Inspection on 27/06/08 for Godolphin House

This inspection was carried out on 27th June 2008.

CSCI found this care home to be providing an Adequate service.

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 11/06/07

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Godolphin House 42 Godolphin Road Helston Cornwall TR13 8QF Lead Inspector Ian Wright Unannounced Inspection 27th June 2008 08:00 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.V363480.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.V363480.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Godolphin House Address 42 Godolphin Road Helston Cornwall TR13 8QF 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) 01326 572609 01326 569432 Ablecare (Helston) Ltd Mrs Denise Matthews 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.V363480.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home providing personal care only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP - maximum 31 places Dementia aged 65 years and over on admission - Code DE(E) maximum 5 places Mental disorder, excluding learning disability or dementia, aged 65 years and over on admission - Code MD(E) - maximum 5 places The maximum number of service users who can be accommodated is 31. 11th June 2007 2. 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 £308-£525 per week. There are additional charges e.g. for chiropody and newspapers. Godolphin House DS0000068601.V363480.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced key inspection took place over ten hours in 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 three care staff about their experiences working in the home. • Informal discussion with staff and other people who use the service. • 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 eight statutory requirements. Action regarding these legal requirements is required within the timescales set. In summary, requirements have been made regarding: • The provision of terms and conditions of residency / contracts for people who use the service. • Pre admission assessment procedures. Godolphin House DS0000068601.V363480.R01.S.doc Version 5.2 Page 6 • • • • • • Care planning. The medication system. Adult protection policies and procedures. The storage and recording of valuables belonging to people who use the service. Staff training, and to develop an ongoing training programme so staff receive health and safety training required according to the law and needs of people who use the service. Quality assurance systems so there are not shortfalls regarding the above matters. The commission will monitor the registered persons to ensure satisfactory improvements are achieved. 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.V363480.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.V363480.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): 2, 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information provided to people who use the service (e.g. statement of terms and conditions of residency / contract) needs some improvement (i.e. the registered persons need to check everyone has received the information, and issue it as necessary). Pre admission assessment procedures are generally satisfactory, although some improvement is required regarding documenting assessments. These measures will ensure people who use the service, and their representatives, can be assured they will receive satisfactory information regarding their rights and responsibilities, and they can be assured a suitable pre admission assessment process is in place. EVIDENCE: Most people who use the service have been issued with a statement of terms and conditions of residency / contract. Copies of this documentation are available on the files of most people who use the service. However this information was absent for at least one person. The registered persons’ need to check with people who use the service / their next kin to ascertain they Godolphin House DS0000068601.V363480.R01.S.doc Version 5.2 Page 9 have received appropriate information. The registered persons subsequently need to issue this information as necessary. The registered persons have an assessment policy and this is satisfactory. Copies of pre admission assessments were contained on the files of most people living in the home. One person, who we case tracked, came from out of county. Although the previous care provider provided information, this appeared to only be provided on the day before admission. It is not clear how the registered persons made the decision they could meet the person’s needs. The registered manager said initially day care was provided for the person, and information was obtained from the previous residential placement. The assessment process however should have been thoroughly documented, and kept on file. Godolphin House DS0000068601.V363480.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 adequate. This judgement has been made using available evidence including a visit to this service. Health and personal care standards are generally satisfactory, although some improvement is required to care planning and the management of medication. People who use the service and their representatives said they were happy with the care provided. EVIDENCE: Care plans for some people who use the service were inspected. These are basic, but the registered persons are in the process of introducing a new system which is more comprehensive. The care plan of at least one person did not reflect their current needs. It was subsequently suggested to the registered persons that the development of a new care plan for people, whose needs have significantly changed, are prioritised. There seems a satisfactory process of review of care plans. Care plans need to have more detailed information regarding medical interventions (e.g. chiropody, dentist, optician, CPN etc.) However, the new care planning system being introduced will have this information. Godolphin House DS0000068601.V363480.R01.S.doc Version 5.2 Page 11 The people who use the service, who the inspector spoke to, said they were not aware they had a care plan, and could not remember being involved in the drafting, or review of their care plans. However everyone, who the inspector spoke to, said they thought the care provided was good. If people who use the service are not involved in their care planning, the registered persons should consider increasing the participation of people who use the service e.g. via a ‘Keyworking system’ particularly when the new system is introduced. Health care support appears to be satisfactory. People who use the service said they had access to relevant external professionals when necessary. The registered manager said no people who use the service currently had pressure sores. The inspector spoke to one district nurse who had no concerns regarding health care in the home. She said the home provided a ‘stimulating environment’ for the people who use the service, and staff always take appropriate action when the district nurses advise them to do something. The medication system was inspected. The medication is now stored in a dedicated medication room, and is stored in locked cupboards and a trolley. Medication is administered via a monitored dosage system. Despite a requirement issued at the previous inspection on 11th June 2007 improvements to the operation of the system are still required: • The medication room needs to be locked. The room is currently accessible to all, and some medication was not locked away, and it was possible to access medication records while staff were not present. • There were some dosages of medication which were signed for but did not appear to be administered. • Some medication was not recorded on medication sheets. • The registered persons need to thoroughly audit the current stock of medication. Some stock items were out of date, some medication did not have a label, and there is some over supply of medication. Some medication appears to need to be returned to the pharmacist • It is recommended a running total is kept of the stock of some medication e.g. Diazepam and Lorazepam. Guidelines should be in the care plan, for this and any other medication, if it is prescribed on an ‘as and when’ (PRN) basis i.e. to inform staff when such medication should be given. The registered persons said all staff that administer medication have received satisfactory training. There is evidence on staff files to suggest some of the care staff have received training regarding the administration of medication. People who use the service were positive about care and support delivered by staff. We also spoke to several relatives of people who use the service and they also were positive about care. Staff were seen as ‘wonderful’, ‘helpful’, and people said they would have confidence in approaching staff if they had a problem. The inspector observed people who use the service receiving appropriate levels of support. Staff enabled people who use the service to have Godolphin House DS0000068601.V363480.R01.S.doc Version 5.2 Page 12 suitable levels of choice about how they spent their time, what food they wanted etc. Godolphin House DS0000068601.V363480.R01.S.doc Version 5.2 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. 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. Appropriate arrangements are in place so people who use the service can enjoy a lifestyle that meets their needs. Food provided is to a good standard so people enjoy a choice of good quality meals that meet nutritional needs. EVIDENCE: People were observed having a choice when they got up. Staff support was observed as being professional, relaxed and unhurried. Some organised activities are offered. There are bingo sessions, flower arranging, a craft club and quizzes. Entertainers visit the home e.g. on a monthly basis. A Summer Fete had been organised the day after the inspection. People who live in the home, who the inspector spoke to, said they were happy with the activities provided. People who use the service said they could receive a daily newspaper if they wished. There are suitable opportunities for people to receive visitors when they wished either in the lounge or in their bedrooms. People who use the service, who the inspector spoke to, said they could make suitable choices regarding when they could get up and go to bed, what they can wear and how they can spend their time. The inspector shared a meal with people who use the service, on the day of the inspection. Food served was of good quality, and there is a choice of food Godolphin House DS0000068601.V363480.R01.S.doc Version 5.2 Page 14 provided at lunch time. A choice of evening tea is provided. A member of staff will see individual residents to ask them what they would like for lunch and tea. Suitable records are kept of meals provided. Staff support at meal times appears to be to a good standard. Godolphin House DS0000068601.V363480.R01.S.doc Version 5.2 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. 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. A suitable complaints procedure is in place, but the adult protection procedure needs some revision. Improvement of this procedure should help in assisting people who use the service to have assurance that appropriate procedures will be followed if there are any allegations of poor practice or abuse. EVIDENCE: The registered persons have a suitable complaints procedure. The registered persons or Commission for Social Care Inspection have not received any complaints regarding this service. Contact details regarding CSCI needs to be updated in some documentation so people, who may wish CSCI to be involved regarding a complaint, know how to approach the commission. People who use the service said they had no concerns, complaints and allegations about the service. They said they would feel confident approaching staff or management if they had any problems. The adult safeguarding (protection) policy needs some development. The policy needs to state the correct procedure if there was an allegation of abuse e.g. the matter should be reported to the Cornwall County Council Department of Adult Social Care, who act as the co ordinating agency, if there are any adult safeguarding (protection) issues. The matter should not be investigated by the registered persons unless they are delegated to do so. Godolphin House DS0000068601.V363480.R01.S.doc Version 5.2 Page 16 However, staff and management seemed generally aware of what to do if there was an allegation of abuse. The registered manager confirmed there had been no allegations of abuse since the last inspection. However, one matter of alleged poor care practice was investigated by Cornwall Adult Social Care between June 2007 and January 2008. The inspector was able to speak, on this inspection, to people who use the service, for whom the safeguarding referral concerned. They were now happy with the service provided. It appears learning has occurred as an outcome of the referral. None of the staff, who the inspector spoke to, said they believed there were any incidents of abuse or bad practice at the home. Although all staff have not currently undertaken training regarding the awareness of abuse, the registered persons said they are arranging this as places become available on courses run by Cornwall County Council. Some initial training should occur on staff induction. For example staff could watch the Cornwall County Council ‘No Secrets’ video, which is available, free of charge to care homes. The registered manager said no referrals of ex staff had been made to the Criminal Records Bureau for inclusion onto the Protection of Vulnerable Adults list (i.e. as people unfit to work with the vulnerable). Godolphin House DS0000068601.V363480.R01.S.doc Version 5.2 Page 17 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. 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. All bedrooms are of a satisfactory size; all are decorated and furnished to a good standard. Most of the bedroom doors do not have locks. There should be Godolphin House DS0000068601.V363480.R01.S.doc Version 5.2 Page 18 a lock (with an overriding facility if necessary) on each door. People who use the service should be issued with a key if they can manage this (e.g. in terms of cognitive ability). It should be the default position of any home that a lock is fitted to each bedroom door and people should be given a key. If people lack the cognitive skills to hold a key, the matter should be risk assessed, and the decision recorded. Everyone should have a lockable space in their bedrooms to put money / valuables. 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 cook said there needed to be better ventilation in the kitchen. We think currently temperatures in the kitchen, due to lack of ventilation, may not comply with health and safety legislation. The registered provider said he would address this issue shortly. The cleaner said she needed another vacuum cleaner for the upper story of the home, as it was difficult to transport a vacuum cleaner up the staircase. She said she used to have two but one was now broken. The registered provider said he would purchase a new one The building was clean and hygienic on the day of the inspection. The building appears to be generally well maintained, although some of the fixtures and fittings and decorations are in need of upgrading. Some of the hallways have been repainted. However some of the walls and doors look like they need an additional coat of paint. It is disappointing that there was not appear to be any consideration taken regarding dementia design when this work was completed, as it could still be confusing for people to find their way around the building. Godolphin House DS0000068601.V363480.R01.S.doc Version 5.2 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 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. Staffing levels and recruitment procedures are satisfactory. However afternoon and evening staffing levels need to be kept under review and preferably should be increased. There have been improvements regarding staff training, however some further work still needs to take place. The statutory requirement issued at the last inspection is renotified. Suitable staff training ensures people who use the service can be assured staff are trained according to the law, and to meet their specialist needs. EVIDENCE: On the day of the inspection staffing levels appeared to be generally adequate i.e. the rota showed three care staff were on duty during in the morning and two staff are on duty in the afternoon and evening. It would be beneficial if staffing levels in the afternoon and evening could be increased by at least one person. This would enable people who use the service to have more opportunities for stimulation and assistance, and for there to be more staff available to assist people with personal care and to go to bed. There are two staff on waking nights. This seems satisfactory considering the current number of people accommodated and their current needs. In addition ancillary staff (cooks, cleaners) were on duty. The manager and deputy manager are also on duty during each weekday. People who use the service were positive regarding the support they received from staff. Godolphin House DS0000068601.V363480.R01.S.doc Version 5.2 Page 20 Personnel and training records of thirteen care staff were assessed. Pre employment checks were generally satisfactory. Nine staff had two references, however those staff who did not were employed prior to the home being owned by Ablecare. All staff files contained either the number of a Criminal Records Bureau check or a copy of a Protection of Vulnerable Adults Check / Criminal Records Bureau check. Where appropriate a Protection of Vulnerable Adults ‘First’ check had been obtained before the person commenced employment. Staff files had a copy of an application form. This included an employment history. However details to ascertain whether the person is physically / mentally fit to work in a care setting should be more detailed-in line with the regulations. On file, there is also suitable information confirming the person’s identity. Records regarding staff training for the sample group were assessed. 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. As people with mental health needs and dementia are also accommodated in this service, it is important staff have some basic training regarding awareness of these issues. There are still some gaps in all staff receiving this training as is required. To ensure this is complied with, it is essential the registered persons put in place a more ‘proactive’ approach to ensure staff receive training required by law, and according to the needs of the people who use the service. It is important a training policy is developed which outlines what training staff require, and when, in the duration of employment. The commission is renotifying the requirement regarding the delivery of training required by law, and according to the needs of people living in the home (e.g. dementia, and mental health training). We have also requested the registered persons provide us an update of training delivered by no later than 01/02/09. The registered persons have a suitable approach to enabling staff to have the opportunity to obtain a national vocational qualification (NVQ) in care. Currently of the 21 care staff; the registered manager said 86 have at least an NVQ level 2. It is essential a copy of the person’s certificate is kept on file to validate they have obtained this qualification. Godolphin House DS0000068601.V363480.R01.S.doc Version 5.2 Page 21 There is evidence most staff have received a structured induction. A copy of the induction checklist was absent for two staff who commenced employment since December 2007. However the registered manager said these people were still completing the checklist. This should be completed by now and filed. Godolphin House DS0000068601.V363480.R01.S.doc Version 5.2 Page 22 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. The registered persons have made some improvement to this service over the past year. However there is still some work to do to ensure the quality assurance process satisfactorily monitors and ensures compliance regarding some key areas of the service (e.g. medication and staff training). These measures will ensure people who use the service can be assured they live in a service which is safe and has a sustained record of improvement. EVIDENCE: The registered provider is Ablecare Limited. Ms. Denise Matthews is the registered manager. We do have some concerns regarding some of the renotifications of previous statutory requirements and suitable management systems need to be put in place to address some issues raised earlier in the report. Godolphin House DS0000068601.V363480.R01.S.doc Version 5.2 Page 23 The registered persons have developed a quality assurance policy which is satisfactory. A survey of the views of people who use the service has been completed. The results appear to be that people who use the service are happy with the care they receive, although the results of the survey have not been collated. Further monitoring needs to take place by the registered providers to ensure some of the regulatory issues highlighted in the report are checked, and either maintained or improved. We are concerned this report has resulted in some renotifications of requirements issued at the previous key inspection in June 2007. Management subsequently need to consider improving their systems to ensure there is compliance with the regulations. Some monies are looked after on behalf of people who use the service, and records are kept regarding this. Money kept for individuals corresponded with totals in records. However, it is difficult to audit how money is spent, as records for hairdressing, chiropody etc. are kept in records in different places. The registered manager said where money is spent on behalf of people who use the service (toiletries, clothing etc.) receipts are obtained and kept on file. The registered persons said accounts are checked monthly and people who use the service and/or their representatives are sent a copy of the person’s account. The registered provider acts as an agent for one person’s financial benefits. Such arrangements should be avoided where possible, although the registered provider said he only carries out the responsibility, as there is nobody else to act on the person’s behalf. It is advisable the company accountant checks and audits records at least annually. Other monies of people using the service are either maintained via individual solicitors or people’s relatives via Power of Attorney arrangements. Otherwise people who use the service are responsible for their finances, and fees are paid via bank transfer. Suitable insurance for the building and people using it appears to be in place. It is important records and the storage of the valuables of people who use the service are improved. Although the registered manager said a record of each person is maintained on individual files, two rings of one person were found in an administrative file regarding them. Such valuables should be stored in the safe, and a clear record of their possession maintained. Where appropriate these should be signed for. The registered provider’s insurance should cover such items. If it does not people concerned need to be informed clearly that the holding of their possessions is at their own risk. People who use the service, who the inspector spoke to, said they believed their valuables are safe in the home, did not think anything had gone missing and felt they could trust staff. Godolphin House DS0000068601.V363480.R01.S.doc Version 5.2 Page 24 The registered persons have a satisfactory health and safety policy. The home has a fire risk assessment. Health and safety risk assessments e.g. regarding the control of legionella are maintained. There are suitable records regarding the testing of fire equipment. The passenger lift was last serviced in June 2008. This was deemed as safe, although the maintenance company made some recommendations. There are records the nurse call system has been serviced. The electrical hardwire circuit of the home was tested and deemed satisfactory in August 2007. Portable electrical appliances were tested in July 2007, and are due to be retested shortly. The Parker bath and other manual handling equipment appear to be serviced appropriately. Some improvement regarding health and safety training is required-as outlined in the previous section of the report. Suitable insurance for the building and people using it appears to be in place. Godolphin House DS0000068601.V363480.R01.S.doc Version 5.2 Page 25 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 2 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 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 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 2 Godolphin House DS0000068601.V363480.R01.S.doc Version 5.2 Page 26 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 OP2 Regulation 5 Requirement The registered persons need to check all people who use the service have received a contract / statement of terms and conditions of residency. If not this information needs to be issued accordingly. This will ensure people who use the service are provided with satisfactory information regarding their rights and responsibilities. (Previous timescale of 27/02/08 not met Second Notification) Pre admission assessments need to be completed by the registered provider, documented and a copy of the assessment kept on the person’s file. This will ensure there is a suitable process, and suitable evidence that people’s needs are assessed, before they are admitted to the service. Care plans must accurately reflect the current needs of the person using the service. This will ensure there is satisfactory information for care staff to DS0000068601.V363480.R01.S.doc Timescale for action 01/10/08 2. OP3 14 01/08/08 3. OP7 15 01/10/08 Godolphin House Version 5.2 Page 27 4. OP9 13(2) 5. OP18 10(1)12(1 )13 6. OP29 OP38 18. 19 provide appropriate care for each individual who uses the service. The medication system must be 01/10/08 operated and managed to a satisfactory standard (For example in line with the Care Homes Regulations 2001 and Royal Pharmaceutical Society Guidelines). The issues outlined in the report must be satisfactorily addressed. People who use the service can then be assured their medication is managed to a satisfactory standard. (Previous timescale of 27/02/08 not met Second Notification) The adult safeguarding 01/10/08 (protection) policy must be updated to reflect guidance issued by the Department of Health ‘No Secrets’ guidance, and local authority guidance. For example; any allegation of abuse must be reported to the local authority. As outlined in their guidance, in the first instance, will act as the lead agency to coordinate appropriate action. This will help to ensure any safeguarding issues are appropriately reported and coordinated by the local authority. The registered persons need to: 01/02/09 1. Develop a training policy, outlining what training staff will receive and when during the duration of their employment. This needs to include all health and safety training required by law. A copy of this needs to be provided to CSCI within 6 months of the date of this report. 2. Ensure all current staff DS0000068601.V363480.R01.S.doc Version 5.2 Page 28 Godolphin House 7. OP31 OP33 7, 9, 12, 13, 24 8. OP35 13 employed complete the current training plan within 6 months of the date of this report (e.g. where gaps exist on the training matrix supplied to CSCI) 3. Provide CSCI with an update of training provided to all staff within 6 months of the date of this report. These measures will ensure staff receive training required by law, meets health and safety requirements and meets the needs of people who use the service. (In regard to the delivery of staff training timescale of 27/02/08 not met- Second Notification) Further develop the quality 01/10/08 assurance system to monitor regulatory standards in the home. Measures taken should be included in the quality assurance policy. This will help improve service quality and help minimise risks to staff and people who use the service. Any valuables held on behalf of 01/08/08 people who use the service should be stored securely and appropriate records regarding their possession maintained. This will ensure the personal belongings of people who use the service, which are held on their behalf, are stored securely. Godolphin House DS0000068601.V363480.R01.S.doc Version 5.2 Page 29 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. 1. 2. Refer to Standard OP9 OP9 OP10 OP24 Good Practice Recommendations It is recommended a running total is kept of the stock of some medication e.g. Diazepam, Lorazepam. Guidelines should be in the care plan/ medication file, for PRN medication, i.e. to inform staff when such medication should be given. Existing people who use the service should be offered a suitable lock and key for their bedroom door. People subsequently admitted to the service should also be offered this facility. This will ensure people who use the service can lock their bedroom door if they wish to improve security and privacy. Review the number of staff provided in the afternoon and evening. 3. OP27 Godolphin House DS0000068601.V363480.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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.V363480.R01.S.doc Version 5.2 Page 31 - 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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