Inspection on 14/08/07 for Goldenley

This inspection was carried out on 14th August 2007.

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 27/09/06

Goldenley 12/09/05

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 14th August 2007 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.V342133.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Goldenley DS0000062909.V342133.R01.S.doc Version 5.2 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 christine.webster@excelcareholdings.com Goldenley Healthcare Ltd Mrs Christine Helen Webster Care Home 38 Category(ies) of Dementia - over 65 years of age (28), Old age, registration, with number not falling within any other category (38) of places Goldenley DS0000062909.V342133.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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. 27th September 2006 Date of last inspection Brief Description of the Service: Goldenley is a purpose built home providing accommodation for up to 38 older people. The Registration category permits the home to provide care to older people and a number of these may have dementia. The layout of the premises consists of two separate lounges. One is a very large lounge and the other is smaller. There are also a few small areas scattered around the home with one or two chairs for residents use. The lounges are separated into resident needs. None of the bedrooms have ensuite facilities. Goldenley is situated close to the local shopping area of South Benfleet. There is 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.V342133.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine Unannounced Inspection, which took place over six hours. This was a full inspection covering all of the National Minimum Standards. 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 six residents and four relatives/friends were spoken to about their life and experiences at Goldenley. Some of the other residents approached were unable to express their thoughts and feelings, but were observed during the day interacting with staff. Most staff members were spoken with informally during the Inspection and any feedback has been included as part of the report. Completed questionnaires were received from relatives and residents and also some from other professionals. The home also completed the Annual Quality Assurance Assessment form (AQAA), which indicates how the home considers it is meeting the National Minimum Standards and what improvements they hope to make within the next twelve months. 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: Goldenley is a well run home which has a good group of staff that have the skills and training required to ensure they meet the residents care needs. Those residents and relatives spoken to were happy with the care they received at Goldenley and felt staff and management were approachable. The new Activities Co-ordinator has worked very hard to try and accommodate all residents’ needs and arrange appropriate activities. Day trips have been organised and there is also a newsletter and activities programme regularly produced so residents know what has been organised. During each of the unannounced inspections there has always been something going on to help stimulate the residents. Many of the staff had completed their NVQ training and the home has over 50 of its staff trained. Goldenley DS0000062909.V342133.R01.S.doc Version 5.2 Page 6 Regular resident and relative meetings are also being organised to give individuals chance to comment on the care received and any concerns they may have. The home also has internal and external audits, which ensure their policies and procedures are being adhered to. What has improved since the last inspection? What they could do better: This was a very good unannounced inspection and the home has worked hard over the last year to ensure all the outstanding requirements had been met. There was clear written evidence for all of the standards inspected. Many of the environment issues have also been met; so all residents can now enjoy a meal at the table, as there is room for everyone. Some carpets and furnishings are beginning to look tired and worn out, but this is an area that the Manager has already identified and it is hoped will be rectified over the next 12 months. Training has been organised for staff, but further training on dementia and infection control needs to be organised. Goldenley DS0000062909.V342133.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Goldenley DS0000062909.V342133.R01.S.doc Version 5.2 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 Goldenley DS0000062909.V342133.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 and 6. Quality of this outcome area is excellent. The home provides prospective residents with sufficient information about the home to help them choose. There is an admission and assessment process and new residents are invited on trial visits. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Goldenley has detailed operational policies to help with the day-to-day running of the home. The Statement of Purpose and Service User Guide has recently been updated. This contains details of the home and the services provided and it has been updated to include more pictures so it is appropriate for those with dementia. A copy of these documents could be found in the home’s foyer and new and prospective residents are given copies during the assessment process. Clear written evidence of this could be found on file. Goldenley has a written contract/terms and conditions of the home. These had recently audited and all resident’s files contained a signed and dated contract. Goldenley DS0000062909.V342133.R01.S.doc Version 5.2 Page 10 The home has a thorough admission process and all new residents are visited to ensure the home are able to meet their needs. A ‘tick box’ needs assessment form is completed during the assessment of new Residents and this contains all the areas listed in Standard three of the National Minimum Standards (NMS). Three resident files were inspected and all contained a fully completed form. Anyone being admitted to the home is invited to visit with relatives or friends, but the home stated in it’s Annual Quality Assurance Assessment form (AQAA) that is this something they wish to ‘encourage more’. One resident confirmed ‘ I had the chance to see Goldenley before coming in as a resident’. Staff had the skills and knowledge for the present residents care needs. Further training has been organised for staff during October/November and this includes infection control, first aid, fire safety, bereavement and dementia training. Goldenley does not provide intermediate care. Goldenley DS0000062909.V342133.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality of this outcome area is good. All residents have a care plan, which contains details of their care needs. Referrals are made to appropriate professionals to ensure that the resident’s health care needs are being met. Policies and procedures for medication are followed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This is an area that the home has been developing and of the three residents files inspected; all contained a care plan, which had been completed around the care needs of the individual. There was clear evidence that these had been reviewed regularly. Training on care plans is in the process of being arranged for staff. During the last inspection there was little evidence that residents and relatives had been involved in their plan of care. The home has stated in the AQAA that this is an area that needs further development and they want to arrange care plan reviews with residents and relatives within the next 12 months. The home has introduced an ‘Assessment and Carers Guide’ form, which provides quick and easy to read details of individual residents and their care needs. This form would be very useful for agency staff who have limited time to ‘get to know’ the residents. Goldenley DS0000062909.V342133.R01.S.doc Version 5.2 Page 12 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). Appropriate referrals had been made to other health care professionals when required. The Home also has a Liaison Nurse who visits the home on a weekly basis and communicates between the GP and the home to ensure that residents receive the health care required. Two questionnaires were received back from health professionals, comments included: ‘Goldenley are always very helpful…they always do their best for their clients. They are very caring and professional in their manner toward the clients and myself and always eager to learn new skills’ and ‘Standards at Goldenley have always been high’. The home was also using specialist equipment to help in the prevention pressure sores. Visits from the optician and dentist are arranged as required. Regular Regulation 37 forms are submitted by the home to the CSCI advising of any falls, deaths or injuries to residents. When further information has been required the home has also investigated the issue and responded appropriately. The home tries to ensure Residents are able to stay at the home in familiar surroundings for as long as possible. There is a written policy on managing death and dying within the home. Some staff had received training for care of the dying and further training had been organised. Goldenley has a policy on the Administration of Medicines, but this was not viewed during this inspection. The home is in the process of changing chemists and training is being organised for staff on the new procedures. The manager is also in the process of working on a medication workbook with staff and during the inspection was witnessed observing a member of staff administering medication. As part of the Inspection process a senior Care was observed during the lunchtime medication round and there were no concerns. Bottles of medication had been dated when opened and residents on PRN medication had written guidance on when this may be required. One health care professional stated ‘staff are always professional and seem to administer medication correctly when I have observed them’. During the day it was noted that staff treated residents with dignity and respect. Those who were unable to converse or had ‘special needs’ were included in the day-to-day activities and appropriate care provided. Relatives spoken to were positive regarding the care the staff provided. During a tour of the home it was noted that each resident had their incontinent pads left on their bed and not hidden away, which did not uphold residents dignity. Feedback from residents and relatives included ‘I am more than happy with the care’, ‘my mother always looks clean’ and ‘staff are understanding and very good. Goldenley DS0000062909.V342133.R01.S.doc Version 5.2 Page 13 The Home’s Annual Quality Assurance Assessment stated that its aim within the next twelve months is to arrange regular care plan reviews with residents and relatives. Also care plan training to be provided to Senior staff which will be cascaded to care staff and other seniors. Goldenley DS0000062909.V342133.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality of this outcome area is excellent. The home offers excellent activities. Residents are given the opportunity of leisure and recreational activities in and outside the home, which suit their needs. The home has a flexible routine, and promotes resident’s independence and choice. Visiting arrangements are open and relaxed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a dedicated ‘Activities Co-ordinator’ who has introduced both stimulation and interesting activities within the home. Residents have been involved in producing artwork for the wall, sing a longs, karaoke, bingo, manicures, and quizzes. She also produces a newsletter and an activity programme-advising residents of outside entertainment that has been arranged. During the inspection a ‘sing a long’ was arranged and during a previous visit to the home the ‘PAT dog’ was visiting. There are clear written records on activities residents had taken part in and also a one to one session to establish the residents likes and dislikes. Those residents and relatives spoken to were very complimentary about the entertainment being arranged ‘The Occupational therapy is very good and social entertainment is regular and of a very high standard’. The home still wish to develop this further and are in the process of organising ‘fund raising’ for a ‘sensory room’ and want to do more for those residents with dementia. Outside activities are also arranged and the home has an interesting selection of photos on the wall of outings that Goldenley DS0000062909.V342133.R01.S.doc Version 5.2 Page 15 have organised. The Home’s Annual Quality Assurance Assessment stated that its aim within the next twelve months is to create a sensory room and purchase equipment to enable more stimulation for dementia residents who cannot participate fully in the activities programme. They also wish to organise more outings for the residents. Routines within the home were fairly flexible and choice is provided in meals, times to get up and go to bed, clothes, bathing times, etc. Both lounges were fully staffed during the inspection and one staff member added that now the home had activities it allowed them to spend more one to one time with those who did not take part. 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, but during the inspection it was noted that this was untidy and could not be able to be used; this is an issue that has been brought up at previous inspections. There are also other areas around the home, which are quiet. One the day of the inspection, residents had a choice of two hot meals at lunchtime and two choices at tea. This was clearly written on blackboards within the dining area. Feed back on the food included ‘the food is good’, ‘it’s very nice’ and ‘lovely dinner’. The meal looked hot and well presented and those residents who needed a soft meal had each individual part pureed. Staff assists those who need feeding earlier so that the environment is more relaxed and to accommodate the number who now need assistance. Staff that were observed feeding, did this with dignity and respect. Hot drinks and snacks are available outside meal times if required. The kitchen was inspected and noted to be clean and tidy. There was a good supply of fresh vegetables and fruit. Goldenley DS0000062909.V342133.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 Quality of this outcome area is good. The home provides good information on making complaints. Residents rights are protected and advocacy services available if needed. This judgement has been made using available evidence including a visit to this service. 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 some complaints had been received since the last inspection, but all 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 will arrange postal votes for any residents who wish to vote in elections. An advocacy service can also be arranged for any residents who need assistance, but most present residents have family to help. The home does not assist with residents ‘personal allowances’ as they have introduced a new system to help make the resident more independent. The Home does have policies and procedures in place to ensure the protection of service users. Sixteen staff had received training on safeguarding people and further training has been organised. Goldenley DS0000062909.V342133.R01.S.doc Version 5.2 Page 17 It was established that appropriate checks are in place to ensure all new staff are suitable to work with vulnerable people and these had been followed. The files of two new recruits were checked and it was noted that both contained relevant checks. No safeguarding people issues have been received since the last inspection and no staff had been referred to the Protection of Vulnerable Adults list. Goldenley DS0000062909.V342133.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Quality of this outcome area is good. The location of the home is suitable for it’s stated purpose, safe and fairly well maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Goldenley consists of one large and a small lounge, which has been divided between those residents with dementia and those with old age. Building work has presently ceased at the home, but the ensuite bedrooms have still not been completed. It was also noted that the ceiling in the new large lounge had cracked in a number of places. Some new furniture has been brought for the dining rooms, which now makes more space in these areas. The lounges also have curtains and blinds to help keep the heat out of the rooms in the hot weather. Carpets in some parts of the home are beginning to look dirty and in need of cleaning or replacing. The home has policies and procedures on infection control and training has also been organised. The home was mostly ‘odour free’ during this inspection. Goldenley DS0000062909.V342133.R01.S.doc Version 5.2 Page 19 The home has a number of small gardens that are accessible to all residents. Staff confirmed that residents use the garden areas and there were garden table and chairs available. The home also has ‘security pads’ to ensure residents do not gain access to areas which may cause them harm. There are also ‘call bells’ in each bedroom and in the lounges, but these were not tested. The home has sufficient toilets around the home, and these have been clearly marked to assist with orientation. The large lounge also has two toilets within close proximity. 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. There was sufficient equipment for present residents. 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 at present have ensuite facilities, but they do have a hand washbasin. Windows have restrictors fitted and each resident’s bedrooms is centrally heated with a radiator and thermostatic control. The homes Maintenance man makes regular checks to the water temperatures and there were clear records. Four residents washbasins were checked to ensure they were within the recommended temperature. Two basins had cold water, one was warm and the last was over 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. The Home’s Annual Quality Assurance Assessment stated that its aim within the next twelve months is to produce a programme for redecoration and replace soft furnishings as required. Goldenley DS0000062909.V342133.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality of this outcome area is good. The home has sufficient staff and there is a robust recruitment procedure. Training is offered to staff and over 50 have achieved a NVQ. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection there were five staff plus one shift leader on in the morning and the afternoon. The large lounge had four staff allocated and the small lounge had one. Some of the residents have very high needs, but staff were always available. The Manager is supernumery to staffing number and the Team Leader assists with both paperwork and care. The staffing rota was seen and contained the required information. Staff morale had improved since the last inspection and this has had an impact on the atmosphere within the home. One staff member stated ‘it is better and things are sorting themselves out’. Feedback from relatives and residents included ‘I think the staff work very hard’ and ‘ we are very satisfied’. The home has 23 care staff and 14 of these have achieved a NVQ 2 or 3. Six more staff had also registered for NVQ training. The home has now reached over the 50 ratio. Regular training is offered to staff and includes Fire Safety, First Aid and Moving and Handling. Generally staff had sufficient knowledge and understanding to provide the care required, but further dementia training is needed. Training has been organised during September October in care of the dying. Goldenley DS0000062909.V342133.R01.S.doc Version 5.2 Page 21 Excelcare have a recruitment process, which if fully implemented meets with the NMS requirements and protects residents. Two new staff member’s files were inspected and these contained all the required information. Excelcare have a set Induction for new staff. It was stated that this was in line with the Skills for Care requirements. Both staff files inspected had evidence of an induction. The Home’s Annual Quality Assurance Assessment stated that its aim within the next twelve months it to include more topics on their training programme and access external programmes where necessary. Goldenley DS0000062909.V342133.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37 and 38. Quality of this outcome area is excellent. The Manager is very experienced and has a good understanding of the residents needs. Excelcare have policies and procedures in place to safeguard both staff and residents. There are clear lines of accountability and support is offered. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Goldenley DS0000062909.V342133.R01.S.doc Version 5.2 Page 23 The Manager 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 evidence of staff coming into the office to discuss care issues or concerns with the Manager and appropriate advice and action being taken. The Manager has good leadership skills and is very approachable Staff morale has improved since the last inspection and this is felt within the atmosphere of the home. New staff have also been recruited and the Manager is looking to recruit more staff. Supervision within the home has been developed since the last inspection. The home had very good evidence that staff had received appropriate supervision. Staff meetings had been organised and also one to one sessions.. There was clear evidence that both resident and relatives meetings had been held since the last inspection. This was an opportunity for both residents and relatives to raise any concerns they may have. Policies and procedures used by Goldenley cover the health and safety and welfare of staff and residents. It has been established on previous Inspections that the Manager is aware of her responsibilities regarding safeguarding both staff and residents. Policies and procedures were in place to ensure safe working practices. Goldenley has a Quality Assurance system, which approaches both relatives and residents for their views on the care received. Surveys on the quality of the food are also completed and submitted to the CSCI. Quality audits within the home are also completed on a regular basis. Regular checks on gas appliances, fire alarm system, lift, emergency lighting, water temperatures, nurse call system and electrics were seen and in order. Although the residents do not use the upstairs of the home, an up to date lift certificate was seen. Appropriate insurance certificates were seen and in order. Goldenley 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 and there is also an advocacy service if required. Staff and resident files are kept secure and Excelcare are registered with the Data Protection Act. Residents can have access to their files if requested. The accident book was viewed and in order. The Home’s Annual Quality Assurance Assessment stated that its aim within the next twelve months is to enrol more staff on the NVQ. They also want to complete outstanding works on the ensuite room and have a more robust redecoration programme Goldenley DS0000062909.V342133.R01.S.doc Version 5.2 Page 24 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 4 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Goldenley DS0000062909.V342133.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 OP10 Good Practice Recommendations Ensure staff are aware of the issue of dignity of residents. It was noted during a tour of the home that staff had left incontinence pads on residents beds. The visitor’s room is not always available for visitors. On the day of the inspection it had been used for storage, this is an area that has been highlighted in previous inspections. It was noted that the lounge ceiling had cracks appearing in it. Please ensure this is safe for residents. Water temperatures within the home ranged from cold, warm and too hot. The recommended temperature for wash hand basins is 43 degrees. 2. OP13 3. 4. OP19 OP25 Goldenley DS0000062909.V342133.R01.S.doc Version 5.2 Page 26 5. OP26 It was noted that some areas of the home were not odour free. Carpets around the home are beginning to look tired and dirty and need of replacement. Recommend dementia training is organised for staff as soon as possible. 6. OP30 Goldenley DS0000062909.V342133.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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