Inspection on 11/07/06 for Goldcrest House

This inspection was carried out on 11th July 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Goldcrest House 12/06/07

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

CARE HOME ADULTS 18-65 Goldcrest House 194 Boothferry Road Goole East Yorkshire DN14 6AJ Lead Inspector David White Key Unannounced Inspection 11th July 2006 09:30 Goldcrest House DS0000064804.V295861.R01.S.doc Version 5.2 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 Goldcrest House DS0000064804.V295861.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 Adults 18-65. 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. Goldcrest House DS0000064804.V295861.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Goldcrest House Address 194 Boothferry Road Goole East Yorkshire DN14 6AJ 01924 504233 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) Genhawk Limited Mr Ralph Parish Care Home 10 Category(ies) of Learning disability (10), Sensory impairment registration, with number (10) of places Goldcrest House DS0000064804.V295861.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2005 Brief Description of the Service: Goldcrest House is owned by Genhawk Ltd and provides care and accommodation for 10 younger adults with a learning disability. The home is in the process of becoming accredited with the National Autistic Society. Goldcrest House is situated in the town of Goole in the East Riding of Yorkshire and endeavours to empower service users in order to maximise their social and independent living skills. Accommodation is provided in single rooms that have been furnished to a good standard. Service users have access to a range of shared space, including lounge, sensory room and a small well-maintained garden and patio area to the rear of the building, which is equipped with garden furniture. The current fees range from £950 to £1950 per week and do not include costs for toiletries, hairdressing and social activities. Goldcrest House DS0000064804.V295861.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report follows an unannounced site visit undertaken on the 11th July 2006. This visit was carried out by one Regulation Inspector and took 7.5 hours with 6 hours preparation time. The home was able to return the requested information before this site visit, and surveys were sent out to relatives and other professionals who had contact with the home. Comment cards were received from three relatives, a GP and a health professional. The site visit comprised of a full inspection of the premises. The care records of three service users were looked at which included service users assessments, care plans and medication records. Staff rotas and health and safety documentation were inspected. Time was spent talking to two service users, two members of care staff, the administrator and the manager of the home. The activity in the home and the interaction between service users and staff was observed. Information was also used from the Regulation Inspector’s inspection record, which detailed the history of the home and relevant information about what had been happening in the home since the previous inspection visit. The focus of the inspection was on a number of key standards, inspecting the case records of a number of service users to establish whether they corresponded with their experiences of life in the home. The manager was available throughout the inspection and the findings were discussed at the end of the inspection. What the service does well: The thorough pre-admission process ensured that prospective service users’ were only admitted to the home if their needs could be met by the staff team. Service users’ said that staff encouraged them to be independent. Care planning centred around the personal wishes and preferences of service users’ on how they wished to live their lives. Care planning information was very detailed and easy to follow so that staff were clear about what actions were needed to meet service users’ needs. Goldcrest House DS0000064804.V295861.R01.S.doc Version 5.2 Page 6 Individual risk assessments considered the benefits to service users’ from taking risks, whilst also being specific about how risks were to be managed properly to safeguard service users’ from harm. Service users’ had access to a range of activities to enable them to pursue their social and leisure interests. Service users’ were given the opportunity to voice their views and contribute towards how the home was run. Staff morale at the home was good and this helped to create a pleasant atmosphere in the home for service users’. What has improved since the last inspection? What they could do better: The home had made improvements in some aspects of the home but there were concerns in relation to the environment and some health and safety matters. The front door of the home needed to be fitted with a magnetic lock as recommended by the fire safety department so that it could open in the event of the fire alarm sounding without the need for a key to protect the safety of the service users’. Goldcrest House DS0000064804.V295861.R01.S.doc Version 5.2 Page 7 Other outstanding issues from the fire safety inspection must be addressed to promote the wellbeing and safety of the service users’. Stored hot water temperature checks needed to be carried out so that service users’ were not put at risk of harm. The downstairs bathroom and banisters on the staircases of the home were in need of re-decoration to improve the living environment for the service users’. 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. Goldcrest House DS0000064804.V295861.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Goldcrest House DS0000064804.V295861.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to the service. Proper pre-admission arrangements were in place to ensure that service users’ could have their needs met by the home. EVIDENCE: The home had a statement of purpose and service user guide which provided information to service users’ about the care and services provided by the home. Each service user had a copy of these documents in their bedroom and the home is planning to provide this information in more suitable formats for those service users’ who have communication difficulties. Three service users’ files were looked at and they identified that staff at the home collect information from a number of sources prior to admission so that they were able to make an informed decision as to whether the needs of prospective service users’ could be met. The home had not had any admissions since the previous inspection visit, however the manager said that when a referral is made to the home he would initially visit the prospective service user to decide whether it would be appropriate to offer the person a trial period at the home. Goldcrest House DS0000064804.V295861.R01.S.doc Version 5.2 Page 10 The service users’ files contained a comprehensive baseline assessment of the prospective service user’s needs and this included an assessment by a psychologist of the capabilities and specific learning disability needs of the individual. Each pre-admission assessment looked at the individual needs of the service user and a planned action of care was drawn up from this information. The daily records reflected the care that was being provided by the home. Goldcrest House DS0000064804.V295861.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. There was a clear and effective care planning system in place to provide staff with the information needed to meet service users’ needs. EVIDENCE: Three service users’ files were looked at and these all provided clear, wellorganised and easy to follow information about each service user. The plans covered a range of health, personal and social care needs and clearly stated how these were to be met. There was an emphasis on encouraging the independence of the service users’ and this was supported by a number of risk assessments in relation to aspects of daily living and which considered the gains that people would get through positive risk taking. One service user said, “I am encouraged to be independent and make my own choices”. The care plans included a personal profile on each service user, which contained information about the person’s interests and likes and dislikes. Each service user had an agreed activity timetable and a service user was able to confirm that participation in activities was optional and that staff were supportive in enabling service users’ to pursue their leisure interests. Goldcrest House DS0000064804.V295861.R01.S.doc Version 5.2 Page 12 Some of the service users’ had communication and understanding difficulties and the care plans clearly set out measures that staff needed to take to promote the service user’s level of understanding and gave specific information about the most effective way to communicate with each individual. Staff had undertaken makaton training to enable them to communicate more effectively with those service users’ who used forms of sign language to communicate. A number of individual risk assessments were in place to promote the independence of the service user and to protect their interests. Clear guidance was given to staff on agreed management strategies for areas of risk. The care records showed that input from health professionals was given and recorded. A survey returned by a care manager said that the home was good at liaising with them in the planning of a service user’s care. Care plans reviews were carried out on a regular basis to address any changing needs and involved the service user as much as possible. Goldcrest House DS0000064804.V295861.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the 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, 15, 16 and 17. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to the service. Improvements in the range of activities and recreational opportunities available to service users’ has enabled service users’ to have more choice to develop their social needs and interests. EVIDENCE: Service users’ have a range of activities to choose from both in and outside of the home. The home had developed an in-house activity programme that provided some structure during the day for those service users’ who were not attending other educational and leisure interests outside of the home. The activity programme is still being developed and included sessions on numeracy, arts and crafts and how to use computers and computer games. Some service users’ attended the local sports centre, swimming baths and pubs and discos. One of the service users’ had a work placement at a local charity shop, another had successfully completed a typing course and one service user had enrolled on a hairdressing course at the local college. At the time of the inspection visit three of the service users’ were on holiday in Yarmouth and all the other service users’ had also been on holiday. Goldcrest House DS0000064804.V295861.R01.S.doc Version 5.2 Page 14 The home had acquired a seven-seated car and this had meant that staff had more opportunities to take service users’ out for trips. The interests and hobbies of each service user were recorded within their care records and one of the service user’s who had always enjoyed going to church was able to attend the local church service every week. Daily records reflected the activities that had been undertaken by each service user. Activity planning was discussed with service users’ within the service user meetings which took place on a monthly basis and which were recorded. Visiting arrangements were flexible and service users’ could see family and friends whenever they wanted to. Service users’ did have access to a telephone in the house and some chose to have their own mobile phone. The manager explained that there had been problems with the previous telephone system and that this had caused some difficulties for people trying to contact the home who needed to speak to staff quickly. The manager had put measures in place to rectify the problem. Service users’ plan their own menus, and do their own food shopping with the support of staff. Three of the service users’ had attended a healthy eating training session that had been held at the home. The home was looking to introduce a picture exchange card (PEC) system for one of the service users’ with communication difficulties that would enable the service user to communicate their menu preferences through the use of pictures. Goldcrest House DS0000064804.V295861.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 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, 19 and 20 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to the service. The health needs of service users’ are met with good access available to specialist services when required. EVIDENCE: Staff aimed to promote the independence of the service users’ and to provide support in a sensitive manner. One service user confirmed that personal support was given to them in accordance with their wishes and staff could be observed to be providing support in a dignified manner. A comment card from a relative of a service user said that the care at the home was very good and that staff communicated well to make sure the relative was kept well informed about the care being provided. Care records stated how service users’ were to be supported. Each service user had access to a GP, a chiropodist and to dental and optical services when required although at least annual checks were carried out. Consideration was given to the physical needs of the service users’ and some of the service user’s were attending a health gym to promote their physical and mental fitness. Each six months staff undertook an overview of each service user’s general health and any outstanding matters were addressed. Records were made of any input from specialist services so that the care staff were kept informed about the care being provided by healthcare specialists and others. Goldcrest House DS0000064804.V295861.R01.S.doc Version 5.2 Page 16 The home’s medication system and facilities were inspected. Proper procedures were in place for the ordering, administration, storage, recording and disposal of medication although it was recommended that the supplying pharmacist sign the home’s disposal of medication records to confirm they had received the returned medication from the home. The Medication Administration Records (MAR) were accurate and up to date. A random check of the medication supplies was made against the MAR sheets and these tallied with the records. Staff had attended some medication training at Selby College to update their skills and knowledge. Goldcrest House DS0000064804.V295861.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 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 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Clear complaints and adult protection policies and procedures were in place and were understood by staff to safeguard service users’ from risk of abuse. EVIDENCE: The home had a complaints procedure that clearly detailed how complaints would be dealt with. A service user knew whom they needed to speak to if they had a complaint and felt confident that the manager would address any concerns properly. Five complaints had been made to the home since the previous inspection and these were logged along with the investigations and actions taken in response to the complaint. The complainant was informed in writing of the outcomes from their complaint in most cases although in one instance feedback had only been given verbally to one complainant. Two comment cards from relatives stated that they were not aware of the home’s complaints procedures. The manager said that the complaints procedure was accessible within the home, however consideration needed to be given as to how the complaints procedure was made available to all relatives including those who did not or who rarely visited the home. In the past the home had managed adult protection matters poorly. Since that time a number of measures had taken place to help protect service users’ from abuse. All the staff at the home had attended abuse awareness training. Abuse awareness also formed part of the induction training for new workers and a recently appointed member of staff was able to confirm this had taken place as part of their induction. Staff spoken to were clear about adult protection procedures and what actions to take if abuse was suspected or had happened. Goldcrest House DS0000064804.V295861.R01.S.doc Version 5.2 Page 18 Since the previous inspection visit the Commission had received an allegation of abuse in relation to some care practices in the home and this was referred immediately to the local authority for them to deal with under their adult protection procedures. The local authority had investigated this matter and no further action had been taken following their investigation. Because the alleged abuse had not been reported directly to the home it was not possible to determine whether the home would be able to deal properly with incidences or allegations of abuse to ensure service users’ would be protected from harm. The manager held a team meeting recently to update staff on what to do if they suspected abuse and all staff were given a copy of the home’s adult protection policies and procedures which they were asked to sign when they had read and understood it. Goldcrest House DS0000064804.V295861.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The environment was satisfactory, however some improvements were needed to ensure the comfort and safety of service users’. EVIDENCE: On the day of inspection the home was warm, bright and comfortable for service users’. All the service users’ were mobile and could access all parts of the home and there was ramped access to the home for people with mobility problems including wheelchair users. At the rear of the home there was a garden and paved patio area where service users’ could sit. The home was undergoing some refurbishment work and had a newly fitted kitchen. Environmental health had visited the home to confirm that the kitchen work had been completed to a satisfactory standard. The lounge and dining room areas were also newly furnished and modernised to a good standard. The laundry room had been re-located and since the previous inspection ventilation systems had been put in place in the laundry area and the laundry floor had been tiled to assist with cleaning. At the previous inspection it had been noted that one service user bedroom was in need of re-decoration and another unoccupied bedroom needed repairs to the ceiling following problems caused by water leakage. Goldcrest House DS0000064804.V295861.R01.S.doc Version 5.2 Page 20 Both those outstanding issues had been satisfactorily addressed. The home had a sensory room that promoted relaxation for service users’ and there was a staff training room that was also used to carry out activity sessions. Individual bedrooms for service users’ had been re-decorated and were clean and spacious. The maintenance and refurbishment programme was still ongoing and it was planned that all the refurbishment work would be completed by the end of 2006, however the downstairs bathroom and the banisters on the staircases looked shabby and in need of more urgent attention. The home had toilet and bathing facilities and random checks of the water temperatures from water outlets were within safe limits so that service users’ were not put at risk from scalding. Hot water temperature checks were carried out by the handyman on a monthly basis, however there were no such checks in place for the regulation and monitoring of the stored water systems to prevent risks from legionella. The manager had recently requested some general fire safety advice from the fire authority and a fire inspection visit had been carried out in May 2006. The home was undertaking some works in order to meet the recommendations of the fire authority from their visit and had addressed some of the matters raised. However other issues remained outstanding in relation to poor fitting doors and frames, replacement of hot and cold smoke seal strips and adjustment of doors and self closing devices and these needed to be addressed to promote the safety of the service users’. The manager said he had made arrangements for this work to be carried out. At the fire inspection visit it was agreed as an interim measure that members of the staff team were to have a key available with regard to the front door of the home and its use as a means of escape. The fire officer had advised that the door should be fitted with a magnetic lock that would open on activation of the fire warning system so that the door would open automatically in the event of a fire without the use of a key. However at the time of the inspection it was observed that a magnetic lock had not been fitted to the fire door and so in the event of a fire the door could only be opened by staff with a key. This potentially placed service users’ at serious risks to their safety and the matter needed to be addressed urgently. The manager said he was treating this as a matter of priority and had made arrangements for the necessary work to be completed and that he would be consulting with the fire authority to make sure they were satisfied with the actions undertaken by the home. The kitchen had recently been refurbished to a modern standard and was clean and tidy. A cleaning schedule was in place to maintain standards of cleanliness in the kitchen. The manager said that fridge and freezer temperature checks were carried out on a daily basis, however there were omissions in the records to confirm that these checks had taken place. Goldcrest House DS0000064804.V295861.R01.S.doc Version 5.2 Page 21 Whilst looking around the environment it was observed that replacements were needed for some light bulbs in the dining lounge that were not working and for two broken light shades in the lounge to ensure that service users’ had adequate lighting. Goldcrest House DS0000064804.V295861.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient staffing levels, proper recruitment procedures and a good staff training programme meant service users’ needs were met and their interests were safeguarded. EVIDENCE: At the time of the inspection there were four members of staff on duty and the manager. The staff duty rotas showed that there were usually four or five members of staff on duty during the day and two waking night staff. Staff said that the staffing levels were “fine” and service users’ commented that staff were always around to help them if assistance was required. The atmosphere in the home was relaxed, staff morale was good and work was carried out in an unhurried manner. Sufficient staffing levels had meant that the home was able to develop an extended activity programme for service users’ and the acquisition of a new car for the home had enabled staff to be able to take people out on trips on a more regular basis. Staff said that the staffing levels enabled them to provide one to one care for individuals and a service user said that they had benefited from this level of input in meeting their leisure and social needs. Goldcrest House DS0000064804.V295861.R01.S.doc Version 5.2 Page 23 The home had a structured training programme and individual records of staff training were kept within individual staff files. 80 of the staff team had attained NVQ level 2 or 3 and eight of the staff were doing the Learning Disability Award Framework (LDAF) training. Staff had received specific training on how to care for people with Autistic Spectrum Disorder and further training was planned. The staff team had attended a range of health and safety training and inspection of the staff files confirmed that all new staff had an induction programme. Staff said that training was encouraged to develop their skills and learning. Regular staff meetings were held and recorded and staff supervision systems were in place. Three staff files were looked at including those of the most recently appointed members of staff. These showed that all the necessary pre-employment checks had been carried out prior to the new workers starting in post. Recruitment procedures promoted equal opportunities and service users’ were involved in the recruitment process for new members of staff. The home had appointed a team leader to support the manager in the running of the home. The interview process for the team leader position included a written test and these were assessed by a manager from another home within Genhawk Ltd to promote non-discriminatory practices as the candidates for the post were all working at the home. Goldcrest House DS0000064804.V295861.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well run and the views of service users were acted upon, however some health and safety matters needed addressing to safeguard the interests and safety of service users’. EVIDENCE: The manager had recently been interviewed to register with the Commission as the manager of the home. He had managed the home for over two years and had completed the Registered Manager’s Award to enhance his managerial knowledge and skills. The home had a team leader who supported the manager in the running of the home. Service users’ and staff were both complimentary about the manager’s abilities. A service user said that they would feel confident that the manager would deal with concerns properly. Goldcrest House DS0000064804.V295861.R01.S.doc Version 5.2 Page 25 Members of staff said they felt “very supported” by the management of the home and one said that they felt that the home had made progress because of the good management arrangements at the home. The manager had put some systems in place to seek the views of service users’ and relatives about the care and services provided by the home. Service users’ were given questionnaires on a three monthly basis to give them the opportunity to give their views about the care and services provided by the home and there was evidence that the manager had acted on information received from these questionnaires. The care records and discussion with a service user confirmed that care plan reviews were carried out with each service user and regular service user meetings were held to discuss matters relating to the home and to plan activities. Comment cards were available at the entrance of the home to give relatives the opportunity to have their say but the manager needed to consider other means of seeking views from relatives and other professionals who had contact with the home in order to involve them in decision-making about the running of the home. The manager had various well-organised systems in place for the auditing of care practices within the home to promote good working practices. A number of health and safety certificates were looked at and were satisfactory. Staff had received updated health and safety and fire safety training and fire drills were carried out on a regular basis and were recorded. However there were some concerns about some health and safety matters. As previously mentioned in this report under the heading of environment, there were concerns that the fire door at the front entrance to the home could not be opened without the use of a key and this potentially placed service users’ at risk to their safety. Although a number of the recommendations from the fire inspection visit had been dealt with satisfactorily some recommendations remained outstanding and these needed addressing. Whilst hot water temperature checks from water outlets had been carried out on a regular basis the regulation and monitoring of stored water temperatures had not taken place and put service users’ at risk to their health. Service users’ monies were discussed and the financial systems used by the home were looked at. Each service user’s money was held individually and records were well maintained to account for incoming and outgoing monies. Service users’ had their own personal bank account and held a bankcard, which enabled them to withdraw monies from their account whenever they wanted with the support of staff where appropriate. Only small amounts of monies were held in the home and these were stored safely and a random check of the monies tallied with the records. Service users could have access to their monies at any time. Individual service user and home records were all in good order, very well organised and information was easy to access. Goldcrest House DS0000064804.V295861.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 X 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 1 X Goldcrest House DS0000064804.V295861.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? 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 YA24 Regulation 13,23 Requirement The registered person must make arrangements for the provision of a fastening to a fire door at the front entrance of the home, which will allow it to immediately open on the activation of the fire warning system without the use of a key. The registered person must consult with the fire authority to ensure that action taken conforms to fire safety standards. The management must address those issues raised within the fire officer’s report with regard to: • Poor fitting doors and frames. • Replacement of hot and cold smoke seal strips. • Adjustment of doors and self-closing devices. Re-decoration work must be carried out in the downstairs bathroom and to the banister areas on the staircases. The registered person is required to have more robust DS0000064804.V295861.R01.S.doc Timescale for action 25/07/06 2 YA24 13,23 11/07/06 3 YA24 23 30/09/06 4 YA42 13 11/07/06 Goldcrest House Version 5.2 Page 28 arrangements in place for the regulation and monitoring of stored hot water temperatures to protect the health, safety and welfare of service users’. 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 YA20 YA22 YA24 YA24 YA39 Good Practice Recommendations The supplying pharmacist should sign the disposal of medication record book to confirm that they have received the returned medication from the home. The registered person should consider ways of making sure that relatives who do not visit the home are aware of the home’s complaints procedure. Fridge and freezer temperatures checks should be recorded on a daily basis. The light bulbs that were not working in the dining room should be replaced, as should the two broken light shades in the lounge. The registered person should consider other means of seeking the views of relatives and other health professionals about the care and services provided by the home. Goldcrest House DS0000064804.V295861.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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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