impermeable. The wall surface had areas of flaking paintwork, exposing plaster. There was also no seal between the floor and wall behind pipework. The kitchen floor needs the current covering to be made good, or replaced if this does not prove possible. It is noticeably stained in places, particularly in the corner by the dishwasher, where there are patches of discolouration from rusting parts of the appliance. Substantial efforts had been made to remove these, and they were less prominent than at the previous inspection. But they were still clearly visible. Secondly, there are still breaks in the floor cover in the opposite corner, where posts have previously been removed. Goatacre House D51_S15911_GOATACRE_v210488_260505_Stage4.doc Version 1.30 Page 18 Goatacre House D51_S15911_GOATACRE_v210488_260505_Stage4.doc Version 1.30 Page 19 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 Service users are supported by staffing arrangements suitable to meet their needs. Service users are protected by effective recruitment practices. EVIDENCE: Goatacre House D51_S15911_GOATACRE_v210488_260505_Stage4.doc Version 1.30 Page 20 Goatacre is registered to provide nursing care, so qualified nursing staff must be on duty at all times. They are supported by carers. Levels vary slightly, depending on the service user occupancy. Staff are deployed to either end of the home. A nurse oversees each group. A senior carer will allocate carers to service users. Carers usually work in pairs, because most residents need two people for support with personal care. People may also be assigned to work one to one, if an individual has specific needs. Overnight cover is provided by waking staff. Some qualified nurses are recruited from overseas. Where necessary, they undertake adaptation training so that their qualification is recognised in the UK. Such nurses work as carers until this process has been completed. The home generally enjoys 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. Sampled staff records for recent appointments showed that all required recruitment checks are completed before new starters take up their posts. The process, and likely timescale, is made clear to all applicants. Goatacre House D51_S15911_GOATACRE_v210488_260505_Stage4.doc Version 1.30 Page 21 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) 31, 33, 37 & 38 The registered manager is a fit person to be in charge of the day-to-day running of the 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’ best interests are upheld by appropriate systems for required areas of record keeping. Most health and safety issues are addressed, promoting service users’ welfare. But some topics need further attention, to ensure that no individual is placed at risk of harm. EVIDENCE: The matron, Marion Mepstead, is the registered manager of the home. She has relevant nursing qualifications in the care of the elderly, allied to extensive Goatacre House D51_S15911_GOATACRE_v210488_260505_Stage4.doc Version 1.30 Page 22 experience in various health care settings. She is also now completing the NVQ Level 4 management qualification. Another senior nurse at the home is also undertaking this course. The matron is supported by nursing colleagues. The home also employs administrative staff who take on various areas of responsibility. The home’s registered provider has regular contact with the service. Goatacre House has not yet fully implemented a quality assurance system. A management consultant is assisting the matron and her deputy 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 was yet available to demonstrate how these sources are collated, to produce a quality audit report, and a service development plan. A number of statutorily required records were checked, and were seen to be well maintained. 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. Goatacre House D51_S15911_GOATACRE_v210488_260505_Stage4.doc Version 1.30 Page 23 The fire log book was inspected. All required checks and instructions were recorded as being carried out, and up to date. Training is carried out each quarter, as required. The system has been devised so that a range of topics are covered, using a variety of approaches. A fire system test was carried out during the inspection, with a prompt response from all staff on duty. Various health and safety training was being arranged for all staff. Much of this would be done with the use of videos and associated resources, that had recently been purchased. There are four trained first aiders amongst the staff team. Relevant equipment is sited at various points around the home. Central heating is supplied 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. There is a system in place at the home to minimise risk. All radiators can be individually temperature controlled by a thermostatic valve. It is the responsibility of staff to check these regularly, and ensure that they are not set too high. A monitoring schedule is in place. But care home standards for older people require that radiators are either covered, or of a guaranteed low surface temperature. If this is not done, service user safety must be demonstrated by individual documented risk assessments for any affected radiators. These must take into account environmental factors, such as location; and relevant service user factors, such as the needs and preferences of a room’s occupant. Where risk assessment indicates that a radiator must be replaced or covered, this must be actioned in order of priority, and in a suitable timescale. A sampled file for a service user who had bed sides fitted contained a care plan stating that these were necessary. But there was no full risk assessment to support this judgement, or set out how they were to be used. There was also no documented evidence of consent. Goatacre House D51_S15911_GOATACRE_v210488_260505_Stage4.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 x 2 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 x 3 x 2 x x x 3 2 Goatacre House D51_S15911_GOATACRE_v210488_260505_Stage4.doc Version 1.30 Page 25 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 OP9 Regulation 13(2); 17(1)(b), Schedule 3(3)(i) 12(1) & (3); 16(2)(m) & (n) Requirement All records relating to service users medication must be kept securely within the home. The persons registered must ensure the provision of activities suited to service users expectations, preferences and capacities. Laundry floor and wall finishes must be impermeable and readily cleanable. (Timescale from 29/04/04 partly met) COMMENT: The area has been redecorated since this requirement was originally set. But problems remained 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) COMMENT: Efforts to clean the floor had not removed deep staining. Breaks in the surface remained as previously seen. The persons registered must D51_S15911_GOATACRE_v210488_260505_Stage4.doc Version 1.30 Timescale for action From 26/05/05. Review and action plan to be completed not later than 31/07/05. Not later than 31/07/05 2. OP12 3. OP26 13(3); 16(2)(j); 23(2)(d) 4. OP26 13(3); 16(2)(j); 23(2)(d) From 26/05/05. 5. OP33 24 Quality Page 26 Goatacre House devise and implement an effective quality assurance system. (Timescale of 31/03/05 not met) COMMENT: The home is implementing a recognised scheme, but had no evidence available as yet of how this was being applied. The persons registered must ensure that documented risk assessments, and written evidence of consent, are in place for any use of bed sides. There must be an individual documented risk assessment for all remaining uncovered radiators. Following risk assessment of uncovered radiators, suitable actions must be taken where identified as necessary. audit and development plan to be produced not later than 30/11/05. From 26/05/05. 6. OP38 12(1), (2) & (3); 13(7) & (8) 13(4) 7. OP38 Not later than 31/07/05. Not later than 30/09/05. 8. OP38 13(4) 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 OP1 Good Practice Recommendations The Statement of Purpose, and Service User Guide, should include more detail on arrangements for consultation with service users and others. Consideration should also be given to producing the Guide in accessible formats. Care plans should all include appropriate detail about the actions necessary to support the assessed needs of service users. A system should be adopted that records the use of nonmedicated creams. Consideration should be given to storing of drugs away from communal areas for service users. COMMENT: This would enhance the homely feel of these areas, and may also help to address the requirement about secure storage of records. Goatacre House D51_S15911_GOATACRE_v210488_260505_Stage4.doc Version 1.30 Page 27 2. 3. 4. OP7 OP9 OP9 5. OP19 Consideration should be given to identifying more suitable locations for the nurses’ station, and matron’s office. COMMENT: Proposals for a future extension of the property will include steps to address this. Implementation of the quality assurance system should be introduced on a phased basis. Photographic proof of identity should be retained on employee files. COMMENT: A new computerised system of staff records is being implemented, that includes the option to attach a scanned photo to each employees file. 6. 7. OP33 OP37 8. Goatacre House D51_S15911_GOATACRE_v210488_260505_Stage4.doc Version 1.30 Page 28 Commission for Social Care Inspection Avonbridge House Bath Road Chippenham SN165 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 D51_S15911_GOATACRE_v210488_260505_Stage4.doc Version 1.30 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!