Inspection on 10/02/06 for Golborne House

This inspection was carried out on 10th February 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Golborne House 16/10/08

Golborne House 26/09/06

Golborne House 15/07/05

Golborne House 14/10/04

Golborne House 06/05/04

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

CARE HOMES FOR OLDER PEOPLE Golborne House Derby Road Golborne Wigan Greater Manchester WA3 3JL Lead Inspector Kath Smethurst Unannounced Inspection 10th February 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Golborne House DS0000005735.V269563.R01.S.doc Version 5.1 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. Golborne House DS0000005735.V269563.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Golborne House Address Derby Road Golborne Wigan Greater Manchester WA3 3JL 01942 726945 01942 276686 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) www.clsgroup.org.uk CLS Care Services Limited Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40), Physical disability over 65 years of age (8) of places Golborne House DS0000005735.V269563.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 40 service users, to include: Up to 40 service users in the category of OP (Older People); Up to 8 service users in the category of PD(E) (Physical Disabilities over 65 years of age) The service should employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection. 15th July 2005 2. Date of last inspection Brief Description of the Service: Golborne House is a two-storey building with pleasant garden areas, situated in the middle of a housing estate, half a mile from Golborne town centre. It is close to shops and other local facilities and is well served by public transport. The Home is spacious with several lounges and dining areas. All bedrooms are single and five have an ensuite toilet facility. There are ample communal toilets and bathrooms situated throughout the home. Golborne House provides personal care and support for forty people over the age of sixty five years. The home is owned and managed by CLS Care Services Limited who have 40 plus homes around Cheshire and the Wigan area. Golborne House DS0000005735.V269563.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced. It took place over five hours during the morning and afternoon. The inspector looked around some but not all of the home, checked care plans and some records. The staff handover was also observed. To get more information about the home the inspector spoke to seven residents, a visitor, the acting manager and five staff. What the service does well: What has improved since the last inspection? Although care plans have always been good new ones have been introduced. The new care plans give people reading them a lot more information about residents and the things they like to do. The way new staff are looked after is much better. They are given a lot of training and support from experienced staff in the home. Golborne House DS0000005735.V269563.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Golborne House DS0000005735.V269563.R01.S.doc Version 5.1 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 Golborne House DS0000005735.V269563.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not inspected during this visit. EVIDENCE: Standards 2,3 and 4 were examined during the last inspection and were satisfactorily met. Golborne House DS0000005735.V269563.R01.S.doc Version 5.1 Page 9 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 In the main care plans were up to date and reflected the care needed, but some relevant records had not always been completed, which meant important information had not been recorded. EVIDENCE: Since the last inspection new care plans have been introduced. These new plans have been introduced in order to assist carers in understanding of residents as a “Whole person”. Staff at the home are currently updating all care plans to incorporate the new documentation. Three of the new style care plans were examined. All contained comprehensive information relating to residents personal, social and health care needs including, life profile, important/memorable events, hobbies, preferences and aims and aspirations. The plans were easy to read, had been regularly reviewed and set out clear guidance for staff to take when providing care. There was evidence that the plans had been signed and agreed by residents and their representatives. The new style care plans contained some very good information which gave any one reading them a good indication of what things are important to residents, their preferences, past lives, personal care needs and chosen Golborne House DS0000005735.V269563.R01.S.doc Version 5.1 Page 10 lifestyle. For example one plan read, “I would like one carer to help me wash and dress. I am a private person and soon get embarrassed so please maintain my dignity” a second “ I like to look smart and would like a carer to shave me each morning” a third “I like to sleep with the lamp on”. Risk assessments were in place in each of the care files inspected. They covered areas such as nutrition, pressure areas and moving and handling. All had been regularly reviewed. One shortfall was noted. While nutritional assessments are undertaken, it was found in one resident’s care plan food intake charts had not always been completed, even though concerns about nutrition had been identified. This needs to be addressed to ensure accurate information regarding food intake is available if the assessment indicates a residents nutritional needs are compromised. Golborne House DS0000005735.V269563.R01.S.doc Version 5.1 Page 11 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 Daily activities within the home are well managed offering choice variety and interest. Visiting arrangements are good ensuring links between residents and their relatives and friends are maintained. Personal support is offered in such a way as to enable residents to exercise choice and control over their lives. EVIDENCE: On the day of the unannounced inspection, the routines of daily living were observed to be flexible. Residents were seen to be getting up in the morning at times that suited them. Staff were attentive to the needs of the residents. They took time to socialise with residents when their duties allowed. A friendly but respectful banter was observed between residents and staff. A part time activity co-ordinator is employed. Unfortunately she wasn’t on duty on the day of the visit so it wasn’t possible to discuss her role with her personally. A record is maintained of the activities provided and care plans take note of residents social interests. For example one care plan read, “Loves watching football” and “Always interested in current affairs” a second “Likes jazz music”. Staff advised that some residents preferred one to one activities and this was catered for. For example one of the residents enjoyed visiting Leigh Market and this was facilitated by the activity co-ordinator. Other activities available include trips out, musical entertainment, dominoes and Golborne House DS0000005735.V269563.R01.S.doc Version 5.1 Page 12 bingo. A visitor spoken with said that families were made welcome to join in any activities and she herself played bingo with her mother every Wednesday. Regular residents meetings are held regularly and well attended. The minutes of the last meeting were examined and indicated residents were satisfied with the range and frequency of activities available. Residents who commented had no adverse comments regarding the range and frequency of activities provided. Residents wishing to maintain their religious links are encouraged to do so. Care plans contain details of resident’s preferred religion. Golborne House has an open visiting policy. There are no restrictions as to when people visit and this was evident, with visitors observed during the whole of the period of the inspection. Further evidence was highlighted in the visitors book where entries showed residents friends and relatives visiting at different times during the day and evening. The only restrictions would be imposed if requested by residents. Anecdotal evidence from both residents and a visitor indicated staff encouraged links to be maintained. A visitor spoken with confirmed both she and other family members were always made to feel welcome by staff. She said she “Always felt involved” and Golborne House was like “A home from home”. Residents spoken to expressed satisfaction with care provided and organisation of life at the home. Observation of care practice and information in care plans indicated residents are encouraged to make choices. For example in respect to where they spend their day. While some residents chose to sit in the lounge a number were observed to spend their time in their own rooms. This was further illustrated in care plans. For example one care plan instructed staff “ I can choose from the menu although this will require time and patience” and “I like to watch TV in my room” while a second plan read “I have occasional unsettled nights but do not wish to take sleeping tablets” and “I like to get washed and dressed independently, although I would like carers to shave me in the morning”. Golborne Houses policy on admission is that residents are encouraged to bring in personal items that will help them to settle in to life at the home, the extent of which is agreed prior to admission. Evidence of personalisation was seen in resident’s bedrooms where personal mementoes and photographs were on display. Feedback from residents confirmed they were able to exercise choice. For example in respect to rising and retiring times. One resident spoken with said, “You can please yourself”. Golborne House DS0000005735.V269563.R01.S.doc Version 5.1 Page 13 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): 18 Policies, procedures and training were in place to safeguard residents from abuse or harm, and for taking any concerns seriously. EVIDENCE: A corporate Adult Protection and Prevention of Abuse policy is in place, which incorporates, whistle blowing. The home ensures all staff completes a POVA and CRB (Protection of Vulnerable Adults Register/Criminal Records Bureau) before they commence work. Training in the signs and recognition of abuse is covered during induction. Good practice was noted in that all grades of staff have recently attended refresher training. Staff spoken with understood the potential indicators of abuse and were aware of the steps they needed to take if there was a suspicion or allegation of abuse. Golborne House DS0000005735.V269563.R01.S.doc Version 5.1 Page 14 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 The standard of the environment within this home is good providing residents with an attractive, homely and clean place to live. EVIDENCE: Golborne House is in the main well maintained internally and externally. It was noted that the flooring in the two toilets (near the dining room) were discoloured and showing signs of wear and tear. This needs to be addressed as part of the planned programme of renewal and maintenance to ensure standards in the home remain good. The Home is spacious with several lounge and dining areas. These areas are furnished with good quality items. Ornaments, fireplaces, pictures and flowers enhance the homeliness of these areas. The garden areas are tidy, well maintained, safe, secure and accessible for residents. Residents and visitors spoken to made no adverse comments about environmental standards in the home. Golborne House DS0000005735.V269563.R01.S.doc Version 5.1 Page 15 With the exception of a slight malodour in one corridor all other areas of the home had good odour control. Discussion with the acting manager indicated that appropriate action was being taken to address this issue. On the day of this unannounced inspection the home was clean throughout. Golborne House DS0000005735.V269563.R01.S.doc Version 5.1 Page 16 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): 27,28 & 30 Staff morale is high resulting in a committed and enthusiastic workforce, this ensures a consistent standard of care for people living in the home, but staffing levels need to be kept under review to ensure care needs are not compromised. A comprehensive training programme is in place, which equips staff with the skills and knowledge they need to meet residents assessed needs. EVIDENCE: On the day of the visit sufficient staff were on duty to meet the residents care needs. Staff were observed to respond speedily to requests for assistance made by residents. The acting manager works on a supernumery basis. Domestic and catering staff support care staff seven days a week. The staff handover was observed. Good practice was noted in that staff were very knowledgeable about the needs of residents and contributed to discussions. During the last inspection it was noted that care staff ratios in the morning had been increased. Discussion with staff indicated this was a short-term measure and numbers would be reverting to previous ratios. This is unfortunate given that residents had commented positively about the increase in residents meetings. Staff spoken with said the increase had been very beneficial in that it enabled them to respond more quickly to resident’s requests for assistance when they wished to get up. When the acting manager is not on duty (evenings and weekends) the care team leaders carry out administrative and supervisory duties in addition to Golborne House DS0000005735.V269563.R01.S.doc Version 5.1 Page 17 providing hands on care. These duties could take care team leaders away form providing direct care to residents. To ensure residents care needs are not compromised staff ratios need to be kept under review. As noted in previous inspections there are only two members of staff on duty each night to assist up to forty residents to bed and support them throughout the night. Given the layout of the building and dependency levels of residents this needs to be kept under review to ensure resident’s needs at night are being fully met. A comprehensive staff development programme is in place and records of training are maintained. There was evidence that new staff undertake induction training that meets the National Training Organisation (NTO) specification following which foundation training is undertaken. Since the last inspection CLS have implemented a new induction policy a copy of which was examined. It is very detailed and covers the following, the first day, day two to the end of six weeks and job specific. Each new employee will have a “mentor” and on-the-job supervision will continue until such time as the member of staff feels or is deemed to be competent. Since the last inspection the home has achieved Investors in People status. Each member of staff has a personal development plan. Ongoing training is available and there is ample evidence that these opportunities are taken up. NVQ (National Vocational Qualifications) are actively promoted. Currently of the 24 care staff 14 have achieved NVQ level 2/3 with a further 5 currently undertaking the award. It was also pleasing to note that training opportunities are made available to catering and domestic staff. For example all domestic staff have attained relevant NVQ awards. Samples of training records were examined. The records confirmed the range of courses that staff had attended. Recent courses undertaken include first aid, nutrition, infection control, fire safety, dementia, moving and handling, protection of vulnerable adults, medication and NVQ 2 and 3. Staff spoken with expressed satisfaction with the range and frequency of training provided. Golborne House DS0000005735.V269563.R01.S.doc Version 5.1 Page 18 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): 31 & 33 The leadership in the home is changing. However, this was being well managed, with clarity and stability being maintained and morale remaining good. The home regularly reviews aspects of its performance through a good programme of self-review and consultations, which include seeking the views of residents, staff and relatives. EVIDENCE: Gill Menguy has recently resigned from her post as registered manager of Golborne House. Diane Emmison (Home Services manager) has been appointed acting manager until a permanent appointment has been made. The acting manager has worked at the home for 14 years and has six years experience in a supervisory position. The acting manger is receiving advice and support from other managers within CLS. Despite these changes there remains a clear line of accountability in the home which both residents and staff are aware of. Record keeping remains good and residents indicated they continue to be satisfied with the care and organisation of life in the home. Golborne House DS0000005735.V269563.R01.S.doc Version 5.1 Page 19 It is understood the company will be reviewing the situation in April 2006. Once a permanent manager has been appointed he/she will need to make an application to the CSCI (Commission for Social Care Inspection) for registration. Effective internal and external quality assurance systems are in place such as staff and residents meetings and visitor/residents surveys. A sample of the most recent completed surveys was examined. The feedback from both residents and visitors was very positive. For example when asked what they liked about the home residents made the following comments, “Staff are very friendly”, “Choice”, “I feel safe and comfortable” and “The home is clean”. When asked the same question comments received from relatives included, “Extremely welcoming and friendly” and “Staff are polite, friendly and helpful”. CLS representatives visit the home on a monthly basis to audit records and speak to residents and staff. A written report is then produced of the findings, which is then forwarded to the CSCI. The home has a system for recording the complaints of those who don’t wish to complain formally. Residents are informed of CSCI inspections and inspection reports are available for visitors and residents to read. The Contracts Section of Wigan Social Services Department, in conjunction with a company called RDB Limited, has undertaken a voluntary star rating of homes in Wigan. As part of the rating process an annual audit of quality is undertaken. This includes consultation with service users and staff. Golborne House has been awarded 5 stars, which is the highest rating. Golborne House DS0000005735.V269563.R01.S.doc Version 5.1 Page 20 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X X X X X X X STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X X X X Golborne House DS0000005735.V269563.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? No 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 OP7 Regulation 14 Requirement Timescale for action 30/03/06 2. OP19 16 & 23 3. OP27 18 4 OP31 8 Food intake charts must be fully completed when concerns there are concerns about resident’s dietary intake and nutrition. As part of the planned 01/06/06 programme of routine maintenance and renewal the flooring in the two toilets near the dining room need to be replaced. To ensure staffing levels are 30/03/06 sufficient a review of ratios must be undertaken on an on-going basis. The registered provider must 30/04/06 appoint a permanent manager and submit their registered manager application to the CSCI. Golborne House DS0000005735.V269563.R01.S.doc Version 5.1 Page 22 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 OP26 OP27 Good Practice Recommendations Consideration should be given to enlarging the laundry area. Consideration should be given to providing an additional member of staff at night. Golborne House DS0000005735.V269563.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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. 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