Inspection on 27/09/06 for Goldenley

This inspection was carried out on 27th September 2006.

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 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 09:30 27 September 2006 th 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.V314590.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.V314590.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.V314590.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. 7th February 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 a number of service users with dementia. The layout of the premises has recently been changed and now consists of two separate lounges. One is a very large lounge and the other is smaller. There are also a few smaller areas scattered around the home with one or two chairs for residents use. At the moment the lounges are not separated into resident needs, but this may be introduced in the future. 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.V314590.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 seven and a half 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 seven residents and five 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. All staff members were spoken with informally during the Inspection and any feedback has been included as part of the report. Questionnaires were also sent out to relatives, GP’s, District Nurses and Social Services regarding their experiences of the home. Six GP’s, one District Nurse and the home’s hairdresser responded and six residents and one relative returned completed questionnaires. At the end of the day the Inspection was discussed with the Team Leader and advice and guidance was given regarding the findings. What the service does well: Goldenley generally a well run home which has a good core group of staff who 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. It was a pleasure to see some residents get up and sing Karaoke, when in past inspection they have just sat in a chair and not participating with other residents. Many of the staff have completed their NVQ training and the home has over 50 of its staff trained. Resident and relative meetings are also being organised to give individuals chance to comment on the care received and any concerns they may have. Goldenley DS0000062909.V314590.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Goldenley DS0000062909.V314590.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Goldenley DS0000062909.V314590.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, and 6. Quality of this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provides prospective residents with enough information about the home to help them choose. There is an appropriate admission and assessment process. 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 contains details of the home and also the services provided. A copy of these documents could be found in the home’s foyer, but it was noted that they did not contain a date of when they were last reviewed. New and prospective residents are given copies during the assessment process, and a new form recently introduced had space to record when this information. Goldenley DS0000062909.V314590.R01.S.doc Version 5.2 Page 9 Goldenley Healthcare Limited has a written contract/terms and conditions of the home. The Home’s Administrator had recently audited the resident’s files to ensure each contained a signed and dated contract, but it was noted that one file inspected did not contain details of the allocated room number. 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 are invited to visit with their relatives or friends, but this is not at present routinely evidenced. One resident stated ‘when I first moved in I would have liked to have been shown round and introduced to the other residents’. The home has a collective group of staff who have been at the home for a number of years and have the skills and knowledge for the present residents care needs. Goldenley does not provide intermediate care. Goldenley DS0000062909.V314590.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. Quality of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plan system is being developed and most resident’s files now contain relevant information on the care required and how this is to be provided. It is clear that referrals are made to appropriate professionals to ensure that the resident’s health care needs are being met. Policies and procedures for medication are not being routinely followed. The death and dying wishes of residents are still not routinely recorded. EVIDENCE: Three residents files were inspected; all contained a copy of a care plan, which had been developed around the care needs of the individual. Some information was better than others, but they are developing well and there was clear evidence that they had been reviewed regularly. The Team Leader was in the process of updating a residents care plan during the inspection due to change of care needs. There was no clear evidence that residents and relatives had been involved in their plan of care. Goldenley DS0000062909.V314590.R01.S.doc Version 5.2 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). 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. The Liaison Nurse was complimentary about the care provided by staff and stated there was a ‘good working relationship between them and communication was good’. 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 has introduced a form to be completed with family members when ‘bed rails’ are needed. This advises the family of the positive and negative issues so they were well aware of any risks. It was also suggested a form similar to this is introduced for the ‘bucket’ seats which are being used by some residents, to ensure their freedom and mobility is not being compromised and it is in the best interest of the individual resident. 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, but it was noted that not all files contained details of the Residents wishes in relation to this. Staff had not received training for care of the dying. Questionnaires were sent to local GP’s and six were returned. All stated that they were satisfied with the overall care provided at the home. They added that staff communicated well and that there was always a Senior member of staff available. None had received any complaints about the service. Goldenley Healthcare Limited has a policy on the Administration of Medicines, but this was not viewed during this inspection. A Senior Care was observed during the lunchtime medication round. Some issues were raised in the recordings made by previous staff such as not following the ‘key’ when medication had not been given. It was noted that bottles of medication had not been dated when opened and not all residents on PRN medication had written guidance to staff on when this may be required. The GP’s stated that they considered the service users medication was appropriately managed within the home. 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 Goldenley DS0000062909.V314590.R01.S.doc Version 5.2 Page 12 spoken to were positive regarding the care the staff provided, but did have some concerns on the ability and understanding of the staff who’s first language was not English. One stated they felt this could restrict residents dignity and respect due to lack of understanding. One issue that was raised with the Team Leader was that two staff were observed by the Inspector transferring a resident and ‘lifting’ her under her arms into a lounge chair. Also during a tour of the home it was noted that each resident had their incontinent pads left on their bed and not hidden away. Feedback from residents included ‘they wait on us hand and foot’, ‘could not get a better place’, ‘I get toast and tea in bed’ and ‘the staff are very kind and would do their utmost to help me’. Relatives were also very positive and their comments included ‘the staff are pretty good’ ‘I am pleased my mum has got her freedom’ and ‘ I am very happy with the care my mum is getting’. Goldenley DS0000062909.V314590.R01.S.doc Version 5.2 Page 13 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. Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home now 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. EVIDENCE: The home now 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. Staff were observed taking part in karaoke with residents and there was a relaxed and fun environment. Even those residents who could not fully take part due to their abilities were encouraged to join in. 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. Goldenley DS0000062909.V314590.R01.S.doc Version 5.2 Page 14 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. Now that there are only two lounges staff appeared to be present though out the day, were this did not always happen when the staff were covering four units. 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. The home had received a complaint regarding the visitor’s room being used for staff meetings and on the day of the inspection the room had been used to store the hoist and furniture had been moved around to accommodate this, which would have made it difficult for visitors to use. There had been some issues regarding the food at previous inspections, but this seems to have been rectified. Residents had a choice of two hot meals at lunchtime and two choices at tea, although sandwiches were often one of the choices. Those residents spoken to stated that they had sufficient food and it was ‘nice’, ‘lovely’ and ‘plenty’. The meal looked hot and well presented and those residents who needed a soft meal had each individual part pureed. One resident stated today ‘we had lamb but there was no mint sauce’. Staff now start to assist those who need feeding earlier so that the environment is more relaxed and to accommodate the number who need assistance. Those staff who were observed feeding, did this with dignity and respect. Hot drinks and snacks are available outside meal times if required. Comments received from residents and relatives included ‘ my mum as put on weight since she has got here’, ‘ the food is good’ and ‘more variety on the meals would be nice’ The kitchen was inspected and noted to be clean, tidy and well stocked. There was a good supply of fresh vegetables and fruit. Goldenley DS0000062909.V314590.R01.S.doc Version 5.2 Page 15 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. Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides good information on making complaints. 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 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 arrange postal votes for those residents who wished 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, but these were not fully inspected. Twelve staff had received training on the recognition of abuse and what action should be taken, but more staff still need to attend. Goldenley DS0000062909.V314590.R01.S.doc Version 5.2 Page 16 It was established that appropriate checks are in place to ensure all new staff are suitable to work with vulnerable people, but it was noted that these had not been fully followed. The files of two new recruits were checked and it was noted that one did not contain a ‘POVA First’ check, but the staff member was working in the home. Criminal Record checks for both staff had been received. No POVA issues have been received since the last inspection and no staff had been referred to the Protection of Vulnerable Adults list since the last inspection. Goldenley DS0000062909.V314590.R01.S.doc Version 5.2 Page 17 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. Quality of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is in the process of being updated and its environment changed. All building work has at present ceased so areas of the home have not been fully completed. Residents do not at present live in a safe, well-maintained environment. EVIDENCE: The layout of Goldenley has recently been changed and now consists of one large and small lounge instead of four individual units. Residents, relatives and staff had mixed feeling with regard to the change in the environment, some like it and others do not. Building work has at present ceased, but the home is not fully completed. Bedrooms are half finished and some parts of the home are in need of redecoration. Goldenley DS0000062909.V314590.R01.S.doc Version 5.2 Page 18 Some new furniture has been brought, but the home is still waiting for other items. The lounges have been decorated and have both tiled and carpet covering. Carpets in other parts of the home are beginning to look dirty and in need of cleaning or replacing. Curtains and blinds have now been added and these will help to keep the heat out of the rooms in the hot weather. It was noted during visits to the home in the summer that the lounges (especially the small lounge) were very hot and quite uncomfortable for staff to work in and residents to sit in. The small lounge has a very low ceiling, which does not allow much airflow. In the small lounge it was noted that not all residents would be able to sit at the tables due to not having enough room. Some residents had their meals on small tables were they were sitting; the Inspector was advised that this was their choice. The large lounge has sufficient tables and those who were able sat at them. The large lounge is bright and has sufficient lighting. Due to the height of the ceiling in the small lounged it is quite dark and the present lighting does not assist in brightening the room. There are no wall lights in either lounge to facilitate reading or other activities. There is a large garden, but it is not easily accessible from the lounges and residents would not be able to use it with out assistance from the staff. Also wheelchair users may have problems accessing this. There are a couple of small paved areas with tables and chairs, which residents can use independently. 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. 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 at Goldenley DS0000062909.V314590.R01.S.doc Version 5.2 Page 19 present have ensuite facilities, but building work has commenced to have some rooms with these facilities. All bedrooms 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. Two washbasins were checked and found to be within 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 was not ‘odour free’ during this inspection. During a tour of the home it was noted that some bathrooms and bedrooms had dirty pads left in them and disposable gloves had also been thrown away in bins without lids. Some of the bedroom carpets are old and in need of replacement. There was also some concerns regarding the tiles fitted in the two lounges. The Inspector was advised that when the tiles are either wet or have food on them they become very slippery. One staff member was off sick due to a fall on the tiles and also a resident had slipped over. The Inspector also found the tiles to be slippery during the lunchtime meal and slipped on food that had fallen on the floor. Action will need to be taken to ensure residents and staff are safe when walking on these. Goldenley DS0000062909.V314590.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has sufficient staff and there is a robust recruitment procedure. Training is offered to staff and 50 have NVQ 2. Staff morale is still low in some staff due to uncertainty in their future employment within the home. EVIDENCE: During the inspection there were five staff plus one shift leader on in the morning and the afternoon. On the day of the inspection an extra staff member came on duty at lunchtime. 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 new layout of the home has assisted in ensuring staff are always present, which did not always occur when it was in units. The Manager is supernumerary to staffing number, but was on annual leave on the day of the inspection. The home does have a Team Leader who was very helpful and assisted in gaining sufficient information for the inspection. The home in the past has had problems with ‘domestic’ staff due to two being on long term sick and the Manager not being able to replace them. A staff member spoken to stated this had not changed. This has had some effect on the cleanliness of the home. Goldenley DS0000062909.V314590.R01.S.doc Version 5.2 Page 21 There is a core group of staff that have been employed at Goldenley for a long time and are aware of the residents needs. Some staff expressed concerns that they had not transferred over to Goldenley Healthcare Limited Contracts and due to this a couple of staff who have been at the home for a long time will be leaving the home for new employment. This is having some effect on the staff morale within the home. The home also has some staff from Poland. Staff and relatives expressed their concerns regarding their ability to understand and speak English. The Inspector was advised that some of the staff from Poland have now enrolled for English lessons to help them in their job role. The home has 33 care staff and 15 of these have achieved their NVQ 2. Four staff also have NVQ 3 and the Manager is in the process of completing her NVQ 4. The home has reached the 50 ratio. Regular training is being offered to staff; training organised includes Fire Safety, First Aid and Moving and Handling. Some updates are required and these include Abuse, dementia, moving and handling and infection control, but generally staff have sufficient knowledge and understanding to provide the care required. It was also recommended that staff have some training in care of the dying. Goldenley Healthcare Limited 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, although it was noted that one did not have a POVA First check. Goldenley Healthcare Limited 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. Rotas were checked during the Inspection and these showed that the correct quota of staff were on duty. It was noted that the rotas needed to be changed to include the job role of each member of staff. Staff spoken to were positive about the new twelve hour shift. Goldenley DS0000062909.V314590.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager is very experienced and has a good understanding of the residents needs. Goldenley Healthcare Limited have policies and procedures in place to safeguard both staff and residents. There are clear lines of accountability and support is offered. EVIDENCE: Goldenley DS0000062909.V314590.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 clear evidence of staff coming into the office to discuss care issues or concerns with the Team Manager and appropriate advice and action being taken. The Liaison Nurse also spoke to staff and the Team Leader to establish how to best meet resident’s needs. From discussion with staff there are some concerns regarding the change of Contracts and how this is going to affect them. Some stated that they would be looking for new employment. Seven staff files were viewed for evidence of supervision. All had received at least one since May 05, and four had received either two or three. Some staff meetings had occurred since the last inspection and minutes of meetings were available. This is an area that still needs further development for some staff. 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 Healthcare Limited 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. Under Regulation 26 of the NMS, the CSCI receive regular reports from Goldenley Healthcare Limited on visits the Regional Operational Manager has completed on Goldenley and any action or good practice that has been highlighted. Goldenley Healthcare Limited also have a Quality Assurance system, which approaches both relatives and residents for their views on the care received. The CSCI received a Quality report in November 2005 with the results and any action required. Another is now almost due. 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 Healthcare Limited 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 Goldenley Healthcare Limited are registered with the Data Protection Act. Residents can have access to their files if requested. The accident book was viewed and in order. Goldenley DS0000062909.V314590.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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 2 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 2 2 2 3 3 3 3 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 3 3 3 2 3 3 Goldenley DS0000062909.V314590.R01.S.doc Version 5.2 Page 25 no 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 OP9 Regulation 13(2) Requirement The Registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. This is in connection to the missed medication, bottles not being dated and also one resident self-administering when staff leave her medication on the side (her care plan should reflect this). 2. OP11 12 (2) The Registered person shall, so far as practicable enable service users to make decision with respect to the care they are to receive and their health and welfare. The is in connection to ensuring that resident files contain details of their wishes in relation to death and dying, as this still does not appear to happening. If staff are to provide this form of care then they should also have training in care for the dying. Goldenley DS0000062909.V314590.R01.S.doc Version 5.2 Page 26 Timescale for action 27/09/06 27/09/06 3. OP18 13(6) The Registered person shall make arrangements, by training staff or by other measures, to prevent service uses being harmed or suffering abuse or being placed at risk of harm or abuse. This is in connection to ensuring all staff attends training on abuse. 31/01/07 4. OP19 23(2)(a) The Registered person shall 27/09/06 having regard to the number and needs of the service users ensure that the physical design, layout of the premises to be used meets with the needs of the service users. This is in connection to the floor covering in both the large and small dining room. Both staff and service users have sustained injuries from falls due to the surface becoming slippery. System need to be put in place to ensure this is rectified. 5. OP20 23(2)(g) The Registered person shall 31/12/06 having regard to the number and needs of the service users ensure that there is adequate sitting, recreational and dining space provided separately from the service users private accommodation. This is in connection to ensuring there is enough dining and sitting space for present service users. 6. OP25 23(2) (p) The Registered person shall 31/12/06 having regard to the number and needs of the service users ensure that ventilation, heating and lighting suitable for service DS0000062909.V314590.R01.S.doc Version 5.2 Page 27 Goldenley users is provided in all part of the care home which are used by service users. This is in connection to the lighting in the small lounge. Lighting in service users accommodation meets recognised standards (lux 150), is domestic in character and includes table-level lamp lighting 7. OP26 13(4)(c ) The Registered person shall ensure that unnecessary risk to the health and safety of service users are identified and so far as possible eliminated. This is in connection to staff disposing of personal care gloves. This is an area that has been highlighted in past inspections. 8. OP30 18(1)(c) (i) The Registered person having regard to the size of the care home, the statement of purpose and the number and needs of service users ensure that persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform. This is in connection to providing staff with dementia training, infection control, POVA and care for the dying. 9. OP32 21(1) This Regulation applies to any matter relating to the conduct of the care home so far as it may affect the health and welfare of a service user. 27/09/06 31/01/07 27/09/06 Goldenley DS0000062909.V314590.R01.S.doc Version 5.2 Page 28 This is in connection to staff moral regarding employment contracts and what plans are in place if long term staff decide to leave the employment of Goldenley at Christmas. 10. OP36 18(2) The Registered person shall ensure that people working at the care home are appropriately supervised. 27/09/06 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 a date be added to the Statement of Purpose and Service Users Guide so it is easily identified when it was last reviewed or updated. Recommend you check residents Contracts/Terms and Conditions to ensure the room number has been completed. Recommend any trial visits are clearly recorded on residents files. Clearly record when residents or relatives are involved in the care plan process. The paperwork has space to record this information, but it had not routinely been completed. The visitor’s room is not always available for visitors. On the day of the inspection it had been used for storage. Staff should be supervised at least six times a year. 2 OP2 3. 4. OP5 OP7 2. 3. OP13 OP36 Goldenley DS0000062909.V314590.R01.S.doc Version 5.2 Page 29 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. 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