Inspection on 12/09/05 for Goldenley

This inspection was carried out on 12th September 2005.

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

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

Other inspections for this house

Goldenley 13/02/09

Goldenley 24/11/08

Goldenley 14/08/07

Goldenley 27/09/06

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

CARE HOMES FOR OLDER PEOPLE Goldenley 11-15 Richmond Avenue South Benfleet Essex SS7 5HE Lead Inspector Mrs Sharon Lacey Unannounced Inspection 12th September 2005 10:00 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 Goldenley DS0000062909.V250717.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. Goldenley DS0000062909.V250717.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Goldenley Address 11-15 Richmond Avenue South Benfleet Essex SS7 5HE 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) 01268 758487 Excelcare Holdings Mrs Christine Ann Castle Care Home 38 Category(ies) of Dementia - over 65 years of age (27), Old age, registration, with number not falling within any other category (38) of places Goldenley DS0000062909.V250717.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person will maintain staffing levels at those declared at the point of registration. Any subsequent review will be undertaken in consultation with the Commission and with reference to the needs of the service user. The service users bedrooms with an area of less than 10 sq.m will be used only following a written assessment. The assessment should include consideration of whether the facilities in the room are suitable for, and acceptable to the service user, taking into account their mobility needs. The service user plan should reflect the assessment of findings. 7th February 2005 2. Date of last inspection Brief Description of the Service: Goldenley is a purpose built home providing accommodation and twenty-four hour residential care for up to 38 older people. The Registration category permits the home to provide care to those service users with dementia. The premises consists of four units (Appleton, Castle, Hardy and Priory), each has its own lounge, dining area, kitchenette, bathrooms and toilets. Goldenley is situated close to the local shopping area of South Benfleet. There are good bus and train links to the area. There is limited parking to the side of the property, but two public car parks are very close if needed. Goldenley DS0000062909.V250717.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Goldenley changed ownership in March 2005 and is now owned by Excelcare, this is their first Inspection. This was a routine, Unannounced Inspection, which took place over eight hours. A tour of the home was completed and also an inspection of relevant records and documentation took place. Areas looked at included information given to residents before being admitted to Goldenley; information gained when residents first come into the home; how information is given to staff on the care required; the facilities and environment of the home; and any complaints that may have been received since the last inspection. Also staffing and management of the home were inspected. During the tour of the home five residents and three relatives were spoken to about their life and experiences at Goldenley. Many of the other residents approached were unable to express their thoughts and feelings, but it was noted that all were clean, tidy and well presented. Five staff members were spoken with during the Inspection and this feedback has been included as part of the report. At the end of the day the Inspection was discussed with the Manager and advice and guidance was given regarding the findings. What the service does well: What has improved since the last inspection? Many of the staff have now completed their NVQ training and the home has over 50 of its staff trained. The Manager has also completed her NVQ 4. The Home now has a Quality Assurance system in place, which approaches staff, residents and relatives for feedback on the home. Goldenley DS0000062909.V250717.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Goldenley DS0000062909.V250717.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Goldenley DS0000062909.V250717.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, and 5. Paperwork completed at the assessment stage does not gain sufficient information. Present and prospective residents are given written information about the home to help them choose. EVIDENCE: The home’s has a Statement of Purpose and Service User Guide contains details of the home and also the services provided. An up to date copy of the Service Users Guide and Statement of Purpose were obtained during this Inspection. The Manager confirmed that new and prospective residents are given copies during the assessment process, but this had not routinely been evidence on the files inspected. Excelcare has a written contract/terms and conditions of the home, but only one of the three files inspected contained a copy. It was also noted that the Terms and Conditions included details of ‘ensuite rooms’, which Goldenley does not have. Goldenley DS0000062909.V250717.R01.S.doc Version 5.0 Page 9 Due to the recent change of ownership, the home is in the process of introducing new paperwork and procedures to assess new Residents. Three files were inspected and the paperwork did not gather enough information to ensure the home could provide the care required. The Manager described a thorough admission process and explained that no one moves into the home without a home visit to ensure they are able to meet their needs. Anyone being admitted to the home is invited to visit with their relatives or friends, but this is not at present routinely evidenced. The home had sufficient equipment appropriate to the care it provides. Present staff have a good level of training, and residents spoken to felt confident that staff had the skills to deliver the support and care they required. Goldenley does not provide intermediate care. Goldenley DS0000062909.V250717.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. Further development needs to be done on recording the information required for planning care, as the present system is confusing. It is clear that referrals are made to appropriate professionals to ensure that the resident’s health care needs are being met. EVIDENCE: Three residents files were inspected; two had been admitted to the home since the change to Excelcare and one had been at the home for more than a year. On the new files the information to staff to provide care to residents is presently confusing and the health, personal and social care needs of each resident was not set out clearly in easy to read individual plans of care. An older file inspected had better care plan information. Excelcare have a comprehensive care plan, which if used covers all the required information, but this had not yet been fully implemented by the home. There was no clear evidence that residents and relatives were involved in their plan of care. Files contained evidence of monthly reviews, but other parts of the care plan had not been changed to incorporate any changes i.e. moving and handling risk assessments. Goldenley DS0000062909.V250717.R01.S.doc Version 5.0 Page 11 The files contained clear evidence to indicate that Residents are supported and have access to a variety of healthcare resources (GP, District Nurse, Hospital appointments, CPN’s etc). The home was also using specialist equipment to help in the prevention pressure sores. The home tries to ensure Residents are able to stay at the home in familiar surroundings for as long as possible. It was noted that not all files contained details of the Residents wishes in relation to death and dying. The home has a lot of dependent residents and many require the assistance of two staff members for personal care, toileting and also assistance with feeding. Staff were observed treating residents with respect, and those who were able confirmed that support was given to maintain their independence and choice wherever possible. Screening is provided in double rooms to ensure privacy is not compromised. Excelcare has a policy on the Administration of Medicines, but this was not viewed during this inspection. The storage, practices and records were inspected and these were well maintained. The home had informed CSCI of a medication incident, but appropriate action had been taken by the Management to help prevent this occurring again. Goldenley DS0000062909.V250717.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. The home offers a flexible routine, and promotes resident’s independence and choice. Visiting arrangements are open and relaxed. Daily activities are not routinely organised. EVIDENCE: There is very little evidence that any organised daily activities are taking place with residents. During the inspection most of the units had the television or music on, but there was no other organised activities or one to one sessions. Some residents stated they would like more activities during the day, as there was little else to do. The Manager stated this is an area that needs further development, they organise outside entertainment, but daily activities are lacking. Routines within the home were fairly flexible and choice was provided in meals, times to get up and go to bed, clothes they wore, bathing times, etc. One resident stated the home tried to be flexible, but this would often depend on the number of staff on duty. The home has an open visiting policy, although they would prefer that visitors missed meal times to ensure the dignity and privacy of other residents is adhered to. There is a separate visitors room available if privacy is required and also other areas around the home, which are quiet. One relative Goldenley DS0000062909.V250717.R01.S.doc Version 5.0 Page 13 mentioned that staff often used the visitor’s room for meetings etc, which prevented any residents using it at this time. Most residents were complimentary regarding the food, although some staff felt there had been some changes since Excelcare had taken over and the quality and quantity was not the same. The Cook confirmed changes had recently been made to the supplier and menus were being changed to incorporate this. She added that the ‘quantity’ issues had been when ‘agency cooks’ were preparing the meals and portions were made too small. One resident stated the food was ‘good and plenty’. The home also keeps nutritional records on what each resident has chosen. Menus were clearly displayed in each of the units. Hot drinks and snacks are available outside meal times if required and it was also noted that each unit had fresh fruit available. It was noted during the inspection that many of the residents needed assistance with eating or encouragement. Due to the layout of the home and staffing ratios it was noted that at teatime many of the residents had to wait for assistance. There was only one staff member per unit and when more than two residents required assistance this caused some difficulties. The kitchens were inspected and noted to be clean, tidy and well stocked. Goldenley DS0000062909.V250717.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18. The home provides good information on making complaints and how to contact the CSCI. Residents rights are protected and advocacy services available if needed. EVIDENCE: There is clear written guidance in the Home’s Service Users Guide and Statement of Purpose on how relatives and residents can make complaints. On viewing the homes complaint folder two complaints had been received since the last inspection and both had been fully recorded, investigated and a satisfactory outcome reached. No complaints had been made to the CSCI. The home encourages residents to exercise their legal rights and arranged postal votes for those residents who wished to vote in the May elections. An advocacy service can be arranged for any residents who need assistance, but most present residents have family to help. The home does assist with residents ‘personal allowances’ and three were checked and found in order. The Home does have policies and procedures in place to ensure the protection of service users, but these were not fully inspected; but it was noted the Whistle Blowing policy was not present. Staff have received training on the recognition of abuse and what action should be taken. It was established that appropriate checks are in place to ensure all new recruits are suitable to work with vulnerable people, and no staff have been referred to the Protection of Vulnerable Adults list since the last inspection. Goldenley DS0000062909.V250717.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Goldenley is a purpose built home and its location and layout of the home is suitable for its stated purpose. It is safe and fairly well maintained; although many of the carpets need attention and the home was not ‘odour free’. EVIDENCE: Goldenley is divided into four units (Castle, Hardy, Priory and Appleton). Each unit has its own lounge, dining area, kitchenette, bathroom and toilets. There is also a large lounge, which is used for larger ’get together’. The units have been segregated into residents needs. Generally the furniture in the home is of good quality and the decoration is satisfactory. Carpets are beginning to look dirty and in need of cleaning or replacing in some areas. The home has a secure garden off each unit, although these would not be suitable for residents use due to the ground being very uneven. There is a central garden, which is safe and has access for wheelchair users. The home also has ‘security pads’ to ensure residents do not gain access to areas which may cause them harm. Goldenley DS0000062909.V250717.R01.S.doc Version 5.0 Page 16 The home has sufficient toilets around the home, and these have been clearly marked to assist with orientation. All bathrooms are a good size and were well laid out to assist with any equipment that may be needed. All were clean, tidy and had appropriate hand washing facilities. Goldenley offers accommodation to residents with a variety of walking abilities. There were grab rails around the corridors of the home and wide doorframes for wheelchairs. The Manager confirmed that there was sufficient equipment for the present residents. If further equipment is needed the Manager stated that a referral would be made to the Occupational Therapist to do an assessment. There is a call bell system in every room, but this was not tested during the Inspection. During a tour of the home it was noted that some residents had chosen to bring in personal belongings and many of the rooms looked ‘homely’. Some of the bedrooms would not be suitable for wheelchair users or those needing lifting equipment due to size and health and safety. None of the bedrooms have ensuite facilities, but they do have a hand washbasin. One resident raised concerns regarding their bed as it was ‘unsafe’ and moved when they tried to get in; this was reported to the Manager for action. Another residents vanity unit needed replacing and carpet cleaned due to a strong smell of urine. Windows had restrictors fitted and each resident’s bedrooms were centrally heated with a radiator and thermostatic control. The homes Maintenance man makes regular checks to the water temperatures, but two washbasins were found to be above the recommended temperature. Goldenley has its own laundry facilities and this was well organised. Most residents stated they were happy with the service and all those residents seen during the Inspection were noted to be clean and well presented. One resident and relative raised concerns regarding lost clothing and this was passed on to the laundry staff and Manager. The home was not ‘odour free’ free during this inspection and it was noted that many of the carpets were dirty and either needed hoovering or cleaning. Bedroom furniture had also had to be moved into the large lounge due to a leak in two of the bedrooms, which was in the process of being rectified, but could cause those residents who ‘wander’ some health and safety issues. Goldenley DS0000062909.V250717.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, and 30 Staff morale is presently low due to changes in management and uncertainty in their hours and rotas. The home does not have sufficient staff and agency staff are still being used to meet staffing requirements. EVIDENCE: During the inspection there were 6 staff plus one shift leader on in the morning, and only five staff and one shift leader in the afternoon. Action was taken to try and get another staff member for the PM shift, but this was not achieved. It was noted that this put pressure on the remaining staff due to many of the residents needing assistance with toileting and feeding. Due to the layout of the home, many times there was only one member of staff on each unit. The Manager is supernumery to staffing number, but as she does not have a Team Leader at present, this is having an increase in her own workload. The home has also had problems with ‘domestic’ staff due to two being on long term sick and the Manager not being able to replace them. This has had an effect on the cleanliness of the home and staff stated this had also increased their own workload as they have tried to keep the units clean. There is a core group of staff who have been employed at Goldenley for a long time and are aware of the residents needs. The home is now using one agency and feedback from management and other staff is that the agency staff have been good workers and well trained. Those seen during the Inspection respected the resident’s dignity. Goldenley DS0000062909.V250717.R01.S.doc Version 5.0 Page 18 Many of the regular staff have now achieved their NVQ2 and the home has reached the 50 recommendation. Two other staff have also achieved their NVQ 3. Regular training is being offered to try and update skills. Other training that has been organised includes Fire Safety, Infection Control, First Aid and Moving and Handling. Excelcare have a recruitment process, which on discussion with the Manager meets with requirements and protects residents. The Manager completes most of the recruitment process herself and is presently recruiting four new staff members. The new staff member’s files were not inspected as they had not yet completed the whole recruitment process and were waiting for references and CRB’s. These will be viewed on future Inspection visits. Excelcare have a set Induction for new staff, which has to be completed within two months of commencement. They then do the TOPPS induction with a Shift Leader and either complete the Foundation course or NVQ2. No new staff had been inducted since the last inspection, so no files were inspected. Goldenley DS0000062909.V250717.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 37 and 38. The Manager is very experienced and has a good understanding of the residents needs. New systems and policies are being introduced at this time, which is causing some concerns amongst staff and residents. The new organisation has clear lines of accountability and support is offered. EVIDENCE: Goldenley DS0000062909.V250717.R01.S.doc Version 5.0 Page 20 The Manager has achieved her NVQ 4 and has considerable experience in managing residential care homes for older people. There are clear lines of accountability within the home. During the Inspection there was clear evidence of staff coming into the office to discuss care issues or concerns with the Manager and appropriate advice and action being taken. From discussion with staff there are some concerns regarding the change of ownership and how this is going to affect them. There is going to be a change in rota and some staff will have to work a 12-hour shift – which they feel may affect the care being provided to the residents. The Manager explained that regular meetings are being organised for staff to allow them to discuss any concerns. The Manager stated that regular staff and service users meetings were organised, but evidence was not gained during this inspection. Of the staff interviewed all confirmed that the home had an ‘open door’ policy and advice or assistance could easily be gained. They also added that the staff supported each other and the manager was very approachable. Policies and procedures used by Excelcare cover the health and safety and welfare of staff and residents. The Manager is aware of her responsibilities regarding safeguarding both staff and residents. Policies and procedures were in place to ensure safe working practices. Regular checks on gas appliances, fire alarm system, lift, nurse call system and electrics were seen and in order; but the lift certificate needed updating. Appropriate insurance certificates were seen and in order. Excelcare do not routinely assist with resident’s finances but there are systems in place to safeguard residents monies. Most present residents have assistance from family or via a Solicitor and there is also an advocacy service if required. Three residents monies were checked during the inspection and all were correct. Staff and resident files are kept secure and Excelcare are registered with the Data Protection Act. The Manager confirmed that residents could have access to their files. Excelcare do have a Quality Assurance system and the Manager has recently sent out questionnaires to staff and service users to gain their views on the home. Once these have been returned they will be collated and a report written. Only one accident had occurred since the last inspection and this had been fully documented and relevant action taken. Goldenley DS0000062909.V250717.R01.S.doc Version 5.0 Page 21 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 3 2 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 2 2 STAFFING Standard No Score 27 2 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 X 3 3 Goldenley DS0000062909.V250717.R01.S.doc Version 5.0 Page 22 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 OP3 Regulation 14 Requirement Produce paper work which ensures that a comprehensive and detailed assessment is compiled which determines that the home can meet the needs of the service user. This should cover the areas listed in 3.3 of the NMS. The Registered person must also ensure that there has been consultation with the service user or a representative of the servic user. The Registered person must confirm in writing to the service user that having regard to the assessment the care home is suitable and can meet the service users needs in respect of thier health and welfare. This must occur for both short stay and permanent service users. Please submit copies of the forms you intend to use as part of the assessment process. 2 OP2 5 The Registered person must ensure that all service users are issued with a contract or terms DS0000062909.V250717.R01.S.doc Timescale for action 31/12/05 31/12/05 Goldenley Version 5.0 Page 23 and conditions and these are available for inspection. Please ensure this document is relevant to the home they are being admitted to. 3 OP7 15 The Registered person, must after consultation with the service user, or a representative, prepare a written plan (the service users plan) as to how the service users needs in respect of his health and welfare are to be met. The care plan should be drawn up with the service users involvment and signed by the service user when ever possible. Care plans should be reviewed at least once a month and updated to reflect changing needs. Please submit copies of the forms that you intend to use for the care planning process. 4 OP12 16 (2)(mn) The Registered person must consult with service users about their interests and provide a programme of activities and provide facilities of recreation. The routines of daily living and activities must be flexible and varied to suit all service users expectations, preferances and capacities. Any acitivities should be clearly recorded to provide written evidence on future Inspection Visits. The Registered person shall make arrangements by training or by other measures, to prevent service users being harmed or suffering abuse or placed at risk DS0000062909.V250717.R01.S.doc 31/12/05 31/12/05 5 OP18 13(6) 12/09/05 Goldenley Version 5.0 Page 24 of harm or abuse. Please submit a copy of the Home’s Whistle Blowing policy and ensure there is copy available at the home. Immediate Action Required. 6 OP25 13(4)(a) (c) The Registered person shall ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to ensure their safety and unnecessary risks to the health and saftey of service users are identified and so far as possible eliminated. This is is connection to the hot water tempretures which were taken in residents bedrooms during the inspection. Immediate Action Required. 7 OP26 16(2)(k) 23(2)(d) The Registered person shall having regard to the size of the care home and the number and needs of the service users keep the home free from offensive odours and ensure that all parts of the care home are keep clean. Immediate Action Required. 8 OP27 18(1)(a) The Registered person shall, having regard to the size of the care home, the Statement of Purpose and the number and needs of service users ensure that at all times suitably qualified, competent and experienced person are working at the care home in such numbers as are appropriate for the health and welfare of service DS0000062909.V250717.R01.S.doc 12/09/05 12/09/05 12/09/05 Goldenley Version 5.0 Page 25 users. This is in connection to not having enough staff at meal times, lack of anciliary staff and being one staff member down on the day of the inspection. Immediate Action Required. 9 OP33 24(2) The Registered person shall supply to the Commission a report in respect of any review/quality assurance conducted regarding the quality of the care provided by the home. 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations Recommend that you ensure it is clearly recorded when new residents receive a copy of the home’s Service User Guide and Statement of Purpose. Recommend you clearly record any trial visits on new Residents files. Please ensure that when reviews have taken place that any changes to the care needs are reflected in other documents such as moving and handling risk assessments etc, as this did not always appear to be happening. Recommend you check care plans and medication charts and ensure there is an up to date photo to assists agency staff and new staff to identify residents. Please ensure that resident files contain details of their wishes in relation to death and dying, as this did not DS0000062909.V250717.R01.S.doc Version 5.0 Page 26 2 3 OP5 OP7 4 OP9 5 OP11 Goldenley appear to have been routinely recorded. 6 OP15 Due to the recent changes in supplier it is recommend you speak to residents and establish whether they are happy with the present menus and also the quantity and quality of the food. Recommend you also look at the present system at meal times as many residents required assistance with eating or encouragement, but due to staffing levels and the layout to the home this was not always possible. 7 OP15 Goldenley DS0000062909.V250717.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Goldenley DS0000062909.V250717.R01.S.doc Version 5.0 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!