Inspection on 03/10/05 for Goffs Park Nursing Home

This inspection was carried out on 3rd October 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Goffs Park Nursing Home 18/07/07

Goffs Park Nursing Home 03/01/07

Goffs Park Nursing Home 25/05/06

Goffs Park Nursing Home 01/06/05

Goffs Park Nursing Home 16/11/04

Goffs Park Nursing Home 01/06/04

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

CARE HOMES FOR OLDER PEOPLE Goffs Park Nursing Home 39 Goffs Park Road Crawley West Sussex RH11 8AX Lead Inspector Miss Helen Tomlinson Unannounced Inspection 3rd October 2005 07:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Goffs Park Nursing Home DS0000024146.V255123.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Goffs Park Nursing Home DS0000024146.V255123.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Goffs Park Nursing Home Address 39 Goffs Park Road Crawley West Sussex RH11 8AX 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) 01293 524942 01293 539506 Goffs Park Care Homes Limited Mrs Elizabeth Bannister Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Goffs Park Nursing Home DS0000024146.V255123.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 37 persons in the category OP (Old age not falling within any other category) to be accommodated at any one time 1st June 2005 Date of last inspection Brief Description of the Service: Goffs Park is a care home which is registered for up to 39 people aged 65 years and over. It provides nursing care. The care home is a converted large detached house, situated in a residential area of Crawley, close to the town centre. Accommodation is provided on 3 floors, which can be accessed using a passenger lift. There are 27 single and 4 double rooms. 1 of the double bedrooms on the third floor was being used as a communal lounge, in order to provide additional lounge space for the residents. This was agreed under the previous registering authority. There is one other medium sized lounge on the ground floor. This is also used as the dining room at meal times. There are large, well kept grounds which are accessible to residents in suitable weather. The service is privately owned by Mr. R. Lallchand and the registered manager is Mrs E. Bannister, who is responsible for the day to day running of the home. Goffs Park Nursing Home DS0000024146.V255123.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection. The inspector arrived on the premises at 7.30am and left at 5pm. Night staff were interviewed on arrival. The registered manager, Mrs Bannister, was present throughout the inspection. During the inspection eight residents, six staff members and one visitor were spoken with. Staff were observed giving support and assistance. Three residents files were examined in detail and other records were seen as was necessary. A tour of the premises took place. Staff files were examined. The focus of this inspection was to monitor the twelve requirements and five recommendations made at the last inspection. At the time of this inspection seven requirements and two recommendations remained unmet. The service will be monitored to ensure compliance with these requirements and the Commission may consider enforcement action should there be continued noncompliance. What the service does well: What has improved since the last inspection? The paperwork used to record the needs and care plans for the residents had been changed. This provided pre-printed documents which included assessments for all health care needs. The medicine trolley on the second floor was appropriately secured to the wall. The medication charts did not contain the errors seen at the last inspection. The registered manager had checked the storage of parental feeds with the manufacturer and been assured that the present storage arrangements met with their recommendations. Staff had received training regarding safe moving and handling. The registered manager said she was confident that all staff were now up to date with this training. The complaint procedure on display in the hallway of the home had been amended and contained correct information. The registered manager said the deployment of staff in the home had been reviewed and all residents were adequately supervised at all times. The refurbishments, which had been ongoing at the last inspection, had been completed and these areas of the home were improved. Goffs Park Nursing Home DS0000024146.V255123.R01.S.doc Version 5.0 Page 6 What they could do better: Not all residents were appropriately assessed to make sure their needs could be met, before being accommodated in the home. The new documentation for the resident’s assessments and plans of care had not been fully completed in the files examined. This lead to gaps in the assessment and implementation of health and social care of the residents. The manager did not confirm, in writing, to the residents, that following assessment the home could meet their needs. There was a lack of social and physical activity in the home. Residents said there was “nothing to do” unless they had their own interests which they could carry on themselves in their own rooms. Some communal toilets and bathrooms did not have a lock on the door. This does not protect the privacy of the residents. Staff working at the care home had not received training adequate for all aspects of the work they were doing. The induction training was not covering all areas of work for the care assistants. There was no training regarding health and safety, infection control or the prevention of abuse of vulnerable adults. The practices and records of medication administration in the home had improved. These still did not meet fully with the Nursing and Midwifery Council guidance in some areas. The recruitment of staff did not include the correct safety checks to make sure the staff were safe to work with vulnerable adults or fit to carry out the work they were employed to do. Resident’s records of a confidential nature were not always securely stored. There had been no change to the available dining space in the home. It remained the practice that residents could eat at an individual table in the lounge or in their rooms. Some residents said this lead to isolation for them and no social interaction at mealtimes. Hot drinks had not been provided during the morning. Some residents said they were not offered a hot drink between breakfast, which could be 8am and lunch at 12.30am. They said they would enjoy a hot drink during this time. Residents were unaware that there was a choice of meal at any mealtime, although this was recorded on the menu in the kitchen. All residents should be actively offered a choice of meal at all meal times. Two bedrooms had torn wallpaper on the walls near to the beds. This should be repaired. There was an offensive odour in some areas of the home, both communal areas and individual residents bedrooms. Several issues which could potentially lead to the spread of infection were brought to the attention of the manager. These included a lack of working soap dispensers in communal bathrooms and toilets, lack of hand paper towels in some areas and staff not wearing correct protective clothing during care practices. Staff were also seen to clean commodes in the bath. Residents, relatives and other people with an interest in the care home should be consulted about the running of the home. Goffs Park Nursing Home DS0000024146.V255123.R01.S.doc Version 5.0 Page 7 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. Goffs Park Nursing Home DS0000024146.V255123.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Goffs Park Nursing Home DS0000024146.V255123.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 Residents were not always assessed before they were accommodated in the home. They were not then assured, in writing, that the home could meet their needs or not. Staff had not received adequate training to enable them to fully and appropriately meet the needs of the residents. EVIDENCE: The latest resident to be accommodated in the home had not been seen or assessed by anyone from the home prior to admission. A faxed copy of a social services assessment was on file. This had been received at the home the day after the resident became accommodated there. This assessment had been done some time ago and was not specific to the current situation with that resident. The registered manager said this had been an emergency admission and there had not been time to visit and assess the resident. It was discussed that this must not occur and all residents must be assessed prior to admission, to ensure the home can meet their needs fully. Staff had received moving and handling training since the last inspection. There was other training required by the staff in order that they could Goffs Park Nursing Home DS0000024146.V255123.R01.S.doc Version 5.0 Page 10 adequately meet the needs of the residents accommodated. This is discussed more fully in the Staffing section of this report. Goffs Park Nursing Home DS0000024146.V255123.R01.S.doc Version 5.0 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 The resident’s files examined had a plan of care documented. This did not cover all aspects of health, personal and social care needs. The resident’s health needs were not fully assessed or met. Some aspects of medication administration and recording did not fully meet the guidance of the Nursing and Midwifery council, although qualified nurses were responsible for this. Staff protected the privacy and dignity of the residents. Some aspects of the environment did not assist the privacy of the residents. EVIDENCE: New documents for recording the resident’s plan of care had been introduced since the last inspection. These provided a thorough way of assessing and planning the care for the residents. On the files examined these various assessments did not contain the necessary information. Some were blank whilst others were partially completed. Where they had been completed the actions recorded were not detailed as to how the various needs should be met. There was no evidence of involvement of the residents in drawing up the care plans. Goffs Park Nursing Home DS0000024146.V255123.R01.S.doc Version 5.0 Page 12 These new documents included health assessments. Again these had either not been completed or where they had, a subsequent plan of care had not been drawn up. For one resident there was no assessment of their risk of developing a pressure sore and no plan of how to prevent this. This resident had developed a pressure sore since their admission to the home. For another the pressure sore risk assessment had been completed, but there was no plan of how staff should reduce this risk. Since the last inspection an adult protection issue regarding pressure sore management had been concluded. The poor documentation and practice in this area of health care was subject to the first stage of enforcement action following this inspection. The resident’s nutritional needs were not assessed nor actions to prevent malnutrition contained in a plan of care. For one very dependant resident their care plan was out of date and stated they were capable of areas of self-care, which they could no longer manage. Staff said they would read the care plans to help them understand what care was needed. Currently these would provide inaccurate and out of date information for staff. For one resident with a high degree of sight loss, there was no specific information about their abilities or needs. No specialist advice had been sought and no additional aids to help their safety and independence had been provided. Where falls had been identified as a risk the risk assessments had not been updated and no prevention or management plan was documented. The observation of care staff, reading of documentation and discussions with staff did not assure the inspector that the health care needs of the more dependant residents were being assessed and met. At the last inspection concerns regarding the use of bed rails were raised. A requirement to fully assess the risks involved, prior to use, fit them correctly to the bed and use protectors was made. At a visit since that inspection the bed rails in place were safely fitted, their use had been assessed for each individual resident and protectors were in place. At this inspection the risk assessments remained in place and bed rails were correctly fitted. Not all had protectors in place and one resident was at risk of hurting themselves when the inspector arrived. This was brought to the attention of the registered nurse. The medication records completed had been correctly filled in. Medication was safely stored. At the last inspection medication labels for prescribed creams had been altered and were being used for other residents. At this inspection one label was seen altered. All other creams seen were in the relevant resident’s bedroom. Medication records were not being completed immediately medication had been given, rather completed on block later in the morning. This indicated that medication actually given at 8am had not been recorded as such until 11am. This practice should cease. The medication trolleys were securely stored. The residents said the staff respected their privacy by closing bedroom and bathroom doors when assisting them and making sure they were adequately clothed at all times. Staff spoken with understood the need for privacy for the residents. Several toilets and bathrooms in various parts of the home did not have locks fitted. Locks appropriate for the needs of the residents should be Goffs Park Nursing Home DS0000024146.V255123.R01.S.doc Version 5.0 Page 13 fitted to all toilet and bathroom doors. Residents said the staff treated them with respect, using the name of their choice and being polite in their approach. Goffs Park Nursing Home DS0000024146.V255123.R01.S.doc Version 5.0 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Residents said there was little going on in the home for them to join in. Family and friends were encouraged and assisted to keep in touch with their relatives. Residents said they had some choice over the way to live within the home. Residents said the food was “tasty and good.” They said there was no choice of menu and no dining table to eat at. EVIDENCE: Residents said there were no specific activities in the home for them to join in with. They said there was sometimes an entertainer came in, but between these visits there was no organised activity. Some residents said they did not mind this as they had televisions, radios, books and interests like knitting to keep them occupied. Others said they would like something to do and someone to talk to. Many residents stay in their own rooms during the day. Although this is their choice some said it was because there was no point going in the lounge as nothing happened in there and they still had no-one to talk to. Some resident’s plans of care included their social interests, family contacts and past life circumstances. Others did not contain any information about the social aspect of the resident’s life. Staff showed an understanding of some individual resident’s interests. A radio was playing classical music for one dependant resident who liked this. For others there was no evidence of appropriate activity or social interaction throughout the day. No specific aids Goffs Park Nursing Home DS0000024146.V255123.R01.S.doc Version 5.0 Page 15 or adaptations for those with sight, hearing or communication difficulties had been obtained. Residents said their relatives and friends could visit any time they wished and they could see them in private or in the communal lounges. Relatives said they visited the residents whenever they liked and were welcomed into the home. Residents said their choices of how to live their lives were respected by the staff. They said they could choose what time to get up and go to bed and where to spend their days. Should residents want a rest on their beds in the afternoon’s staff assisted them to do so. The residents who were able said they enjoyed the majority of food served to them. They said there was no choice of meal at lunch or suppertime. The chef showed the various choices documented on the menu, for lunch and supper. Residents were unaware of these choices. It was discussed that all residents should be aware of the choices of meal available to them at all meal times. There is no specific dining space provided. Residents either ate their meal at a portable table in the lounge or in their own bedrooms. This had not been changed since the last inspection and a requirement to provide dining space remains in place. Residents spoken with said they had no hot drink served between breakfast and lunchtime. This meant they went from 8am to 12.30pm without a hot drink. Many of the residents said they wanted a drink at this time and it should be provided. Goffs Park Nursing Home DS0000024146.V255123.R01.S.doc Version 5.0 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Residents were confident to discuss any issues or concerns with the staff at the home. Some practices and the lack of training did not protect the residents from abuse. EVIDENCE: No complaints had been received since the last inspection. Since the last inspection the complaints procedure displayed in the hallway had been altered and was correct. Staff had not received training in the protection of vulnerable adults. The registered manager said that all staff were aware of the policies and procedures within the home regarding this issue. The whistleblowing policy was not separated and was incorporated into the general procedure for reporting abuse. This should be amended, a separate policy and procedure devised and all staff should have a copy. Staff must be trained in the protection of vulnerable adults in their care. Goffs Park Nursing Home DS0000024146.V255123.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22 and 26 The home was generally well maintained. Some specific issues were highlighted to the maintenance man during the inspection. The specialist equipment needed to meet the resident’s needs was present in the home. There was an offensive odour in some parts of the care home. Several issues of concern regarding the prevention of spread of infection were raised. EVIDENCE: Goffs Park is a detached, converted house and as such the layout is small corridors, on 3 floors, with bedrooms off them. Whilst this was said to be an attraction to some visitors and residents spoken with, it also presented some difficulties in ensuring the highly dependent residents were adequately supervised. Since the last inspection some bedrooms had been redecorated and recarpeted. These were much improved due to this. Some corridors had been redecorated and had new carpets fitted. These too were improved. The carpet gripper in the doorway of one corridor was raised and caused a trip hazard. Goffs Park Nursing Home DS0000024146.V255123.R01.S.doc Version 5.0 Page 18 Most areas of the home were well maintained, bright and clean. Two bedrooms had wallpaper which was torn. In one of these it was hanging off the wall close to the resident’s head. It was discussed that this was an ongoing issue with these two residents who removed the paper themselves. Alternative decoration should be considered. Fire doors were closed or held open with appropriate devices. Some specialist equipment, to meet the needs of the residents, was available in the home. This included hoists, assisted baths, grab rails, toilet seats and frames and call bells. At the last inspection concerns were raised regarding the availability of call bells for the residents. Some had not been in full working order and some had not been left within easy reach for the residents. At this inspection all call bells seen were in working order and most were in reach for the residents. One resident, who had sight difficulties and was at risk, did not have their call bell to hand. This issue should be revised with all staff. Pressure relieving equipment was in use for some residents. As discussed earlier the care plans and health assessments did not make clear how the decision to use which equipment had been made. The home was generally clean. There was an offensive odour in some individual bedrooms and corridors. This was discussed with the registered manager who was exploring alternative cleaning options. Some concerns were raised with regard to the practices to prevent the spread of infection. Staff were seen to handle soiled linen without the correct protective clothing, hand washbasins in some toilets, sluices and bathrooms did not have working soap dispensers or paper towels. One care staff was seen to clean a commode in a communal bath. Staff had not received training regarding infection control. All these issues must be addressed to prevent the spread of infection in the home. Goffs Park Nursing Home DS0000024146.V255123.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29 and 30 The numbers of staff were adequate to meet the needs of the residents. The recruitment procedures in the home do not protect the residents. Staff did not receive the training they required to do their jobs adequately. EVIDENCE: The duty rota for week commencing 2nd October 2005 was examined. This did not document who the Registered nurses on duty were. The number of care staff was sufficient to meet the needs of the residents accommodated. At the last inspection the deployment of staff was discussed with regard to the supervision of dependant residents. The registered manager said this had been reviewed and all residents were supervised during the day. Two staff recruitment files were examined. These did not contain all the information necessary. For both staff members there was no evidence of a check against the protection of vulnerable adults register prior to starting work. For one there was no Criminal Records Bureau check on file. There were unexplained gaps in the employment record. For one staff member there was one reference and for another there were none. Names of referees had been supplied. For one there were no education details. A requirement was made at the last inspection regarding recruitment and this had not been met at this inspection. The recruitment process in the home was the subject of the first stage of enforcement action following this inspection. Staff training in respect of safe moving and handling had been completed since the last inspection. No other staff training had taken place. Induction training had been recorded. This did not meet with the requirements and training guidance. The registered manager said she had a copy of this guidance and Goffs Park Nursing Home DS0000024146.V255123.R01.S.doc Version 5.0 Page 20 would alter the training to make it appropriate. Several areas of concern were raised regarding the lack of staff training. These were specifically, infection control, health and safety, protection of vulnerable adults and first aid. These areas of staff training must be addressed. Staff had received fire safety training although some staff had not had this for nine months. It was discussed that staff should have fire safety training on a regular basis. Goffs Park Nursing Home DS0000024146.V255123.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,35,37 and 38 Residents were not consulted about the running of the care home. Resident’s monies are not managed by the home. Not all records required to safeguard residents were kept in the home. Some practices, procedures and lack of training did not protect the health and safety of the residents. EVIDENCE: There was no system of consultation with the residents or relatives/visitors set up in the home. The registered manager said that she spoke informally with residents in the mornings. There were some questionnaires which were given out to residents each year. There were no resident, relative or staff meetings. Staff and visitors to the home were spoken with regarding specific issues by the manager, but not invited to give their views and comments more formally about the running of the home. Residents and others with an interest should be consulted about the running of the home. Goffs Park Nursing Home DS0000024146.V255123.R01.S.doc Version 5.0 Page 22 The registered manager said that the home does not manage the finances of any residents. This is either done by themselves or by family members. As discussed in the personal care section of the report not all records regarding the resident’s care were kept. Records regarding the staff recruitment were not adequate. All records required to be kept in the Care Home Regulations 2001 must be kept in the care home. They should be up to date, in good order and securely stored. Throughout the report there are issues discussed which impact on the health and safety of residents. These include concerns around infection control, first aid, staff training, appropriate use of equipment and record keeping. The health and safety of residents in the home should be protected at all times by the policies, working practices and environment of the home. The accident book was examined. This was completed. One entry was unclear and staff should be reminded of the importance of accurate record keeping. Goffs Park Nursing Home DS0000024146.V255123.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 2 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 x x 2 x x x 2 STAFFING Standard No Score 27 3 28 x 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 1 x 3 x 2 2 Goffs Park Nursing Home DS0000024146.V255123.R01.S.doc Version 5.0 Page 24 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 OP3 Regulation 14 Requirement Timescale for action 31/10/05 2 OP7 15 3 OP8 14(2) 4 OP8 12(1)(a) Accommodation will not be provided in the care home unless an appropriately qualified person has assessed the needs of the resident. A plan of how the resident’s 30/11/05 needs in respect of health and welfare are to be met, must be documented. This should be drawn up with the resident where possible. The resident’s health care needs 31/07/05 must be assessed and these assessments kept under review and revised with a change in condition. This requirement remains unmet since the inspection of 1/6/05. The timescale given of 31/7/05 has expired. The health care needs of the 30/06/05 resident must be met with particular attention to pressure area care, nutrition and continence. This requirement remains unmet since the inspection of 1/6/05. The timescale given of 30/6/05 has expired. DS0000024146.V255123.R01.S.doc Version 5.0 Goffs Park Nursing Home Page 25 5 OP8 13(4)(c) 6 OP10 12(4)(a) 7 OP12 16(2)(m)( n) 8 OP15 23(2)(g) 9 OP18 13(6) 10 11 OP26 OP26 16(2)(k) 13(3) Unnecessary risks to the health or safety of residents are identified and eliminated. Bed rail protectors must be in place at all times. This part of a requirement remains unmet since the inspection of 1/6/05. The timescale given of 9/6/05 has expired. The registered person shall make suitable arrangements to make sure the care home is conducted in a manner which respects the privacy and dignity of the residents. Suitable locks must be fitted to toilet and bathroom doors. The registered person must consult the residents about their social interests and make arrangements for them to engage in social and community activities. Residents should be consulted about a programme of activities and provide facilities for recreation. The registered person shall ensure there is adequate sitting, recreational and dining space provided from the resident’s private accommodation. This requirement remains unmet since the inspection of 1/6/05. The timescale given of 31/12/05 has not expired. The registered person should make arrangements, by training staff, to prevent residents being harmed or suffering abuse or being placed at risk of harm or abuse. The care home must be kept free from offensive odours. The registered person shall make arrangements to prevent infection, toxic conditions and the spread of infection at the DS0000024146.V255123.R01.S.doc 09/06/05 31/11/05 31/12/05 31/12/05 31/12/05 30/11/05 31/10/05 Goffs Park Nursing Home Version 5.0 Page 26 12 OP29 13 OP30 14 OP37 care home. The registered person must ensure all people employed to work at the care home are fit to do so. All information in Schedule 2 should be obtained for all members of staff prior to employment. This requirement remains unmet since the inspection of 1/6/05. The timescale given of 30/6/05 has expired. 18(1)(a)(c The registered person must ) ensure all staff receive training appropriate to the work they are to perform. This requirement remains unmet since the inspection of 1/6/05. The timescale given of 31/8/05 has expired. 17 All records in Schedules 1,2,3 and 4 must be kept. All records must be up to date and securely stored. This requirement remains unmet since the inspection of 1/6/05. The timescale given of 31/7/05 has expired. 19 and Schedule 2 30/06/05 31/08/05 31/07/05 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 Refer to Standard OP9 OP15 Good Practice Recommendations The medication records should be completed immediately medication is administered. A hot drink should be provided between breakfast and lunchtime. A choice of meal should be actively offered to all residents at meal times. All staff should have a copy of the whistleblowing procedure at the home. DS0000024146.V255123.R01.S.doc Version 5.0 Page 27 3 OP18 Goffs Park Nursing Home 4 5 6 OP19 OP22 OP33 The wallpaper which is torn, in two resident’s bedrooms, should be repaired or replaced. The raised carpet gripper should be replaced. All residents should have their call bells to hand at all times. Residents, visitors and staff should be invited to comment on the running of the home. Goffs Park Nursing Home DS0000024146.V255123.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Goffs Park Nursing Home DS0000024146.V255123.R01.S.doc Version 5.0 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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