Inspection on 29/11/05 for Gold Hill Residential Home

This inspection was carried out on 29th November 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

Gold Hill Residential Home 27/02/09

Gold Hill Residential Home 24/09/08

Gold Hill Residential Home 30/04/07

Gold Hill Residential Home 15/12/06

Gold Hill Residential Home 21/04/06

Gold Hill Residential Home 29/07/05

Gold Hill Residential Home 14/03/05

Gold Hill Residential Home 18/08/04

Gold Hill Residential Home 26/03/04

Gold Hill Residential Home 15/12/03

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

CARE HOMES FOR OLDER PEOPLE Gold Hill Residential Home 5 Avenue Road Malvern Worcestershire WR14 3AL Lead Inspector N Andrews Unannounced Inspection 09:30 29 November and 2 December 2005 th nd 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 Gold Hill Residential Home DS0000018654.V270253.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. Gold Hill Residential Home DS0000018654.V270253.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Gold Hill Residential Home Address 5 Avenue Road Malvern Worcestershire WR14 3AL 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) 01684 574000 Manor Care Limited Mrs Susan Carol Powell 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 of places (40) Gold Hill Residential Home DS0000018654.V270253.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The Home may also accommodate one named person with mental health needs who is below the age of 65 years. The Home may also accommodate a maximum of two people, under the age of 65, with both a mental disorder and physical disorder. The Home may also accommodate any service user who has a dementia illness who was resident in the Home on 16 November 2005. The Home will not admit any prospective service user who has a diagnosed dementia illness. 29th July 2005 Date of last inspection Brief Description of the Service: Gold Hill is a large building occupying a corner position on a hill within close proximity to the centre of Malvern. There is a theatre nearby and Malvern has all of the amenities usually associated with a small town. There are carparking facilities at the front of the premises and a garden is located at the side of the building. The premises, which were formerly used as a hotel, have been adapted for their present use as a residential care home. The home is registered to provide a residential i.e. personal, care service for a maximum of 40 older people. The service users are accommodated in 24 single bedrooms and 8 double bedrooms on four levels i.e. lower ground, ground, first and second floor. Sixteen of the single bedrooms and 7 of the double bedrooms have an en suite facility. Several of the bedrooms enjoy attractive views of the Malvern Hills and the surrounding countryside. The home has a small, twoperson passenger lift. The home also has two lounges on the ground floor and a dining room on the lower ground floor. The dining room has an adjoining conservatory that is used as a smoking area by the service users that smoke. The homes stated aim is to offer the best of care whilst preserving the right of each resident to be regarded as an individual and to assist each resident to achieve maximum independence. Gold Hill Residential Home DS0000018654.V270253.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 that took place over two days. At the time of the inspection there were 37 service users in residence in the home. A further two service users were in hospital undergoing medical assessments. The home had one vacant place. The inspection included a tour of the premises. Time was spent with the registered manager and also with the deputy manager assessing the progress made by the home in implementing the requirements and recommendations arising from previous inspections. Some of the service users’ records and staff files were inspected and individual discussions were held with three service users and two members of staff. A brief discussion was also held with two relatives of one of the service users. The three service users with whom discussions were held all spoke positively about the staff. The members of staff were described as ‘very good’ and ‘very kind’. One service user said, ‘The staff go out of their way to help you. All the staff are helpful, some particularly so’. Another service user said, ‘The staff are good. They treat you fair. They try to do their best for you and try to help you where they can. The staff are efficient and do their work well’. One service user said that the registered manager and deputy manager ‘had been very helpful and kind’. One service user said, ‘I’m being treated alright’ and another confirmed that they were treated in a respectful manner. The service users were asked about the food provided. One service user said, ‘The food is alright as far as I’m concerned’. Another service user said, ‘The food could sometimes be a bit better. The helpings could be bigger’. Another service user said that the food was, ‘mainly very good’. It was stated that the staff ‘take a lot of trouble to find out what you like and a choice of food is offered’. Two of the service users felt confident about referring any concerns that may arise to the staff. They also felt that any complaints or concerns would be dealt with quickly and appropriately. One service user confirmed that the service users were free to get up and go to bed when they wished. Another service user said that they would ‘sometimes prefer to stay up later than the staff expect’. One service user said, ‘I would like to be involved in a few more activities’. The two members of staff with whom discussions were held stated that they were happy working at the home. Both members of staff confirmed that they had received a copy of their terms and conditions of employment (contract) and a job description. They both said that they enjoyed working with their colleagues. One member of staff said that the ‘bosses were nice to work for’. It was also stated that good relationships existed between the staff and between the staff and service users. One member of staff felt that the level of staffing was sufficient to enable the staff to spend time with the service users, including escorting two service users to the shops. It was confirmed that the service users were able to get up and go to bed when they wished. The staff Gold Hill Residential Home DS0000018654.V270253.R01.S.doc Version 5.0 Page 6 suggested that the home could be improved if there were fewer sandwiches and more hot suppers for the service users, a bigger laundry and a staff room. The relatives of one of the service users with whom a brief discussion was held spoke positively about the home and the care that had been provided. They stated that the staff had been ‘very good’ and that their relative had been ‘as happy at the home as she would have been anywhere’. They said that they were pleased with the ‘support that had been provided by the district nurse and that their relative had always been kept very clean’. They said that what ‘you would expect to be done had been done’. The deputy manager, who was mentioned in particular, was described as ‘five star’. The home was inspected against 20 of the National Minimum Standards. Five of the Standards were met, ten were nearly met and five were not met. It was pleasing to note that a small number of the requirements arising from previous inspections had been implemented. In particular, those that had been outstanding for a considerable period of time e.g. the installation of thermostatically controlled mixer valves. However, the number of requirements and recommendations that needed to be addressed following this inspection was still unacceptably high. It is a matter of concern that the number of requirements had increased since the previous inspection from 32 to 38 and the number of recommendation had increased from 15 to 16. A greater effort must be made to reduce the number of requirements and recommendations to a more acceptable level. Enforcement action may be taken if these essential aspects of the home are not addressed within the timescales given. What the service does well: What has improved since the last inspection? Since the previous inspection thermostatically controlled mixer valves had been fitted to all hot water outlets used by service users. A new industrial washing machine with a programming ability had been purchased. New carpets had been provided in several bedrooms and corridors. Training for staff had been provided in various core areas including moving and handling and basic food hygiene and also in the care of people with dementia. Improvements had also been made to the premises, both internal and external. Gold Hill Residential Home DS0000018654.V270253.R01.S.doc Version 5.0 Page 7 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. Gold Hill Residential Home DS0000018654.V270253.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 Gold Hill Residential Home DS0000018654.V270253.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): 1, 4 and 5. The contents of the statement of purpose, service users’ guide and statement of terms and conditions of residence all needed to be improved. The home needed to demonstrate that the service offered to people with a dementia illness is based on current good practice and reflects relevant specialist guidance. Prospective service users had an opportunity to visit the home prior to admission. EVIDENCE: A copy of the home’s statement of purpose and service users’ guide were made available for inspection. The home’s response to the requirement that was made in regard to the statement of purpose as a result of previous inspections was assessed. The requirement was that the statement of purpose must be amended to include all of the information required by Regulation 4 and Schedule 1 as outlined in this (i.e. the previous) report. It was pleasing to note that the statement of purpose included the amendments that were referred to in the previous report. However, there was an incorrect reference to the conditions of registration at the top of page 9. This must be amended. In addition, the reference to the provision of ‘Therapeutic Activities’ on page 16 must specify in detail the therapeutic techniques used and the arrangements made for their supervision. The complaints procedure should also state that Gold Hill Residential Home DS0000018654.V270253.R01.S.doc Version 5.0 Page 10 complainants may refer a complaint to the CSCI at any stage, should the complainant wish to do so. The reference to emergency admissions on page 12 should include the information contained in Standard 5.3 of the National Minimum Standards. The statement of purpose must also include details of the services and facilities provided for service users with a dementia illness. The requirement still stands. The home’s response to the requirement and recommendation that were made in regard to the service users’ guide as a result of previous inspections was assessed. The requirement was that the service users’ guide must be amended to include all of the information referred to in Regulation 5 and Standard 1.2 as outlined in this (i.e. the previous) report, and copies given to all current and prospective service users. It was noted that the service users’ guide did not include the terms and conditions in respect of accommodation to be provided for service users including the amount of fees or a standard form of contract for the provision of services and facilities by the registered provider to service users. This information must be included. Therefore, the requirement still stands. The recommendation was that information about how to contact the local social services and health care authorities should be included in the service users’ guide. The recommendation had not been implemented and still stands. The home’s response to the requirement that was made in regard to Standard 2 as a result of the previous inspection was assessed. The requirement was that the home must provide one clear, accurate and comprehensive statement of terms and conditions of residence that includes the period of notice and all the other information detailed in Standard 2.2. A copy of the Service Users’ Agreement was made available for inspection. The Service Users’ Agreement included the period of notice but did not include any information regarding the fees payable and by whom (service user, local or health authority, relative or another) or the rights and obligations of the service user and registered provider and who is liable if there is a breach of contract. In addition, the Service Users’ Agreement contained incorrect information relating to the address of the directors and an inappropriate reference to Norfolk County Council in paragraph 2. The Service Users’ Agreement must be amended. The requirement had not been implemented and still stands. The home’s response to the two requirements that were made in regard to Standard 3 as a result of the previous inspection was assessed. The first requirement was that the home’s assessment form must be amended to include all of the issues referred to in Standard 3.3 as outlined in this (i.e. the previous) report and individuals who are self-funding and without a care management assessment must be assessed using one comprehensive and appropriately worded form in accordance with Regulation 14. A copy of the home’s assessment form was made available for inspection. It was noted that the assessment form included a direct or indirect reference to most of the issue listed in Standard 3.3. However, the assessment did not include any Gold Hill Residential Home DS0000018654.V270253.R01.S.doc Version 5.0 Page 11 reference to mental state and cognition. The requirement had not been fully implemented and still stands. The second requirement was that a clear, comprehensive and detailed assessment that identifies all of the needs of the service users must be undertaken and recorded. The requirement had not been implemented and still stands. The registered manager stated that the staff received support from external agencies in their care of the service users e.g. chiropodist and continence adviser. It was stated that the continence adviser had assessed all of the service users. The district nurse was visiting the home on a daily basis. Five service users were receiving the attention of the district nurse i.e. to give insulin, change dressings and checking blood sugar etc. The registered manager said that none of the current service users received or required the help of a physiotherapist or occupational therapist. Three service users received visits from the community psychiatric nurse from the Touchstone Centre each week. All of the service users were registered with local GPs. No specialised care is provided for the service users with a dementia illness. The home did not aim to meet the needs and preferences of people from any specific minority ethnic community, social/cultural or religious group. The registered manager confirmed that prospective service users were invited to visit the home prior to admission and that, following admission, the first four weeks were regarded as a trial (introductory) period. The registered manager, deputy manager and other senior staff were involved in visiting and assessing prospective service users in the community prior to their admission. The home avoided admitting service users in an emergency if at all possible. The home’s policy and procedure on pre-admission visits and the trial period of four weeks following admission should be clearly stated in the service users’ guide. Gold Hill Residential Home DS0000018654.V270253.R01.S.doc Version 5.0 Page 12 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 and 9 The home worked well with outside agencies to ensure that the service users’ healthcare needs were met. However, improvements were needed in regard to care plans and the administration of medication. EVIDENCE: It was confirmed that all of the service users had a care plan and that all of the care plans were in the new updated format. A copy of the care plan was made available for inspection. The care plan consisted of various forms. As a care plan the forms were confusing because they referred to assessments, personal profile, needs and preferences etc. The forms did not make clear the action that needed to be taken by care staff to ensure that all aspects of the service users’ needs were met. The deputy manager confirmed that the changes to the care plan were recorded in the daily report book and in the seniors’ handover book but not in the care plan. The reviews of the care plans were recorded on forms that were headed ‘evaluation of care’. The deputy manager completed the ‘evaluation of care’ forms in respect of each service user every month with the help of a senior member of staff. The date of the reviews should be recorded in full. It was noted that the care plan in respect of one service user had not been updated since 08/12/04. The deputy manager stated that the service users attended meetings to review their care every six or twelve months. Not all of the service users had signed the review forms. Gold Hill Residential Home DS0000018654.V270253.R01.S.doc Version 5.0 Page 13 The home’s response to the two requirements that were made in regard to Standard 7 as a result of previous inspections was assessed. The first requirement was that recordings made on a daily basis must contain adequate information about all aspects of the service users, including emotional care and social interaction. The requirement had not been implemented and still stands. The second requirement was that risk assessments must be put in place for skin care, nutrition and falls. The deputy manager stated that risk assessments had been carried out and recorded regarding falls, nutrition and skin care in respect of all service users that required them. It was stated that the district nurse carried out the risk assessments regarding skin care. Having regard to the age, infirmity and general frailty of the majority of service users the deputy manager was advised to ensure that a risk assessment was carried out and recorded on falls and nutrition in respect of all the service users. One service user who was overweight had not undergone a nutritional assessment and had not been referred to a dietician. The requirement had not been fully implemented and still stands. It was confirmed that a risk assessment had been carried out and recorded in respect of the six service users who smoked. One of the risk assessments was inspected. It was noted that the risk assessment did not include any reference to the home’s policy not to allow service users to smoke in their bedrooms or during the night and that smoking was only permitted in the designated area i.e. the conservatory on the lower ground floor. The staff were supported in their care of the service users by outside agencies. The registered manager stated that none of the service users had pressure sores. Any signs of pressure sores developing were reported to the district nurse. The district nurse provided pressure relieving mattresses and cushions. The home received visits from the community psychiatric nurses. The consultant psychiatrist monitored the care of four service users. Two service users attended reflexology sessions each week within the home. Nutritional screening had not been carried out in respect of all the service users as indicated above. The registered manager stated that dental checks were carried out ‘as and when necessary’. The registered manager confirmed that ‘none of the service users required a hearing test at present’. It was also stated that the optician visited the home every three months. The registered manager confirmed that ‘all of the service users had had their eyes tested within the last year’. The deputy manager stated that three service users had been provided with bedside rails. It was confirmed that the provision of bedside rails always followed an assessment by the district nurse. It was also confirmed that the provision of bedside rails had been recorded in the service users’ care plans and that the use of the rails was kept under regular review. A copy of the home’s policy and procedure on the administration of medication was made available for inspection. It was noted that the registered manager had reviewed the policy and procedure on 17 June 2005. The section within the procedure for dealing with errors in the administration of medication contained an out of date reference to the National Care Standards Commission Gold Hill Residential Home DS0000018654.V270253.R01.S.doc Version 5.0 Page 14 (NCSC). The wording must be replaced by a reference to the Commission for Social Care Inspection (CSCI) to which all medication errors must be reported. None of the service users had been assessed as being capable of administering their own medication. The home had suitable, lockable facilities for the safekeeping of medication including a controlled drug cupboard. It was confirmed that the registered manager, deputy manager and two other senior staff were responsible for monitoring the home’s procedure for the administration of medication. The records for the administration of medication were checked. It was noted with concern that the record for the administration of controlled drugs in respect of one service user dated 10, 13 and 22 November 2005 had not been signed for by two staff. The Medication Administration Record (MAR) Charts in respect of another service user dated 24 November 2005 also contained gaps in the recording for the administration of the morning medication. A notice of immediate requirement was issued to the registered manager in regard to this matter at the conclusion of the inspection. The home’s response to the requirement that was made in regard to Standard 9 as a result of previous inspections was assessed. The requirement was that all of the care staff must be provided with accredited training that includes basic knowledge of how medicines are used and how to recognise and deal with problems in use and the principles behind all aspects of the home’s policy on medicines handling and records. The registered manager confirmed that all of the staff involved in the administration of medication i.e. all of the senior members of staff, had undertaken the relevant training. A list of the names of all of the staff that had undertaken the training was made available. The registered manager stated that the training ‘The Safe Handling of Medicines’ was in the form of a twelve-week, distance-learning course. The requirement had, therefore, been implemented. The registered manager stated that the home had a positive relationship with the local pharmacist. It was confirmed that the pharmacist visited every month and checked the Nomad monitored dosage system used by the home. The home’s response to the two recommendations that were made in regard to Standard 10 as a result of the previous inspection was assessed. The first recommendation was that all the staff should be reminded of the importance of respecting the service users’ privacy and dignity by always knocking the bedroom doors before entering the service users’ bedrooms. The registered manager stated that all of the staff had been spoken to individually about this issue. The recommendation was, therefore, regarded as having been implemented. The second recommendation was that fixed screening should be provided in all of the double bedrooms except where the service users e.g. a married couple, have chosen not to have them. In these cases the decision of both service users should be recorded in their individual care plans. The recommendation had not been implemented and still stands. The home’s response to the requirement and recommendation that were made in regard to Standard 11 as a result of the previous inspection was assessed. The requirement was that the home’s policy and procedure on ‘Dealing with a Gold Hill Residential Home DS0000018654.V270253.R01.S.doc Version 5.0 Page 15 Dying Resident’ must be amended in accordance with Regulation 37 as outlined in the guidance given in this (i.e. the previous) report. A copy of the policy and procedure was made available for inspection. The policy and procedure had been partly amended i.e. the reference to the ‘nurse on duty’ had been changed to a more appropriate form of words. However, the policy and procedure did not include any guidance for referring the death of a service user to the CSCI in accordance with Regulation 37. This omission was pointed out to the registered manager who amended the policy and procedure during the period of the inspection. The requirement had, therefore, been implemented. However, it was also noted that that the policy and procedure did not include the correct telephone number of the CSCI. The policy and procedure should be amended accordingly. The recommendation was that the service users’ wishes concerning terminal care and arrangements after death, should be discussed, recorded in their individual care plans and carried out. The deputy manager stated that the subject of dying and death was regarded by some of the service users as a sensitive issue and, consequently, the majority of the care plans did not contain details of their funeral arrangements. The sensitivity of some of the service users and, in certain cases their relatives, in regard to this matter was acknowledged. Nevertheless, a lot of homes manage to obtain all of the appropriate information and it important that the home continues to endeavour to do the same. The recommendation had not been fully implemented and still stands. Gold Hill Residential Home DS0000018654.V270253.R01.S.doc Version 5.0 Page 16 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 The routines of daily living and activities made available were flexible and varied. EVIDENCE: The registered manager stated that the home provided musical activities, board games and chair exercises for the service users. It was also stated that a hairdresser visited the home and that the staff provided a daily manicure for the service users. Three service users visited the shops and two service users also attended a day care service at Rowan House. A mobile library service supplied the home with large print books each month. The service users’ birthdays were celebrated. Arrangements were in hand to celebrate Christmas. The arrangements included a shopping trip and a Carol service. The service users had recently been helped to write their Christmas cards. The registered manager said that mealtimes were flexible and that there was a choice of two main meals or a salad available every day. The registered manager also said that the daily routines were flexible. She confirmed that the service users got up and went to bed when they wished to and that the service users’ routines were not governed by the wishes or shift patterns of the staff. It was also confirmed that members of The Priory visited the home twice a month to hold a Communion service. Both the local vicar and the Roman Catholic priest visited the home occasionally. One service user attended pottery classes at Touchstone Day Centre. Two other service users visited a Gold Hill Residential Home DS0000018654.V270253.R01.S.doc Version 5.0 Page 17 local pub each week. The service users were informed verbally about social activities and information was also displayed on the notice board. The home’s response to the recommendation that was made in regard to Standard 13 as a result of the previous inspections was assessed. The recommendation was that relatives, friends and representatives of service users should be given written information about the home’s policy on maintaining relatives and friend’s involvement with service users at the time of an admission to the home. The service users’ guide stated, ‘Service users’ family, relatives and friends are encouraged to visit regularly and maintain contact by letter or telephone when visiting is not possible’. The recommendation was, therefore, regarded as having been implemented. Gold Hill Residential Home DS0000018654.V270253.R01.S.doc Version 5.0 Page 18 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 Changes needed to be made to the home’s policies and procedures and further training provided in order to ensure the safety and protection of the service users. EVIDENCE: A copy of the home’s policy and procedure on ‘The Protection of Vulnerable Adults’ was made available for inspection. The policy and procedure must include the address and telephone number of the Adult Protection Coordinator and the Commission for Social Care Inspection to whom all alleged or suspected cases of abuse must be referred. A copy of the home’s ‘Whistle Blowing’ policy was also made available for inspection. The policy did not make it sufficiently clear that a member of staff may refer any concern to the CSCI without the home’s internal mechanisms for investigation having to be exhausted first. The registered manager thought that the home had a copy of ‘No Secrets’. However, a copy could not be found or made available during the inspection. The registered manager was advised how to obtain a copy. The registered manager stated that no allegations or instances of suspected abuse had been reported to her or otherwise come to her attention within the past twelve months. The registered manager also confirmed that she had had no reason to be concerned about the way in which the service users were cared for by the staff. It was also confirmed that no member of staff had had to be referred for consideration for inclusion on the Protection of Vulnerable Adults (POVA) register. The registered manager stated that she had undertaken POVA training organised by the Care Homes Association during 2004. It was confirmed that the deputy manager had not undertaken POVA training. It was also stated that ‘Abuse Awareness’ training had taken place in 2004. However, a list of the names of the staff that had undertaken the training was not made Gold Hill Residential Home DS0000018654.V270253.R01.S.doc Version 5.0 Page 19 available. A copy of the home’s ‘Physical Restraint Policy’ was made available for inspection. The policy was brief but included relevant guidance for staff. The policy was last reviewed on 1 March 2004. The policy should be reviewed. The home’s response to the recommendation that was made in regard to Standard 18 as a result of previous inspections was assessed. The recommendation was that the home’s policy and procedure regarding service users’ money and financial affairs should be amended in order to include a reference to all of the issues referred to in Standard 18.6 and the guidance contained in this (i.e. the previous) report. A copy of the home’s policy and procedure on ‘Residents’ Financial Affairs’ was made available for inspection. The policy and procedure had not been amended and did not cover all of the issues referred to in Standard 18.6. For example, it did not include an appropriate reference to consultation on finances in private and did not preclude staff involvement in assisting in the making of or benefiting from service users’ wills. The recommendation had not been implemented and still stands. Gold Hill Residential Home DS0000018654.V270253.R01.S.doc Version 5.0 Page 20 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): 22, 23, 24, 25 and 26 Various improvements were needed to the environment including the service users’ bedroom accommodation. EVIDENCE: The home’s response to the one requirement and three recommendations that were made in regard to Standard 19 as a result of previous inspections was assessed. The requirement was that the rotten window frames must be replaced and others must be repainted, where necessary. It was pleasing to note that work had been undertaken to implement the requirement. However, the work had not been completed e.g. in bedrooms 2, 3, 4, 11, 12, 15 and 16 and, therefore, the requirement had not been fully implemented and still stands. The first recommendation was that consideration should be given to improving the means of access to the home for people who use wheelchairs. There was no evidence to show that the recommendation had been addressed. The need to provide appropriate access to the home for people who are permanent wheelchair users is now considered to be of sufficient importance for the recommendation to become a requirement. The second recommendation was that a programme of routine maintenance and renewal of the fabric and decoration of the premises should be produced and Gold Hill Residential Home DS0000018654.V270253.R01.S.doc Version 5.0 Page 21 implemented. The registered manager stated that she did not have a programme to make available for inspection. Therefore, there was no evidence to show that the recommendation had been implemented. The recommendation still stands. The third recommendation was that curtains or blinds should be provided in all bathroom and toilet facilities in order to enhance the privacy of the service users and to create a more homely environment. The registered manager confirmed that the recommendation had been implemented. The home’s response to the two requirements that were made in regard to Standard 20 as a result of the previous inspection was assessed. The first requirement was that all the chairs and sofas in the communal areas that are too low or worn and no longer suitable for use by service users that are frail or that have mobility problems must be replaced with more appropriate seating. The registered manager stated that new seating had been ordered and that the items should be delivered by 31 December 2005. It was pleasing to note that this matter had been progressed. However, the requirement had not been fully implemented and still stands. The second requirement was that the carpet in the dining room must be re-laid. The requirement had been implemented. The home provided a two-person passenger lift to all floors and ramped access was provided to most internal parts of the premises. Access to some of the service users’ bedrooms on the first floor was gained via three stairs. The deputy manager stated that the service users who were accommodated in this part of the home had been assessed as being physically capable of negotiating the stairs safely. The home’s response to the requirement and recommendation that were made in regard to Standard 22 as a result of the previous inspection was assessed. The requirement was that handrails must be provided in all of the corridors as outlined in this (i.e. the previous) report and grab rails in all of the communal toilets. It was noted that a grab rail had not been provided in the toilet on the second floor. The requirement had not been fully implemented. The recommendation was that the advice of a qualified occupational therapist should be sought in order to ensure that the home provides all of the recommended disability equipment and environmental adaptations to meet the needs of the service users. The registered manager stated that the occupational therapist had been contacted but had not yet visited the home. The recommendation had, therefore, not been fully implemented and still stands. A mobile hoist was kept on the lower ground floor. The registered manager stated that the passenger lift was used to transfer the hoist for use on the other floors. The home also had an assisted bath i.e. a manually operated hoist, on the second floor and a portable, battery-operated hoist. The registered manager stated that several service users were able to use the bath without the need for a hoist and several service users used their en suite bathing facilities. Two service users had poor eyesight as a result of glaucoma. However, it was stated that their visual impairment did not severely restrict what they were able to do i.e. read and Gold Hill Residential Home DS0000018654.V270253.R01.S.doc Version 5.0 Page 22 watch television. It was confirmed that audio-cassettes would be provided for them from the mobile library, if necessary. The registered manager confirmed that there was sufficient storage space within the home and, in addition, a garage and two garden-sheds outside. A staff alarm call system was installed throughout the home. As a pre-existing home i.e. a care home that was registered prior to 1 April 2002, Gold Hill did not have to meet the present space standards in regard to bedroom sizes. The home had 24 single bedrooms and 8 double bedrooms. Sixteen single bedrooms and 7 double bedrooms had an en suite facility. The information provided by the home indicated that one single bedroom was below 10 sq. metres in size and that all of the double bedrooms were above 16 sq. metres in size. Two of the service users were permanent wheelchair users. The size of their bedroom accommodation was satisfactory. The room dimensions and layout options of at least two of the single bedrooms were not able to ensure that there was room on either side of the bed to enable access for carers and any equipment needed. The home’s response to the two requirements that were made in regard to Standard 24 as a result of the previous inspection was assessed. The first requirement was that all of the items of furniture specified in Standard 24, as outlined in this (i.e. the previous) report, must be provided in rooms occupied by service users. The service users’ bedrooms where deficiencies in the facilities provided had been previously identified were inspected. The following deficiencies were noted, • Bedrooms 4 and 29 – there was no carpet, only one accessible double electric socket and comfortable seating for only one person. • Bedrooms 5, 6, 9, 16 and 21 - there was only one accessible double electric socket. • Bedroom 10 – there was only one bedside table, no fixed screening and no bedside lighting. • Bedroom 11 – there was no bedside lighting and no lockable storage space. • Bedroom 14 – there was no fixed screening, only one accessible double electric socket and only one bedside table. • Bedrooms 15, 17 and 32 – there was comfortable seating for only one person. • Bedroom 19 – there was no fixed screening, the pipe work in the en suite facility needed to be boxed and some of the tiles below the wash hand basin were in need of replacement. • Bedroom 22 – there was no bedside lighting, no bedside table and no window restrictor. • Bedroom 23 – there was no fixed screening. • Bedroom 24 – there was comfortable seating for only one person and the floor covering in the en suite facility was in need of replacement. • Bedroom 28 – there was no carpet and no bedside lighting. Gold Hill Residential Home DS0000018654.V270253.R01.S.doc Version 5.0 Page 23 Bedroom 33 – there was comfortable seating for only one person and only one accessible double electric socket. • Bedroom 30 – the carpet was in need of replacement. The requirement, therefore, had not been implemented and still stands. The second requirement was that all stained baths and wash hand basins must be replaced with new baths and wash hand basins as indicated in this (i.e. the previous) report. The baths and wash hand basins were inspected. It was pleasing to note that some improvements had taken place in regard to this requirement since the previous inspection. The registered manager stated that the wash hand basin in the communal toilet on the second floor was being replaced during the inspection. However, it was noted that the baths in the en suite facilities of bedrooms 22, 24 and 26 were still in need of resurfacing or replacement. The requirement, therefore, had not been fully implemented and still stands. The home was centrally heated and the service users’ bedrooms were individually and naturally ventilated. The home’s response to the three requirements and one recommendation that were made in regard to Standard 25 as a result of the previous inspection was assessed. The first requirement was that thermostatically controlled mixer valves must be fitted to all hot water outlets used by service users, including the wash hand basins in their bedrooms, in order to prevent the risk of scalding. The registered manager confirmed that the requirement had been implemented. The second requirement was that portable heaters must be removed from all areas of the home used by service users, including the service users’ bedrooms. The registered manager stated that portable heaters had been used in two bedrooms. However, she confirmed that the heaters had been removed. The requirement, therefore, had been implemented. The third requirement was that pipe work in areas used by service users must be guarded. The registered manager stated that work was being carried out to address this issue and had almost been completed. However, the requirement had not been fully implemented and still stands. The recommendation was that the service users should be able to control the heating in their own bedrooms. The registered manager stated that she had contacted Advance Heating regarding this issue and that the heating company had written to the registered provider. It was stated that the matter would be dealt with when the project was taken on by the heating company. However, the recommendation had not yet been implemented and still stands. The laundry was inspected. The laundry contained liquid soap and paper towel dispensers. It was noted that the paint on the walls was flaking. However, the laundry walls were re-painted during the inspection. It was also noted that a new industrial washing machine with a sluicing facility had been provided. The home’s response to the three requirements that were made in regard to Standard 26 as a result of the previous inspection was assessed. The first requirement was that hand washing facilities must be prominently sited in the laundry. The requirement had been implemented. The second requirement Gold Hill Residential Home DS0000018654.V270253.R01.S.doc Version 5.0 Page 24 • was that evidence must be provided to show that all the staff have been trained in, and that they adhere to the correct procedures and practices for dealing with the disposal of soiled linen. The registered manager stated that she and the deputy manager had provided training to all of the staff regarding the correct procedures and practices for the disposal of soiled linen during a two-week period in September 2005. A record of the names of all the staff that had undertaken the training together with their signatures and dates was made available for inspection. In addition, the registered manager stated that the home had also issued a leaflet to all the staff called ‘Training Supplement Infection Control (including MRSA). The requirement had been implemented. It was stated that a trolley was used for transporting soiled linen through the dining room to the laundry. The third requirement was that the home must be kept free from offensive odours, in particular bedrooms 2 and 19. No offensive odours were apparent in the home during the inspection. The requirement, therefore, was regarded as having been implemented. Copies of the home’s ‘Policy for the Control of Infection’, ‘Infection Control Procedures’ and ‘Soiled Linen Policy’ were made available for inspection. The policies and procedures did not refer to dealing with spillages. The home’s infection control policies and procedures must be amended in order to include dealing with spillages. The registered manager was advised to obtain a copy of the Guidelines for Infection Control in Care Homes (2003) produced by Herefordshire and Worcestershire Local Health Protection Unit to assist this process. The registered manager stated that the quality of the home’s water supply had been tested during 2005. A copy of the ‘Bacteriological Analysis Certificate of Results’ in regard to water tests dated 11 July 2005 was made available for inspection. The results showed that the tests for Legionella were negative. Gold Hill Residential Home DS0000018654.V270253.R01.S.doc Version 5.0 Page 25 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 and 30 The staff were deployed in a satisfactory way. However, the staff recruitment procedures needed to be more robust in order to ensure the safety and protection of service users. The home provided induction and other relevant forms of training for the staff. However, the staff training records needed to be updated. EVIDENCE: The home maintained a recorded staff rota showing the names of the staff that were on duty at any time of the day or night. It was confirmed that usually the registered manager and deputy manager were on duty throughout the day Monday to Friday. In addition to the catering, domestic and maintenance staff, two senior staff and four care staff were normally on duty during the day. In the evenings, one senior member of staff and three care staff were on duty together with one kitchen assistant and one ‘supper cook’. Three members of staff were employed to carry out domestic duties. The registered manager confirmed that one senior member of staff and three care assistants were always on waking duty at night. The home did not employ any staff for ‘sleeping-in’ duties. The registered manager stated that the ‘geography of the home prevented any problems with staff falling asleep on duty’. The registered manager stated that she made spot checks on the night staff approximately every two months. One member of staff who was below the age of 21 years was employed to work in the evenings to help with washing up and setting the tables. The home’s response to the requirement that was made in regard to Standard 29 as a result of the previous inspection was assessed. The requirement was Gold Hill Residential Home DS0000018654.V270253.R01.S.doc Version 5.0 Page 26 that staff files must contain all the information and documents listed in Schedule 2. The files of three members of staff were inspected. It was noted with concern that the file in respect of one member of staff did not contain a photograph, a full employment history or a second written reference. (The second written reference arrived on the day of the inspection). The same file and the file in respect of another member of staff did not contain any declaration of offences. The registered manager stated that she had issued the wrong application forms and that the correct application forms did include an appropriate statement requiring prospective staff to declare any convictions/cautions for any past offences. The registered manager was reminded of the importance of obtaining all of the relevant information in regard to prospective staff prior to their appointment and of the importance of following the correct staff recruitment procedures. The requirement had not been implemented and still stands. A notice of immediate requirement was issued to the registered manager in regard to this matter at the conclusion of the inspection. It was also noted with concern that the file in respect of one member of staff did not contain a recent Criminal Records Bureau (CRB) disclosure check and in the case of another member of staff the CRB disclosure check had been obtained after the person had commenced employment at the home. The registered manager was reminded of the importance of obtaining an enhanced disclosure check from the CRB in regard to all prospective staff prior to the commencement of their employment at the home in order to ensure the safety and protection of the service users. A notice of immediate requirement was issued to the registered manager in regard to this matter at the conclusion of the inspection. The registered manager was also given advice regarding the correct procedure to follow in cases where prospective staff had declared a conviction/caution for offences. The home had a recognised induction-training programme that is modulebased. Two members of staff had commenced the induction training. However, the training needed to be progressed further. The registered manager stated that foundation training was not undertaken because the staff employed were either already long-serving and/or experienced or went straight on to undertake the NVQ level 2 training. The registered manager stated that all the staff had a minimum of three paid days training per year. It was also confirmed that each member of staff had an individual training and development assessment and profile called a ‘Training Needs Assessment Form’. However, it was noted that the forms needed to be updated. For example, the last recorded moving and handling training for two members of staff were 3 October 2001 and 21 May 2003, respectively. Similarly, the last recorded fire safety training was 30 January 2002 and 15 April 2002, respectively. The registered manager stated that she had not had the time to keep the records up to date. There was no record of the staff having undertaken any training in the protection of vulnerable adults from abuse. Gold Hill Residential Home DS0000018654.V270253.R01.S.doc Version 5.0 Page 27 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, 34, 37 and 38 The procedures for handling the service users’ personal allowances had become more transparent. However, the standard of the home’s record keeping and system for monitoring the quality of the service needed to be improved. EVIDENCE: The home’s response to the requirement that was made in regard to Standard 31 as a result of the previous inspection was assessed. The requirement was that a disclosure check from the Criminal Records Bureau must be obtained by the registered manager. The registered manager stated that, since the previous inspection, she had made an application for a CRB disclosure check through the CSCI. The CSCI records showed that no recent disclosure application had been received. The registered manager was given advice on this matter. The requirement had not been implemented and still stands. The home’s response to the two recommendations that were made in regard to Standard 32 as a result of the previous inspection was assessed. The first Gold Hill Residential Home DS0000018654.V270253.R01.S.doc Version 5.0 Page 28 recommendation was that an attempt should be made to reintroduce a key worker system for the benefit of the service users. The registered manager stated that the senior staff ‘tended to take on the role of key workers’. However, the recommendation had not been implemented and still stands. The second recommendation was that the home should introduce management planning and practice that will encourage innovation, creativity and development. The recommendation had not been implemented and still stands. The home had commercially produced quality assurance system that had been purchased fro Mulberry House. However, it was not being operated. The last recorded checks had been made in December 2003. The home’s response to the requirement and recommendation that were made in regard to Standard 33 as a result of the previous inspection was assessed. The requirement was that an annual development plan for the home, based on a systematic cycle of planning, action, review, reflecting aims and outcomes for service users, must be introduced in accordance with the requirements of Regulation 24 and Standard 33. The requirement had not been implemented and still stands. The recommendation was that the results of service user surveys should be published and made available to current and prospective service users, their representatives and other interested parties, including the CSCI. The registered manager said that some of the responses from the questionnaires that had been issued had still not yet been received. Consequently, the results of the survey had not been analysed or published. The registered manager also stated that positive feedback had been obtained from the service users’ reviews. However, the recommendation had not been implemented and still stands. There was no evidence to demonstrate the home’s commitment to lifelong learning and development for each service user. The registered manager said that service users’ meetings were held every month and notes of their views and comments were recorded in the ‘Residents’ Comments Book’. Six ‘comments’ were recorded during 2005. The most recent ‘comment’ was dated 5 August 2005. There was scope for recording the service users’ comments more frequently i.e. at least every month following the service users’ meetings. The registered manager said that questionnaires had been issued to the service users, their relatives and to other stakeholders in October 2005. However, only twelve responses had so far been received. Not all of the home’s policies and procedures were being regularly reviewed and action to implement requirements identified in inspection reports was not being progressed within agreed timescales. The home’s response to the recommendation that was made in regard to Standard 34 as a result of the previous inspection was assessed. The recommendation was that a business and financial plan for the establishment should be drawn up, made open to inspection and reviewed annually. The registered manager stated that a copy of the business plan was not maintained in the home and was, therefore, not available for inspection. The recommendation, therefore, still stands. The home had a copy of a valid Gold Hill Residential Home DS0000018654.V270253.R01.S.doc Version 5.0 Page 29 employers liability insurance certificate provided by Fortis for not less than £5m. The certificate expired on 31 March 2006. The home’s response to the requirement that was made in regard to Standard 35 as a result of the previous inspection was assessed. The requirement was that the practice and procedure for handling the service users’ money must be revised in order to ensure that it is clear, detailed and accurate. The registered manager stated that the former practice of invoicing the service users’ relatives at the end of each month for the expenses incurred by the service users had ceased. The home now handled the personal allowances in respect of 24 service users. A member of staff was the Appointee for one service user. The practice whereby any member of staff or anyone connected with the running of the home acts as the Appointee or agent on behalf of any service user should be avoided wherever possible. It was confirmed that the home kept the money that was held for all of the service users in individual wallets in a lockable storage facility. Each service user had an ‘Allowance Sheet’ on which all incoming and outgoing amounts were recorded and dated. The system for recording the service users’ money was checked and the amounts held and the records maintained tallied. Receipts were issued for the money that was spent in respect of the service users’ personal expenses e.g. newspapers, toiletries, hairdressing and chiropody. The requirement had been implemented. The home’s response to the requirement that was made in regard to Standard 36 as a result of the previous inspection was assessed. The requirement was that care staff must receive formal supervision at least six times a year that includes all aspects of practice, philosophy of care in the home and career development needs. It was pleasing to note that the staff files that were inspected contained evidence to show that most of the supervision meetings that were taking place were being held at the required frequency. However, one member of staff had not attended any individual supervision meetings during 2005 and two members of staff had had only two supervision meetings during 2005 i.e. on 6 May and 20 September 2005 and 17 May and 14 August 2005 respectively. There was no record of any individual supervision meetings for the deputy manager. The requirement, therefore, had not been fully implemented and still stands. The records maintained by the home were inspected. The home maintained most of the records that it was required to keep. It was noted, however, that the accident book contained a record of 77 accidents since 1 April 2005. The registered manager was advised to continue to ensure that a record was kept of all the accidents that occurred, including minor accidents. The registered manager was also advised to check the records regularly e.g. at least monthly, to see if any patterns were emerging that would indicate the need to carry out or review risk assessments, change care practices or to increase the levels of care provided etc. The home had received five complaints since February 2005, two of which had been made by the same service user. The complaints Gold Hill Residential Home DS0000018654.V270253.R01.S.doc Version 5.0 Page 30 had been dealt with satisfactorily. The fire records were checked. It was noted with concern that the record of the last fire alarm test was dated 5 November 2005. The registered manager stated that the fire alarms had been tested by ADT on 25 November 2005. The registered manager also stated that it had been confirmed that all of the fire safety precautions were satisfactory. A member of staff stated that the fire alarms had been tested but that she had forgotten to record the tests. Fire alarm tests must be carried out weekly and recorded at the time that the tests are undertaken. A notice of immediate requirement was issued to the registered manager in regard to this matter at the conclusion of the inspection. The home’s response to the requirement that was made in regard to Standard 37 as a result of the previous inspection was assessed. The requirement was that a visit to the home by the registered provider must take place at least once a month and a written report on the conduct of the home supplied to the CSCI and the registered manager in accordance with the requirements of Regulation 26. The registered manager stated that she did not have any reports made in accordance with Regulation 26. The CSCI had received only one copy of a report made in accordance with Regulation 26 that was dated 28 October 2005. The requirement, therefore, had not been implemented and still stands. Copies of the statement of the procedures to be followed in the event of accidents and in the event of a service user becoming missing were made available for inspection. The procedure to be followed in the event of accidents contained an out of date reference to the National Care Standards Commission. The reference should be removed and replaced with a statement that all accidents in the home must be reported to the Commission for Social Care Inspection (CSCI) in accordance with Regulation 37. The accident procedure should also include an appropriate reference to the administration of first aid and to summoning the emergency services where necessary. Similarly, a statement should be included in the procedure to be followed in the event of a service user becoming missing that all such incidents must be reported to the CSCI without delay in accordance with Regulation 37. The risk assessments for the safe working practice topics covered in Standard 38 were made available for inspection. Risk assessments for some of the topics referred to in Standards 38.2 and 38.3 had not been carried out or had not been reviewed since 2000 or 2001. The registered manager stated that she had not had the time to carry out all of the risk assessments. A notice of immediate requirement was issued to the registered manager in regard to this matter at the conclusion of the inspection. The home’s response to the five requirements that were made in regard to Standard 38 as a result of the previous inspection was assessed. The first requirement was that arrangements must be made to ensure that all the staff received suitable training in infection control, food hygiene, and health and safety in accordance with Regulations 13 and 18 and Standard 38.2. The registered manager stated that some staff had still not undertaken training in infection control. It was stated that all the staff that had not yet undertaken the infection control training would complete the training in January 2006. The registered manager Gold Hill Residential Home DS0000018654.V270253.R01.S.doc Version 5.0 Page 31 stated that all the members of staff, except eight who were not involved in the preparation and handling of food, had undertaken food hygiene training. The registered manager also stated that all the staff had received updated training in health and safety. However, the information contained in the Training Needs Analysis dated June 2005 provided for inspection by the registered manager indicated that a total of twelve members of staff had not undertaken any training in health and safety. The requirement had not been fully implemented in respect of infection control training or health and safety and, therefore, this element of the requirement still stands. The second requirement was that a risk assessment must be carried out, recorded and kept under review in respect of the service user who uses a wheelchair without footplates attached. It was confirmed that this requirement had been implemented. The deputy manager also confirmed that a note of the service user’s refusal to have footplates attached to her wheelchair was recorded in her care plan. The risks to the service user and the potential adverse criticism of the staff in the event of an accident occurring were discussed. The deputy manager stated that the service user’s husband would be asked to sign an appropriately worded statement acknowledging the service user’s decision. The third requirement was that a valid electrical safety certificate for the home provided by a qualified electrician must be obtained and made available for inspection. The registered manager stated that phase two of the outstanding work to upgrade the home’s electrical system had not yet been completed. The requirement had, therefore, not been implemented and still stands. The fourth requirement was that opening restrictors must be fitted to the windows in bedrooms 7 and 22. The requirement had not been implemented and still stands. The fifth requirement was that the carpet near to the door opening to bedroom 19 must be re-laid. The requirement had been implemented. Gold Hill Residential Home DS0000018654.V270253.R01.S.doc Version 5.0 Page 32 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 1 1 X 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X X X 2 3 1 2 2 STAFFING Standard No Score 27 3 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 2 X X 2 1 Gold Hill Residential Home DS0000018654.V270253.R01.S.doc Version 5.0 Page 33 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 Requirement The statement of purpose must be amended to include all of the information required by Regulation 4 and Schedule 1 as outlined in this report. (Previous timescale of 30/09/05 not met). The service users guide must be amended to include all of the information referred to in Regulation 5 and Standard 1.2 as outlined in this report, and copies given to all current and prospective service users. (Previous timescale of 30/04/05 not met). The home must provide one clear, accurate and comprehensive statement of terms and conditions of residence that includes all of the information detailed in Standard 2.2. (Previous timescale of 30/09/05 not met). The homes assessment form must be amended to include all of the issues referred to in Standard 3.3, including mental state and cognition, and individuals who are self-funding DS0000018654.V270253.R01.S.doc Timescale for action 31/01/06 2. OP1 5 31/01/06 3. OP2 5 31/01/06 4. OP3 14 31/01/06 Gold Hill Residential Home Version 5.0 Page 34 5. OP3 14 6 OP4 12 7 OP7 15 8 OP7 15 9 OP7 13,15 10 OP7 13,15 11 OP9 13 and without a care management assessment must be assessed using one comprehensive and appropriately worded form in accordance with Regulation 14. (Previous timescale of 30/09/05 not met). A clear, comprehensive and detailed assessment that identifies all of the needs of the service users must be undertaken and recorded. (Previous timescale of 30/09/05 not met). The home must be able to demonstrate that the care provided for service users with a dementia illness is based on current good practice and reflects specialist guidance. The care plans in respect of each service user must include all of the aspects of care referred to in Standard 3.3 reviewed every month and any changes recorded, signed and dated. Recordings made on a daily basis must contain adequate information about all aspects of the service users, including emotional care and social interaction. (Previous timescale ‘with immediate effect not met). Risk assessments must be put in place for nutrition and falls. Service users who are significantly overweight or underweight should be referred to a dietician. (Previous timescale of 30/09/05 not met). The risk assessments on smoking must be reviewed in order to ensure that they include all of the relevant control measures in accordance with the guidance outlined in this report. The reference to the NCSC in the home’s procedure for dealing DS0000018654.V270253.R01.S.doc 31/01/06 31/03/06 31/01/06 31/01/06 31/01/06 31/01/06 31/01/06 Page 35 Gold Hill Residential Home Version 5.0 12 OP9 13 13 OP18 12,13 14 OP18 12,13 15 OP18 12,13,18 16 OP19 23 17 OP19 13,23 18 OP20 16 with errors in the administration of medication must be deleted and replaced with a reference to the CSCI and a statement that all errors in administration must be reported to the CSCI in accordance with Regulation 37. The records of the administration of the service users’ medication must be checked at regular and frequent intervals by senior staff, e.g. daily, in order to ensure that they are fully and accurately maintained at all times. The home’s policy and procedure on ‘The Protection of Vulnerable Residents’ must include the full address and telephone number of the Adult Protection Coordinator and the CSCI to whom all cases of suspected or alleged abuse must be reported. The home’s ‘Whistle Blowing’ policy must be amended in line with the Public Interest Disclosure Act 1998 to make it clear that any concerns may be referred to the CSCI without the home’s internal investigation mechanisms having to be exhausted first. Training in the protection of vulnerable adults from abuse must be provided for all the staff including the deputy manager. The rotten window frames must be replaced and others must be repainted, where necessary. (Previous timescale of 31/10/05 not met). An appropriate means of access at the entrance of the home i.e. a permanent ramp, must be provided for people who use wheelchairs. All the chairs and sofas in the communal areas that are too low or worn and no longer suitable DS0000018654.V270253.R01.S.doc 02/12/05 31/01/06 31/01/06 31/03/06 31/03/06 31/03/06 31/12/05 Gold Hill Residential Home Version 5.0 Page 36 19 OP22 13,16 20 OP24 16 21 OP24 16,23 22 OP25 13 23 OP26 13 24 OP29 17,19 25 OP29 19 for use by service users that are frail or that have mobility problems must be replaced with more appropriate seating. (Previous timescale of 31/10/05 not met). A grab rail must be provided in the communal toilet on the second floor. (Previous timescale of 30/09/05 not met). All of the items of furniture specified in Standard 24, as outlined in this report, must be provided in rooms occupied by service users. If the provision of any item poses an unacceptable risk to the service user or they decline the provision, details of the discussions and decision about this should be recorded in the assessment of the service users needs. (Previous timescale of 30/09/05 not met). All stained baths and wash hand basins must be resurfaced or replaced with new baths and wash hand basins as indicated in this report. (Previous timescale of 31/10/05 not met). Pipe work in areas used by service users must be guarded. (Previous timescale of 31/10/05 not met). The home’s infection control policies and procedures must be amended in order to include dealing with spillages and other relevant information. Staff files must contain all the information and documents listed in Schedule 2. (Previous timescale of 30/09/05 not met). Two relevant, written references must be obtained in respect of all prospective staff prior to the commencement of their employment at the home and any gaps in employment records DS0000018654.V270253.R01.S.doc 31/01/06 31/01/06 31/01/06 31/01/06 31/01/06 31/01/06 02/12/05 Gold Hill Residential Home Version 5.0 Page 37 26 OP29 19 27 OP30 17,18 28 OP31 19 29 30 OP33 OP33 24 24 31 OP36 18 32 OP37 13,17,23 33 OP37 26 must be explored. An enhanced disclosure check must be obtained from the CRB in respect of all prospective staff prior to the commencement of their employment at the home. The records of the training provided for or to be undertaken by staff as detailed in the individual training and development assessments and profiles must be kept up to date. A new disclosure application must be made to the Criminal Records Bureau by the registered manager. (Previous timescale ‘with immediate effect’ not met). The home’s quality assurance system must become fully operational and effective. An annual development plan for the home, based on a systematic cycle of planning, action, review, reflecting aims and outcomes for service users, must be introduced in accordance with the requirements of Regulation 24 and Standard 33. (Previous timescale of 30/09/05 not met). Care staff, including the deputy manager, must receive formal supervision at least six times a year that includes all aspects of practice, philosophy of care in the home and career development needs. (Previous timescale of 31/10/05 not met). Fire safety checks must be carried out and recorded in respect of all fire safety equipment, including fire alarms and fire extinguishers. A visit to the home by the registered provider must take place at least once a month and a written report on the conduct of the home supplied to the CSCI DS0000018654.V270253.R01.S.doc 02/12/05 31/01/06 31/01/06 31/01/06 31/01/06 31/03/06 02/12/05 31/01/06 Gold Hill Residential Home Version 5.0 Page 38 34 OP37 17 35 OP38 13 36 OP38 13,18 37 OP38 13 38 OP38 13 and the registered manager in accordance with the requirements of Regulation 26. (Previous timescale of 30/09/05 not met). The statements of the procedure to be followed in the event of accidents and in the event of a service user becoming missing must be amended in accordance with the guidance given in this report. Risk assessments must be carried out and recorded for all the safe working practice topics covered in Standards 38.2 and 38.3. Arrangements must be made to ensure that all the staff receive suitable training in infection control and health and safety in accordance with Regulations 13 and 18 and Standard 38.2. (Previous timescale of 30/09/05 not met). A valid electrical safety certificate for the home provided by a qualified electrician must be obtained and made available for inspection. (Previous timescale of 31/08/05 not met). Opening restrictors must be fitted to the windows in bedrooms 7 and 22. (Previous timescale of 30/09/05 not met). 31/01/06 09/01/06 31/01/06 31/03/06 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Gold Hill Residential Home DS0000018654.V270253.R01.S.doc Version 5.0 Page 39 1 2 3 OP1 OP5 OP10 4 5 6 7 OP11 OP11 OP18 OP18 8 9 OP19 OP22 10 11 OP25 OP26 12. 13. 14. OP32 OP32 OP33 15 OP33 Information about how to contact local social services and health care authorities should be included in the service users’ guide. The home’s policy and procedure on pre-admission visits and the four-week trial period following admission should be clearly stated in the service users’ guide. Fixed screening should be provided in all of the double bedrooms except where the service users e.g. a married couple, have chosen not to have them. In these cases, the decision of both service users should be recorded in their individual care plans. The home’s policy and procedure on ‘Dealing with a Dying Resident’ should include the correct telephone number of the CSCI. The service users wishes concerning terminal care and arrangements after death, should be discussed, recorded in their individual care plans and carried out. A copy of ‘No Secrets’ should be obtained and kept in the home. The homes policy and procedure regarding service users money and financial affairs should be amended in order to include a reference to all of the issues referred to in Standard 18.6 and the guidance contained in this report. A programme of routine maintenance and renewal of the fabric and decoration of the premises should be produced and implemented. The advice of a qualified occupational therapist should be sought in order to ensure that the home provides all of the recommended disability equipment and environmental adaptations to meet the needs of the service users. The service users should be able to control the heating in their own bedrooms. The home should obtain a copy of the ‘Guidelines for Infection Control in Care Homes (2003)’ produced by Herefordshire and Worcestershire Local Health Protection Unit. A key worker system should be introduced for the benefit of the service users. The home should introduce management planning and practice that will encourage innovation, creativity and development. The results of service user surveys should be published and made available to current and prospective service users, their representatives and other interested parties, including the CSCI. The home should be able to demonstrate a commitment to lifelong learning and development for each service user, DS0000018654.V270253.R01.S.doc Version 5.0 Page 40 Gold Hill Residential Home 16 OP34 linked to implementation of their individual care plans. A business and financial plan for the establishment should be drawn up, made open to inspection and reviewed annually. Gold Hill Residential Home DS0000018654.V270253.R01.S.doc Version 5.0 Page 41 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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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