Inspection on 26/09/06 for Golborne House

This inspection was carried out on 26th September 2006.

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

The inspector 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 10/02/06

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 26th September 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.V306697.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. Golborne House DS0000005735.V306697.R01.S.doc Version 5.2 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.V306697.R01.S.doc Version 5.2 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. 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. A standard fee of £370 per week is charged. Additional charges are made for hairdressing, toiletries, hairdressing, newspapers, clothes and transport. Golborne House DS0000005735.V306697.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspection site visits took place over a period of seven hours. The home had not been told that the inspector would visit. The inspector looked around parts of the building and checked some paperwork about the running of the home and the care given. To get more information about the home five residents, the manager and four staff were spoken with. Care staff were also watched as they went about their work. Before the inspection comment cards were sent to residents, relatives and people such as social workers, district nurses and doctors. Two residents and two general practitioners returned comment cards. What the service does well: Residents spoken with said they liked the staff. They were also happy with the way the staff cared for them, as they made sure they got the care that was needed. Staff were described as “very good” and “kind”. Before people come to live at the home staff visit residents, either at home or in hospital, to make sure the care needed can be provided. Each resident had a named carer, called a key worker, who would help them have a bath, go shopping for them or keep their clothes tidy. The records kept on residents (care plans), includes a lot of information about the things residents need support with and the things they like to do. This means staff have the information they need so they can make sure residents get the care and support they need. Staff have done a lot of training, which helps them look after people properly. The home makes sure that before staff starts work they are properly checked to make sure they are suitable to care for people living in the home. The staff ask residents and their relatives what they think about the food, activities, environment and staff and what things they could to do to improve residents lives. Golborne House DS0000005735.V306697.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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.V306697.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 Golborne House DS0000005735.V306697.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Proper assessments are carried out prior to admission ensuring the home is able to meet prospective residents identified needs. EVIDENCE: Inspection of the records of two of the most recent admissions showed a full assessment of physical care needs had been completed and where applicable social work assessments had been taken note off. The assessment document was detailed and included information relating to physical and social care needs. Discussion took place in respect of the assessment process undertaken. The care team leader advised that if possible prospective residents are visited prior to admission at home or hospital, whether they are paying for themselves or the local authority funds their care. This was felt important to ensure the home was able to meet needs. Golborne House DS0000005735.V306697.R01.S.doc Version 5.2 Page 9 Prospective residents are encouraged to visit the home. If this is not possible relatives usually looked around the home prior to their relative’s admission. New residents are allocated a key worker. Feedback in returned resident comment cards indicated they were provided with sufficient information prior to coming to live in the home. Two residents spoken with confirmed staff asked them about the things they need help with and their preferences. Golborne House DS0000005735.V306697.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. 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. Health care needs were well met with evidence of good multi disciplinary working taking place on a regular basis. The medication at this home is well managed promoting good health. Personal support is offered in such a way as to promote resident’s privacy and dignity. EVIDENCE: Three care plans were examined. All contained comprehensive information relating to residents personal, social and health care needs. Each area of risk has a separate record. Supplementary information includes personal care record and weight. Daily entries in care notes were completed in all the plans Golborne House DS0000005735.V306697.R01.S.doc Version 5.2 Page 11 examined and gave a good indication of the care provided and residents well being. In addition to internal reviews there was evidence of external reviews (Social Services) having taken place. The care plans examined contained some very good information in respect to resident’s likes/dislikes and chosen lifestyle. For example one plan read, “At night I prefer my door locked” a second, “I prefer to drink water during the day”. All the plans contained life profiles with information about important events, previous jobs, places visited on holiday, war experiences, interests, style fashion, memorable moments, current interests, sporting interests, preferences and aims and aspirations. Good practice was noted as the information provided gave readers a good insight as to the people, things and events important to residents. Residents are allocated a key worker. Key workers take a “special interest” in individual residents, assist them with bathing and contribute to care plans. It was evident from discussions with staff they knew a great deal about resident’s preferences, likes and chosen lifestyle. One shortfall was noted. While they majority of the records of resident’s weights were completed regularly, omissions in recording were noted in one of the care plans examined. In this instance the care plan instructed staff to weigh the resident weekly due to concerns about nutritional intake. However this had not been done. The record of weight showed that this resident weighed 81.40 kilograms on the 26/9/06. The resident was next weighed on the 21/9/06 and weighed 78.60 kilograms (a loss of 2 kilograms). This was discussed with the care team leader who advised this had been identified and the residents GP had been contacted. In future staff need to be mindful where concerns regarding nutritional needs have been identified weight is monitored as instructed. Residents spoken with and those who returned comment cards liked the staff and were happy with the care provided. One resident who returned a comment card wrote, “I like living here and I feel safe” and “Staff are always helpful-I don’t have to wait long for help”. The health care needs of residents were well met. Individual care records inspected showed evidence of visits from general practitioners, chiropodist, optician and district nurses. Residents who returned comment cards confirmed they received the medical support they needed. Prior to the inspection comment cards were sent to health care professionals in order to ascertain their views. Two general practitioners returned comment cards. Neither highlighted any areas of concern regarding the standard of care Golborne House DS0000005735.V306697.R01.S.doc Version 5.2 Page 12 provided. One general practitioner wrote, “Staff always communicate appropriately and accurately. I feel the level of care they give is excellent”. A detailed medication policy and procedure was in place, which covered all relevant areas including controlled drugs, self-medication and homely remedies. . The home uses a monitored dosage system supplied by a local pharmacy. Accurate records were in place for the receipt and disposal of medication. All staff involved with medication at Golborne House has received relevant training. It was positive to note that only a small number of designated staff are allowed to handle medication. The home has regular contact with the local pharmacist for advice, information and medication checks. Samples of MAR (Medication Administration Records) were examined and were found to be up to date and accurate. Most of the Medication Administration records were printed by the pharmacy for staff to fill in when medications were given. But, some records were handwritten. The handwritten entries were not checked and signed by a second member of staff. This is recommended to reduce the risk of mistakes in handwritten instructions. Medication storage was secure and orderly with no evidence of overstocking. Currently none of the residents have been prescribed controlled drugs. But if the need arose a separate safe storage and recording systems are provided. A lockable drug trolley is provided which when not in use is securely stored. A lockable medication fridge is also available which is used to store eye drops, antibiotics etc. The temperature of the fridge is monitored. It was observed in the morning that the medication round took some considerable time. The medication round was started at 9.00am and it was not completed until 11.00am this was discussed with the senior carer. The senior advised she made sure residents who required medication at lunchtime had their morning medication first to ensure a sufficient interval between doses. As the medication administration records are pre-printed staff need to ensure the time medication is actually administered is amended. Feedback from residents was positive about how they were assisted with personal care tasks. All residents said they were encouraged to be as independent as possible, that staff did not make them feel embarrassed and that they knocked on bedroom doors before entering. They all felt they were well looked after. Written evidence in care plans showed that resident’s needs in respect to privacy and dignity were considered important. For example one care plan read, “I like to wear deodorant, wear jewellery and perfume” a second, “When I get changed I lock my bedroom door as I like privacy”. Golborne House DS0000005735.V306697.R01.S.doc Version 5.2 Page 13 The staff spoken with also demonstrated, by giving examples, their awareness of how important it was to make sure that residents were treated with respect and dignity at all times. Golborne House DS0000005735.V306697.R01.S.doc Version 5.2 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 & 15 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. 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. The dietary needs of residents were well catered for, with a balanced and varied selection of food available at each mealtime. 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. A friendly but respectful banter was observed between residents and staff. Golborne House DS0000005735.V306697.R01.S.doc Version 5.2 Page 15 A part time activity co-ordinator is employed. However on the day of inspection she was providing cover for absent staff so the advertised activities did not take place. Details of weekly and future planned activities are displayed. Weekly activities include dominoes, crafts, bingo, shopping, gardening, sing-a-longs, walking group, computer group and reminiscence. Future planned activities include a race night, coffee morning, fire work display and trip to Blackpool illuminations. Care plans take note of residents social and leisure interests. For example it had been identified that one of the residents liked gardening. Staff had encouraged this interest and had encouraged the resident to plant borders, tubs and grow tomatoes. Residents who returned comment cards said they were happy with the activities provided. In addition the minutes of the last residents meeting held on the 22/8/06 also indicated satisfaction. Although it is evident a good range of activities take place this was not reflected in records. The activities individual take part in were not documented. Discussion took place regarding the benefits of doing so for example providing further evidence of the activities available. It was pleasing to note that by the second day of the visit this advice had been acted upon with the introduction of individual activity records. Residents wishing to maintain their religious links were encouraged and enabled to do so. Different denominations visited the home. The home has an open visiting policy. There are no restrictions on the time people visit evidence of which was highlighted in the visitor’s book, where entries showed residents friends and relatives visiting at different times during the day and the evening. The only time restrictions would be imposed is when requested by residents. Residents were observed getting up in the morning at times that suited them and to choose where they spent their day. Residents able to comment confirmed they had a choice of meal and rising and retiring time. It should be noted a number of residents have memory and communication difficulties so were unable to confirm they were able to exercise choice. Nevertheless observation of care practice indicated residents could make choices. For example some residents were seen to choose the privacy of their own rooms. Staff were observed asking residents which meal option they preferred. Resident’s rooms are personalised and residents are able to bring personal items in the home. Care plans take note of personal preferences and chosen lifestyle for example one plan read, “I prefer to wear pants” a second, “I like a bath once or twice a week and I prefer my daughter to do it”. Golborne House DS0000005735.V306697.R01.S.doc Version 5.2 Page 16 There is a 4 weekly menu cycle, which offered a varied choice of nutritional food. Meat and fish were offered on a daily basis, as well as a good assortment of vegetables. Milk puddings and custard were served on a regular basis and tinned fruit or fruit pies were also regularly on the menu. Breakfast is served on a flexible basis, the main meal being served at teatime and a light lunch served at around midday. A choice of drinks and snacks are provided throughout the day. A choice is offered at every meal. Details of the menu are displayed. Meals are eaten in the main dining room or several smaller lounge/diners throughout the Home. The dining areas were clean and efforts had been made to give an air of domesticity. Dining tables were tastefully set with linen tablecloths so ensuring a congenial atmosphere. Lunch on the day of inspection consisted of soup and sandwiches or hotdogs followed by homemade cake or fruit and cream. A good selection of sandwich fillings was available. Residents were given time to enjoy their meal and support was given in a discreet and individual manner. There has been consistently good feedback was given about the choice and standard of the meals offered. All residents spoken with during this inspection very complimentary about the food served. On resident described the meals as “Very good”. Golborne House DS0000005735.V306697.R01.S.doc Version 5.2 Page 17 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 & 18 Quality in this area is good. This judgement has been made from the evidence gathered both during and before the visit to the service. There is a well publicised and accessible Complaints Procedure with evidence resident’s concerns are listened to and acted upon. Policies, procedures and training were in place to safeguard residents from abuse or harm, and for taking any concerns seriously. EVIDENCE: A detailed complaints procedure is in place. Details of how to complain are contained in the “Service User Guide” which each resident has a copy of. A system is in place for recording complaints. The homes complaints book was examined and showed three complaints had been logged since the last inspection in February 2006. The complaints made directly to the home related to comments made by a resident to a visitor and care practice. There was written evidence the complaints had been thoroughly investigated. All the concerns raised had been resolved to the complainant’s satisfaction. No formal complaints have been received by the CSCI over the past year. Those residents able to comment indicated they felt able to approach staff with any concerns. None of the residents who returned comment cards had made a complaint but all confirmed they knew whom to approach if the need arose. One resident wrote, “I can talk to any of the staff”. Golborne House DS0000005735.V306697.R01.S.doc Version 5.2 Page 18 An 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) check before they commence work. No recent POVA (Protection of Vulnerable Adults) investigations have taken place. Staff spoken with understood the importance of reporting any allegations or suspicion of abuse. Training in the signs and recognition of abuse is covered during induction and in NVQ training. Good practice was noted in that staff have routinely complete updated protection of vulnerable adults training. Golborne House DS0000005735.V306697.R01.S.doc Version 5.2 Page 19 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, 24 & 26 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. In the main the standard of the environment within this home is good providing residents with an attractive, homely and clean place to live. However some improvements are needed to ensure standards don’t fall below an acceptable level. EVIDENCE: Golborne House is a two storey building situated in the middle of a housing estate, close to Golborne village. The home is set in extensive grounds. The garden areas well maintained and enclosed. This ensures residents can enjoy the garden in safety. Garden furniture is also provided for residents. The Home is spacious with several lounges, a dining area and hairdressing room. These areas are furnished with good quality items. Ornaments, pictures and flowers enhance the homeliness of these areas. Golborne House DS0000005735.V306697.R01.S.doc Version 5.2 Page 20 While standards are generally good some improvements are required. The flooring in the bathroom (near room 23) was stained and discoloured and needs to be replaced. It was also noted that the wallpaper in the corridors was showing signs of wear and tear and as such plans need to be made to redecorate these areas. A sample of bedrooms was examined. Bedrooms were personalised with photographs and personal mementoes on display. Doors are fitted with locks that can be opened by staff in an emergency. On the day of the inspection the home was clean and odour control was good. Policies and procedures were in place with regard to infection control. Staff were provided with protective aprons and disposable gloves. Liquid soap and paper towels were provided near to hand washing facilities. Staff were observed to be maintaining good hygienic practices. All laundry is undertaken on site. Residents spoken with had no adverse comments about the standard of laundry service. Although functional the laundry is quite small. The senior member of staff on duty advised that discussion had taken place about enlarging the laundry but no decision had been made. Given the size of the home it would be beneficial if the facility was extended and this is recommended. Residents spoken with and those who returned comment cards had no adverse comments regarding environmental standards in the home. One resident described the home as always being “Nice and clean”. Golborne House DS0000005735.V306697.R01.S.doc Version 5.2 Page 21 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, 29 & 30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. The staff team, were competent, efficient and committed to providing good care to the residents. Recruitment procedures for staff are robust which ensures people living in the home are protected. A comprehensive training programme is in place, which equips staff with the skills, and knowledge to meet residents assessed needs. EVIDENCE: Five care staff have recently left the homes employ to take up posts in another CLS care home. Inevitably this had some impact leading to a number of vacant posts. New staff have now been recruited and all vacancies have been filled. Three new staff have now commenced work. A further two will begin working at the home once CRB (Criminal records Bureau) checks have been returned. On the first day of the site visit both the manager and home services manager were off sick. During the visit there were four care staff working, including the Care Team Leader. While domestic and catering staff provided support, the care team leader and three care staff were extremely busy throughout the visit. Staff spoken with also confirmed this and felt additional staff at peak Golborne House DS0000005735.V306697.R01.S.doc Version 5.2 Page 22 periods would be beneficial. Information provided in the pre-inspection questionnaire indicated residents dependency levels were high. For example information indicated 10 residents had cognitive difficulties, all residents required assistance with washing/dressing and 20 residents required assistance with toileting. The time staff spent on meeting the personal care needs of the residents were as a consequence high. Although care staff were attentive to residents personal care needs they had very little time to spend quality time with residents. In addition duty rosters showed that in the evening and weekend there are four staff working on each day shift, one of these is a Care Team Leader who is counted in staffing but is responsible for the shift when the manager is not on duty. To ensure residents care needs are not compromised staff ratios should to be kept under review particularly when the manager is not on duty. 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. The files of four staff employed were examined and showed all necessary recruitment checks had been undertaken. All contained: written application forms, 3 references, Criminal Records Bureau (CRB) check and verification of identification. Good practice was noted in that any gaps of employment and the reasons for leaving previous jobs had been explored and interview notes were maintained. The home has achieved Investors in People status. 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) specifications following which foundation training is undertaken. Staff spoken with confirmed they had undertaken induction training. Samples of training records were examined. The records confirmed the wide range of courses that staff had attended and that ongoing training is available. Staff spoken with were happy with the range of training provided by the home. Mandatory training needs are well met. Recent courses undertaken include, food hygiene, fire safety, moving and handling, first aid and protection of vulnerable adults. 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. Golborne House DS0000005735.V306697.R01.S.doc Version 5.2 Page 23 Training records also show staff have undertaken a range of more specialised training, including care plan awareness, prevention of pressure sores, continence awareness, nutrition, medication and dementia care. NVQ (National Vocational Qualifications) are actively promoted. Currently 98 of staff are in receipt of NVQ level 2 and 3. This is commended as the percentage is significantly above the required standard. Golborne House DS0000005735.V306697.R01.S.doc Version 5.2 Page 24 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, 35 & 38 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. 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. Resident’s financial interests are safeguarded. The health, safety and welfare of residents and staff are promoted and protected. Golborne House DS0000005735.V306697.R01.S.doc Version 5.2 Page 25 EVIDENCE: Since the resignation of the former manager in February 2006 Diane Emmison has taken on the role of acting manager. The acting manager has worked at the home for 14 years and has six years experience in a supervisory position. Support is provided from Head Office through regular visits and telephone contact. Despite the 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. The home has now been without a registered manager for some six months. Steps need to be taken to resolve this situation and a permanent manager appointed. The responsible individual needs to be mindful that it is a condition of registration that “The service should employ a suitably qualified and experienced Manager who is registered with the CSCI”. While management arrangements are satisfactory, the current situation should not continue for an indefinite period. The person responsible must keep the CSCI informed of progress in this matter. Internal and external quality assurance systems are in place. Regular resident and staff meetings take place and are minuted. CLS representatives visit the home on a monthly basis to audit records and speak to residents and staff. A written report is 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. 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. Feedback from residents spoken with and in returned resident comment cards indicated staff listened to and acted on what they said. Records are held of all residents financial transactions. A record is kept of monies credited and debited and receipts were obtained for financial transactions. Secure facilities are provided for the safe keeping of money. However on the day of the visit the senior member of staff on duty did not have access to resident’s personal allowances. She advised that the only members of staff who had keys to the safe were the manager and the home services manager (both were off on the day of the visit). When asked what would happen if one of the residents wanted money, the care team leader advised funds were available in petty cash. Any transactions would then be debited on resident’s financial records. It is fully recognised the policy of only Golborne House DS0000005735.V306697.R01.S.doc Version 5.2 Page 26 designated staff having keys to the safe is to ensure financial interests are safeguarded, nevertheless this could lead to residents not having access to their monies. Therefore some consideration needs to be given to making alternative arrangements when designated staff are not working. With the pre-inspection materials, the manager provided a list of maintenance and associated records. Information provided indicated all were up to date. Fire safety records showed that that all fire tests and maintenance procedures had been undertaken regularly. Records also indicated that fire drills and instruction had taken place at frequent intervals. Training records indicated that training and regular updates are provided to staff in key areas such as moving and handling, fire safety, first aid, infection control, fire safety awareness etc. There were satisfactory policies and procedures in place relating to the recording and reporting of accidents to residents and staff. Samples of accident records were examined and were found to be appropriately maintained. Golborne House DS0000005735.V306697.R01.S.doc Version 5.2 Page 27 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 2 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 X X 3 Golborne House DS0000005735.V306697.R01.S.doc Version 5.2 Page 28 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 15 Timescale for action To ensure resident’s health is not 30/11/06 compromised staff must ensure weight is monitored and prompt action taken once a loss has been identified. As part of the planned 31/12/06 programme of routine maintenance and renewal the flooring in the bathroom near room 23 needs to be replaced. The registered provider must 31/12/06 appoint a permanent manager and submit their registered manager application to the CSCI. Requirement 2. OP19 16 & 23 3. OP31 8 Golborne House DS0000005735.V306697.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. 2. 3. 4. 5. Refer to Standard OP19 OP26 OP27 OP27 OP35 Good Practice Recommendations To ensure environmental standards don’t fall below an acceptable standard plans should be made to re-decorate corridors. Consideration should be given to enlarging the laundry area. To ensure staffing levels are sufficient a review of ratios should be undertaken. Consideration should be given to providing an additional member of staff at night. A system whereby residents can access their personal allowance at any time should be implemented. Golborne House DS0000005735.V306697.R01.S.doc Version 5.2 Page 30 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. Extracts may not be used or reproduced without the express permission of CSCI Golborne House DS0000005735.V306697.R01.S.doc Version 5.2 Page 31 Golborne House DS0000005735.V306697.R01.S.doc Version 5.2 Page 32 - 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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