Inspection on 11/06/07 for Godolphin House

This inspection was carried out on 11th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Godolphin House 09/06/09

Godolphin House 27/06/08

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

CARE HOMES FOR OLDER PEOPLE Godolphin House Godolphin House Godolphin Road Helston Cornwall TR13 8QF Lead Inspector Ian Wright Unannounced Inspection 08:30 11th and 12th June 2007 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 Godolphin House DS0000068601.V340495.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. Godolphin House DS0000068601.V340495.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Godolphin House Address Godolphin House Godolphin Road Helston Cornwall TR13 8QF 01326 572609 01326 569432 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) Ablecare (Helston) Ltd ****Post Vacant**** Care Home 31 Category(ies) of Dementia - over 65 years of age (5), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (5), Old age, not falling within any other category (31) Godolphin House DS0000068601.V340495.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include one named person under the age of 65 years. Date of last inspection Brief Description of the Service: Godolphin House is near the centre of the town of Helston. There is a bus which goes past the home to the centre of town. The home provides residential care for up to thirty-one elderly people, five of who may have a dementia or mental illness. The home also provides some day care. Accommodation is over 4 floors with a shaft and stair lift provided. There are two lounges on the upper ground floor and a small lounge on the lower ground floor. The home has three double rooms which can also be used for single occupancy. There is a small garden at the front and limited parking space at the back of the home. A copy of the inspection report was available in the hallway at the time of the inspection. The range of fees at the time of the inspection is £380-£525 per week. There are additional charges e.g. for chiropody and newspapers. Godolphin House DS0000068601.V340495.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced Key Inspection took place over nineteen hours over two days. All of the Key Standards were inspected. The methodology used for this inspection was: • To case track four people who use the service. This included interviewing the people who use the service about their experiences and inspecting their records. • Interviewing four staff about their experiences working in the home. • Informal discussion with other people who use the service and staff. • Observing care practices. • Discussing care practices with management. • Inspecting records and the care environment. Other evidence gathered since the previous inspection such as notifications received from the home (e.g. regarding any incidents which occurred) were used to help form the judgements made in the report. What the service does well: What has improved since the last inspection? What they could do better: This inspection has resulted in twelve statutory requirements. These requirements require suitable action to take place within the timescales set. The above average number of requirements on this inspection may be the result of there being a new provider, and management team in place, which are learning how to run the business and the regulatory issues involved. Godolphin House DS0000068601.V340495.R01.S.doc Version 5.2 Page 6 In summary; • Clarification is required from the registered provider regarding the needs of the people admitted to the service, to ascertain if the registered provider is only accommodating people who they are registered to provide care for. As a consequence management may need to be more careful regarding its assessment processes when admitting new people to the home. • All people who use the service need to have a contract / statement of terms and conditions of residency. • The medication system needs to be managed more effectively. • The recording of monies kept on behalf of people who use the service needs to be improved. • The adult protection policy and procedure needs improvement. • The Commission for Social Care Inspection must be notified of various incidents that affect people who use the service, as outlined in the regulations. • Staff recruitment checks need improvement; in particular procedures regarding Criminal Records Bureau checks. • Staff training still needs improvement. • The manager needs to submit an application to be registered with the Commission for Social Care Inspection. This will ensure there is a person legally responsible for the day-to-day management of the home. • Health and safety precautions need to be improved. The Commission will monitor compliance with the requirements set. 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. Godolphin House DS0000068601.V340495.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Godolphin House DS0000068601.V340495.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered provider has developed a statement of purpose and a service user guide. The statement of purpose needs to be updated and reflect the service provided. Although the service user guide is generally good, this needs to be issued to people who use the service, and/or their representatives. The registered provider has developed a contract / statement of terms and conditions of residency. However this documentation needs to be issued to people who use the service, and / or their representatives. The provision of suitable information ensures people who use the service are aware of the services the registered provider offers. This information also helps ensure people who use the service are made aware of their rights and responsibilities. The registered provider has a suitable assessment procedure. There is suitable evidence that people who use the service have been assessed appropriately before admission is arranged. However the registered provider must not admit people to live in the home outside agreed registration categories. This is because the registered provider is not registered to provide services for people outside what is listed on the registration certificate. Suitable assessment Godolphin House DS0000068601.V340495.R01.S.doc Version 5.2 Page 9 procedures ensure the registered provider only accommodates people who the provider can suitably meet their needs. EVIDENCE: The service user guide and statement of purpose were inspected. The documents were generally satisfactory. However only the documents relating to the current registered provider, with up to date information regarding the service, need to be available for inspection. Documents relating to the previous registered persons should not be on view and should be archived. The statement of purpose and service user guide also need to clearly state what service is provided to what service user group. The manager was not clear that the home could only admit five service users with dementia, and five service users with mental disorder (mental health problems). Subsequently, CSCI has asked the registered provider to check they have not admitted people to the service over and above what the home is registered for. The registered provider needs to provide the Commission with more information regarding current service users’ needs and diagnoses. The service user guide needs to be issued to people who use the service, and/ or their relatives. The registered provider has an assessment policy. There is satisfactory evidence that a senior member of staff has assessed the people who use the service, before admission was arranged (for example copies of pre admission assessments were available for inspection). Some of the people who use the service who the inspector spoke to, remembered a senior member of staff completing an assessment before they moved to the home. Some people who use the service said they were able to visit the home before moving in, and others said a relative visited on their behalf. In some cases a copy of a social services / health assessment has been obtained by the registered provider. The service does not provide intermediate care. Godolphin House DS0000068601.V340495.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is generally good. This judgement has been made using available evidence including a visit to this service. People who use the service have a generally satisfactory care plan for which there is suitable evidence of regular review. Suitable care plans help to ensure service users receive all the care they need for example in a consistent manner. There is suitable evidence that staff ensure health care needs are met. Some improvement is required to the medication system – for example regarding recording of administration- so people who use the service can be assured their medication is managed to a satisfactory standard. People who use the service said they felt staff worked with them in a manner, which respected their privacy and dignity, and this was also evident from the inspectors’ observations. EVIDENCE: Care plans for some people who use the service were inspected. These appeared to be satisfactory, and contained suitable information to assist staff to provide care. It would be useful if care plans had a brief history of the service user’s life (e.g. where did the person live? Do they have a family? Do they have any specific interests? What job did they do?). Records of opticians, Godolphin House DS0000068601.V340495.R01.S.doc Version 5.2 Page 11 doctors, and chiropody appointments are currently kept in the manager’s office. It would be helpful if this information is kept in the staff room with other care records so it is more readily available to care staff. Up to date manual handling risk assessments were not contained in people’s files- although the manager said this information is currently being updated and would be filed with care plans shortly. It is also important when care plans are reviewed, where possible the person who uses the service (and / or their representative), is consulted about the persons’ needs and wishes. Although some people who use the service did not appear to be aware of their care plans, all service users said the care they received was appropriate and carried out in a manner according to their wishes and needs. There was satisfactory evidence care plans are reviewed for most service users. Health care support appears to be satisfactory. People who use the service said they can see a doctor or other medical practitioner when this is necessary. The inspector spoke to a district nurse who said, in their view, care was satisfactory. The medication system was inspected. Medication is stored in locked cupboards and administered via a monitored dosage system. The operation of the system is only adequate. Several errors in the administration and recording of medication were noted during the inspection: • Dosages of medication administered to three service users were not signed for, although they appear to be administered. • Three dosages of medication for one service user had been taken from the blister pack, and were not accounted for. The manager asked some of the staff involved in the administration of the medication and they were unable to provide a reason for the absence of the medication. The manager said staff that administer medication have received training in this area. The majority of staff training records inspected had a copy of a training certificate regarding the administration of medication, completed in the last two years. People who use the service spoke positively regarding the attitude of staff, and said staff respected their privacy and dignity. People who use the service said staff always knock on their doors, and post is always received unopened. However the inspector raised concerns regarding the investigation of an adult protection issue, as outlined in the ‘Complaints and Protection’ section of this report. Godolphin House DS0000068601.V340495.R01.S.doc Version 5.2 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. 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. Routines are flexible to meet the needs of people who use the service. Some activities are offered. This ensures people who use the service can have a daily routine that suits their needs and have various opportunities for social activity. People who use the service have opportunity to have visitors and attend religious services so they can maintain some links with the wider community. People who use the service are encouraged to make choices regarding how they live their lives, and can maintain control over their financial affairs. Arrangements for meals are generally satisfactory although it is recommended the registered provider consults further regarding the choice of evening tea offered. People who use the service however have a varied and wholesome diet. EVIDENCE: The inspector was able to speak to many of the people who use the service. All said they could get up and go to bed when they wanted to, and that routines were not rushed. Some activities are available for example bingo, crafts, an exercise group and board games. The county council library visits the home. One service user has one to one outings with a member of staff, which she pays for in addition to her basic fee. The manager said occasional trips are also offered to other people who use the service. People who use the service said Godolphin House DS0000068601.V340495.R01.S.doc Version 5.2 Page 13 they did not feel obliged to participate in any organised activities and many are happy to spend time in their bedrooms reading or watching TV. People who use the service said they were able to receive visitors when they wished either in one of the lounges or in their bedrooms. Some service users said they participated in the monthly communion service, which takes place at the home. People who use the service said they felt they could exercise choice over their lives for example how to spend their time, what they could wear etc. Management look after some small amounts of money on behalf of people who use the service. Staff do not act as appointee for government financial benefits, for any of the people who use the service. Records are kept of fees paid to the registered provider. The registered provider, currently looks after no valuables belonging to people who use the service. Records of cash looked after on behalf of people who use the service need to be improved. For example although there are records of expenditure and money received kept, no balance is maintained for individual monies. This could subsequently result in errors which are difficult to trace. Where possible a signature should be obtained of the member of staff administering the money and the service user receiving any money. The manager said a new system is planned, but a column detailing the running balance needs to be implemented as an interim measure. People who use the service said they felt their personal belongings were safe, and said nothing that belonged to them had disappeared. The inspector shared a meal with some people who use the service. Food served was of good quality and there was a choice available of main course and sweet for people. This is excellent as there is often only a limited choice in many care homes. People who use the service all said they were generally satisfied with the food provided. They said there was always enough food and meals were well cooked. Several people who use the service expressed dissatisfaction with the recent change in how evening teas are organised. The inspector understands there used to be more or less unlimited choice of evening tea available, but management felt this had become too unwieldy to organise. As a consequence, there is now one hot option or a choice of sandwiches. Many of the people who use the service were unhappy with the sandwiches, and one person complained about other food provided at teatime. People who use the service said they did not feel adequately consulted about the changes. The inspector believes the food offered at teatime is satisfactory. However, the registered provider is advised to consult further regarding food provided at teatime, so people who use the service are happier with the food provided. Godolphin House DS0000068601.V340495.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered provider has a suitable complaints procedure, and any concerns or complaints appear to be managed effectively. This should ensure people who use the service can be assured any concerns or complaints are taken seriously and dealt with effectively. The registered provider must review and amend its prevention of abuse policy and procedure. Any allegations of abuse must always, in the first instance be reported to the Department of Adult Social Care (DASC), and CSCI must be informed. A suitable policy and procedure regarding adult protection will assist in ensuring people who use the service are protected against abuse and poor practice. EVIDENCE: The registered provider has a suitable complaints procedure. Except regarding the evening tea arrangement, people who use the service who spoke to the inspector had no complaints about the service they received. The registered provider has received one complaint since the last inspection in April 2006. From the discussion with the manager and documentation inspected, this appeared to be responded to appropriately. The registered provider has two policies regarding adult protection. One regarding abuse, and a second called ‘No Secrets’ (the name of government guidance). The policies should be streamlined into one, and it needs to be clear that in the event of any allegation, the matter is reported to the Department of Adult Social Care i.e. Cornwall Social Services (DASC) to lead the investigation. Godolphin House DS0000068601.V340495.R01.S.doc Version 5.2 Page 15 The inspector was concerned regarding the investigation of a recent incident of suspected abuse. The matter was not referred to DASC, as the lead agency. Similarly, the Commission for Social Care Inspection (CSCI) were not informed as required by the regulations. The manager however did investigate the matter, and has since forwarded information on to DASC and CSCI. The Commission accepts the registered provider was not aware of the correct procedures, although it is their responsibility to ensure they are so. Subsequently the registered provider needs to ensure their adult protection policy is updated and suitable training regarding local authority procedures takes place. The matter has now been referred to DASC, and a decision regarding the outcome of the investigation is outstanding at the time of writing. Staff were described as ‘kind’ by many service users, and the people the inspector spoke to said they were not aware of any poor or abusive practice. Staff the inspector spoke to also said practices within the team were to a good standard. Some staff have received training regarding the awareness and prevention of abuse. Godolphin House DS0000068601.V340495.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Godolphin House provides a suitable facility to provide care for elderly people. The building was clean, light, warm and well maintained at the time of the inspection. People who use the service can subsequently be assured that Godolphin House provides suitable facilities to meet their needs. EVIDENCE: The building was inspected. On the ground floor there is a large through lounge, which can be divided into two via a screen. There is also a smaller lounge on the lower ground floor. The home has a separate dining room on the ground floor. Toilet and bathroom facilities are suitable, for example, assisted bath facilities are available for people with mobility problems. The home has a lift which links the ground floor with the lower floors, and a chair lift which links the ground floor to the upper floor. Godolphin House DS0000068601.V340495.R01.S.doc Version 5.2 Page 17 There are two shared bedrooms (currently let as single bedrooms) and twentyseven single bedrooms. Three of the single bedrooms have an ensuite toilet and wash basin. There are suitable laundry and kitchen facilities. People who use the service were positive regarding the facilities provided. The building was clean and hygienic on the day of the inspection. The building appears to be generally well maintained, although some of the walls and doors are badly scuffed and will need to be redecorated shortly. The manager said the registered provider was planning this soon. Some of the corridors may prove to be confusing to people with dementia. When corridors are redecorated principles of design for people with dementia need to be considered. There are many publications available which would be useful for the registered provider to look at for example: Dementia Voice: http:/www.dementia-voice.org.uk/index.htm or the Dementia Development Centre Stirling: http:/www.dementia.stir.ac.uk/publications/design_housing.htm Other organisations may be able to offer assistance, or sell publications, which will offer advice regarding suitable design for homes for people with dementia. Godolphin House DS0000068601.V340495.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is generally adequate although recruitment checks are poor. This judgement has been made using available evidence including a visit to this service. Staffing levels in the home are currently satisfactory, although these should be kept under review as people become more dependant. Satisfactory staffing levels ensure people who use the service receive appropriate levels of support when they need it. Recruitment procedures, particularly in regard to Criminal Record Bureau checks, need considerable improvement so people who use the service can be assured they are in safe hands and protected at all times. Staff training requires some improvement so staff have appropriate knowledge and skills to support people who use the service. EVIDENCE: On the first day of the inspection the following staffing was provided: • • • • • • One One One One Two Two member of staff from 07:45 to 17:00 member of staff from 07:45 to 13:15 member of staff from 07:30 to 13:30 member of staff from 09:00 to 18:00 members of staff from 16:45 to 22:30 waking night staff from 22:30 to 08:00 In addition the manager, deputy manager and ancillary staff (maintenance, cooks, cleaners) were on duty. People who use the service were positive regarding the support they received from staff, and comments were made that Godolphin House DS0000068601.V340495.R01.S.doc Version 5.2 Page 19 staff were approachable and worked well as a team. Some comments were made that there should be more staff available in the afternoon and evening so staff could socialise more with people who use the service, and provide more activities. Staffing will most probably need to increase as the profile of the resident group becomes more dependent. It is therefore, at this stage, recommended staffing levels in the afternoon and evening are kept under review. This will ensure the needs of people who use the service continue to be met appropriately. The registered provider has a suitable approach to enabling staff to have the opportunity to obtain a national vocational qualification (NVQ) in care. The preinspection questionnaire stated that in May 2007 84 (16 out of 19) care staff had at least an NVQ 2 in care. Recruitment checks completed when staff are employed are poor. The records of twelve care staff (i.e. all the staff on duty on 11th June 2007) were inspected. The records of four other staff who have commenced employment since December 2006 were also inspected. Records show the majority of staff have, on file, proof of identification, an application form, and records regarding training received. However there appears to be significant problems with procedures regarding criminal record checks: • One member of staff who had recently been employed did not have a Protection of Vulnerable Adults ‘First’ (POVA First) check, and subsequent Criminal Records Bureau (CRB) check, but was working unsupervised. The person only had one written reference. • A second member of staff only had a CRB check from a previous job. Although this was dated March 2007, these checks are not transferable between employers. • Three domestic staff who commenced employment since April 2007 did not have a POVA First check and it was not clear if CRB checks have been applied for. • One member of staff has a police caution. The manager has said, because of the circumstances of this, it was decided not to dismiss the person. However there does not appear to be any notes of a formal meeting to discuss the matter with the person, or a subsequent risk assessment. As a consequence an immediate requirement has been issued to ensure the registered provider ensures any new staff have a POVA First check before they commence employment, an assessment is made regarding the suitability of the person with a criminal conviction, and all staff have a CRB check completed. The registered provider must also inform the Commission of what supervision arrangements will be put in place regarding staff who do not have a satisfactory CRB disclosure. Confirmation regarding these matters must be made in writing to the Commission for Social Care Inspection as soon as possible. Godolphin House DS0000068601.V340495.R01.S.doc Version 5.2 Page 20 Training records were also inspected for the twelve staff. By law all staff must have: • Regular fire training in accordance with the requirements of the fire authority • There must always be at least one first aider on duty (at appointed person level). • All staff must have manual handling training. • All staff must have basic training in infection control. • If staff handle food they must receive training regarding food hygiene. • All new staff must have an induction and there should be a record of this. There are some gaps in training required by regulation. For example: • Fire Training. There were records that some staff received fire training in the autumn of 2006, although some staff did not appear to have received this training at all. • First Aid. No staff in the sample group appeared to have a first aid certificate. There was for example no first aider on duty at night. • Manual Handling. Some staff had last received this training in 2005 or 2006. Some staff had only received this training in 2002 or 2004. Some staff did not appear to have received any training in this area. • Infection control. Approximately half the sample group appeared to have received this training in 2006. Other staff do not appear to have received this training. • Food hygiene. Approximately half the sample group received this training in July 2006. The other half of the group had not appeared to have received this training. The manager said fire, first aid training, and manual handling training would be completed shortly. The registered provider has said some staff were completing first aid training on the day of the inspection, and manual handling training for some staff was to be completed the day after the inspection. One recently employed member of staff said they had received two days induction when they started to work at the home. Most recently employed staff have a record of their induction. A checklist was absent for one member of staff, although the manager said this would be with the person’s supervisor as it was in the process of completion. The registered provider is currently designing a new induction handbook which looks comprehensive. Records show three of the sample group have received training regarding dementia. The manager said other staff would receive this training shortly. However no training appears to have occurred regarding mental disorder and this needs to be arranged. The manager said staff have recently had training regarding care planning. Records also show that some staff have also had training regarding diabetes, and health and safety. Godolphin House DS0000068601.V340495.R01.S.doc Version 5.2 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 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 adequate. This judgement has been made using available evidence including a visit to this service. Management arrangements currently do not meet regulatory requirements. The registered provider must ensure an application for a registered manager is submitted to the Commission for Social Care Inspection, as a matter of priority, so this can be determined. Having an approved registered manager in charge of the home will ensure there is a legally accountable person managing the home on a day to day basis. There is a quality assurance system in place which should help to ensure the views of people who use the service are considered when developing service improvement. The management of monies of people who use the service needs some improvement so monies are accounted for appropriately. Health and safety precautions, although adequate, need some improvement so service users can be assured they live in a safe environment. Godolphin House DS0000068601.V340495.R01.S.doc Version 5.2 Page 22 EVIDENCE: The registered provider Ablecare (Helston) Ltd took over the ownership of the home in December 2006. The director of the company Mr J McInulty lives on the premises but was away when this inspection took place. The registered manager’s post is currently vacant, although Ms. Denise Matthews is currently the acting manager. Mrs Matthews has said she intends to apply to the Commission for Social Care Inspection to register as the manager of the home. As the registered provider has not had a registered manager since December 2006, the application needs to be forwarded to the Commission as a matter of priority. The registered provider has a quality assurance policy, which appears to be satisfactory. A survey of the views of people who use the service took place in 2006 and appears to be positive. Three staff meetings have so far occurred in 2007. There are the results of financial investment in the home for example new kitchen equipment, and several of the bedrooms have been redecorated. There are further plans to redecorate the hallways, and install a new lift. It is recommended, as part of the quality assurance process, that an annual development plan is set up (for example to address matters raised in CSCI inspection reports and any planned developments regarding the service). Policies and procedures need to be reviewed and for example should include details of the new registered provider. Details regarding updating the statement of purpose, and adult protection policies are outlined earlier in this report. Policies should also have details of the CSCI office now this is situated in Devon. Management of the monies of people who use the service is generally adequate. Improvement however is required to the financial records of people who use the service, as outlined under NMS 14. The registered provider has a satisfactory health and safety policy. Fire equipment appears to be checked and serviced regularly. There is a suitable fire risk assessment. A gas safety certificate was obtained in November 2006 and these appliances appear to be safe. There appears to be a suitable policy regarding the prevention of legionella, and a schedule of testing to prevent legionella, is in place. Health and safety risk assessments are satisfactory. However some improvement regarding health and safety precautions needs to take place: • Training in various aspects of health and safety need to take place so the registered provider meets legislative requirements (e.g. moving and handling training, fire training). This is outlined in the previous section of the report. Godolphin House DS0000068601.V340495.R01.S.doc Version 5.2 Page 23 • • • • Some action is required to ensure the passenger lift meets legal requirements, as outlined in the service report dated January 2007. Testing of the electrical hardwire circuit occurred in May 2005 (as outlined in the previous inspection report). However the certificate for this must be available for inspection. If this cannot be found a duplicate should be obtained. Portable electrical appliance testing needs to take place at intervals determined by Environmental Health and the Health and Safety Executive. Records regarding the servicing of hoists, specialist baths etc. need to be available for inspection. Godolphin House DS0000068601.V340495.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 1 2 3 2 3 X 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 1 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X 2 X X 2 Godolphin House DS0000068601.V340495.R01.S.doc Version 5.2 Page 25 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 OP1 Regulation 4, 5, 6 Requirement The registered person shall— (a) Keep under review and, where appropriate, revise the statement of purpose and the service user’s guide; and (b) Notify the Commission and service users of any such revision within 28 days. (c) Ensure a copy of the statement of purpose and service user guide are supplied to the Commission and each service user. 2. OP2 5 The registered person shall supply to the service user and / or their representatives: (a) A description of the services offered by the care home to service users; (b) The terms and conditions in respect to services and accommodation DS0000068601.V340495.R01.S.doc Timescale for action 01/09/07 01/09/07 Godolphin House Version 5.2 Page 26 (c) (d) provided Details of total fees (i.e. as outlined in the regulations.) A standard form of contract for the provision of services and facilities by the registered provider to service users. A copy of this information must be kept on individual service user files. 3. OP1 OP3 OP4 4, 12, 14 The registered person shall ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users. The registered person shall not provide accommodation to service users unless their needs have been assessed by a suitably qualified or suitably trained person. ( For example: (a) Accommodation and care must only be provided to the type and number of service users as outlined on the CSCI registration certificate. (b) The registered provider must provide to CSCI a list of the current service users outlining their needs and diagnoses at the time of admission to the home.) 4. OP9 13(2) The registered person shall make 01/08/07 arrangements for the recording, handling, safekeeping, safe administration and disposal of DS0000068601.V340495.R01.S.doc Version 5.2 Page 27 01/08/07 Godolphin House 5. OP14 OP35 12(1) 13(6) 6. OP18 10(1) 12(1) 13 medicines received into the care home. (For example medication must always be signed for when administered, and medication administered / disposed of must always be accounted for). The registered person shall 01/09/07 ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users. (For example accurate and auditable records of monies maintained on behalf of service users must be maintained) The registered person shall 12/06/07 ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users. (For example: 1. The adult protection policy must be updated to reflect guidance issued by the Department of Health ‘No Secrets’ and the local authority. 2. Any allegation of abuse must be reported to the local authority, who as outlined in their guidance, in the first instance will act as the lead agency to investigate any allegations. Other agencies such as the police may need to be involved. 3. Any staff accused of abuse may need to be suspended on full pay during the course of the investigation. Such a decision needs to be made in liaison with the registered provider’s legal advisors and the statutory agencies involved). DS0000068601.V340495.R01.S.doc Version 5.2 Page 28 Godolphin House 7. OP18 10(1), 12, 13, 37 Immediate Requirement The registered person shall give notice to the Commission without delay of the occurrence of matters listed in the regulation such as: 1. Any event in the care home which adversely affects the well-being or safety of any service user; 2. Any allegation of misconduct by the registered person or any person who works at the care home. Any notification made in accordance with this regulation which is given orally shall be confirmed in writing. 01/08/07 8 OP29 18. 19 The registered person shall not employ a person to work at the care home unless the person is fit to do so. Satisfactory checks must be completed on the person to ascertain this. (For example two written references, a Protection of Vulnerable Adults ‘First’ check, a Criminal Records Bureau check etc. as outlined in Schedule 2 of the Care Homes Regulations 2001). Immediate Requirement The registered provider must inform the Commission in writing as soon as possible what supervision arrangements will be put in place for staff who do not have a satisfactory CRB disclosure. 12/06/07 9 OP29 18. 19 The registered person shall not employ a person to work at the DS0000068601.V340495.R01.S.doc 12/06/07 Godolphin House Version 5.2 Page 29 care home unless the person is fit to do so. For example staff must be of integrity and good character. (For example the registered provider must investigate the suitability of the employment of an employee after CSCI raised concerns regarding an undeclared criminal conviction on the persons CRB Disclosure). The registered provider must inform the Commission in writing, as soon as possible, what action will be taken once the investigation is complete. Immediate Requirement 10. OP29 18. 19 The registered person shall ensure that persons employed to work at the care home receive training appropriate to the work they are to perform. This must include suitable assistance, including time off, for the purpose of obtaining further qualifications appropriate to such work. (For example such training must include training: • As required by regulation such as infection control, food hygiene and first aid. • Regarding dementia and mental disorder • Fire training and manual handling training as required by regulation.) The registered provider shall appoint an individual to manage the care home where— (a) There is no registered manager in respect of the care home; and (b) the registered provider (i) is an organisation or DS0000068601.V340495.R01.S.doc 01/01/08 11. OP31 7, 8, 9 01/08/07 Godolphin House Version 5.2 Page 30 12. OP38 13, 23 partnership; is not a fit person to manage a care home; or (iii) is not, or does not intend to be, in full-time day to day charge of the care home. The registered person shall ensure that— (ii) (a) All parts of the home to which residents have access are so far as reasonably practicable free from hazards to their safety; Unnecessary risks to the health or safety of residents are identified and so far as possible eliminated. The premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally; Equipment provided at the care home for use by residents or persons who work at the care home is maintained in good working order; 01/09/07 (a) (c) (d) (For example there must be: (1) Evidence portable electrical appliances are regularly tested. Evidence of this must be forwarded to the commission. (2) Evidence the passenger lift is maintained and meets legal requirements. Evidence of this must be forwarded to the Godolphin House DS0000068601.V340495.R01.S.doc Version 5.2 Page 31 (3) commission. Records regarding the servicing of equipment is available for inspection. 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 OP15 OP19 OP27 OP33 Good Practice Recommendations The registered provider should consult further with people who use the service regarding food offered at tea times. The registered provider should bare in mind principles of dementia design when undertaking any refurbishment and redecoration of the home. Keep under review staffing levels in the afternoon and evening to ensure they meet the needs of the people who use the service. Set up an annual development plan as part of the quality assurance process. Godolphin House DS0000068601.V340495.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Devon Office Unit D1 Linhay Business Park Ashburton Devon TQ13 7UP 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 Godolphin House DS0000068601.V340495.R01.S.doc Version 5.2 Page 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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