Inspection on 14/06/05 for Goole Hall

This inspection was carried out on 14th June 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Goole Hall 21/05/08

Goole Hall 22/05/07

Goole Hall 07/08/06

Goole Hall 23/05/06

Goole Hall 28/10/04

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

CARE HOMES FOR OLDER PEOPLE Goole Hall Swinefleet Road Old Goole East Yorkshire DN14 8AX Lead Inspector Diane Wilkinson Unannounced 14 June 2005 10.00 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 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. Goole Hall J53_s61976_Goole Hall_v226217_140605_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Goole Hall Address Swinefleet Road Old Goole East Yorkshire DN14 8AX 01405 760099 01405 760099 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Heltcorp Limited Mrs Patricia Ann Hopkins Care Home 28 Category(ies) of OP Old Age registration, with number DE(E) Dementia - over 65 of places Goole Hall J53_s61976_Goole Hall_v226217_140605_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 28th October 2004 Brief Description of the Service: Goole Hall is a privately owned care home that is registered to care for and accommodate 28 older people, including those with dementia. The home is owned by Heltcorp Limited, a company that owns other care homes in Yorkshire, although not in the East Riding of Yorkshire. The home is accommodated in a large detached house situated in extensive grounds in open countryside on the outskirts of Goole. The home is accessible to all service users via the provision of a passenger lift and ramps. Individual accommodation is provided in 19 single rooms and five shared rooms. Eighteen of these rooms have en-suite facilities. The home has various outside areas where service users can choose to sit out. The home is not close to local amenities but is on a bus route. There is a car park to the rear of the premises. Goole Hall J53_s61976_Goole Hall_v226217_140605_Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 6 hours, including one hours preparation time prior to the inspection. The inspection included a tour of the premises and examination of documentation, including care plans. The inspector spoke to several service users, two relatives/carers, a health professional, two members of staff and the registered manager. What the service does well: What has improved since the last inspection? Some of the requirements and recommendations outstanding from the previous inspection have been actioned. One of the bathrooms has been refurbished and now provides a safe and comfortable environment for service users. There is now a formal staff supervision system in place that allows staff to have a one to one meeting with a manager. Goole Hall J53_s61976_Goole Hall_v226217_140605_Stage 4.doc Version 1.30 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. Goole Hall J53_s61976_Goole Hall_v226217_140605_Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Goole Hall J53_s61976_Goole Hall_v226217_140605_Stage 4.doc Version 1.30 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 standard(s) 3 A service user’s individual needs are assessed prior to admission to ensure that their care needs can be met and that the home is an appropriate placement for the service user. EVIDENCE: Records examined and discussion with staff and relatives evidences that a service user’s individual needs are assessed prior to admission to the home. Staff visit service users in their own home or in hospital, depending on where they are currently situated, and an assessment commences at this stage. The inspector spoke to the carer of a person who was recently admitted to the home, who said that the person ‘looks much better’ since admission to the home, and that they are very satisfied with the admission process and the care provided by the home. The service user said ‘I feel much safer now’. A community care assessment and care plan is received from care management prior to any service user being admitted to the home. Goole Hall J53_s61976_Goole Hall_v226217_140605_Stage 4.doc Version 1.30 Page 9 The registered manager informed the inspector that service users have been refused admission to the home because the initial assessment evidenced that their care needs could not be met. Care plans are developed that are based on the community care assessment/care plan and the home’s own assessment. Goole Hall J53_s61976_Goole Hall_v226217_140605_Stage 4.doc Version 1.30 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 standard(s) 7 and 9 There is a clear consistent care planning system in place to provide staff with the information they need to meet service users’ needs. The systems for the administration of medication are good but staff must receive accredited training to ensure that medication is being administered safely. EVIDENCE: A care plan booklet is used by the home to record the care needs of each individual service user. These documents are especially designed to meet the requirements of the National Minimum Standards and are being well used by the home. There is a thorough record of each service user’s care needs and comprehensive risk assessments for pressure care, behaviour, personal care, falls, physical health and mental health. The booklet has been signed by service users indicating their involvement in developing the plan of care. Reviews are attended by service users whenever this is possible. Key workers record a monthly summary of the person’s health and well being over the month, and any changes that need to be made to the care plan are recorded. A record is kept of visits from the GP and other health professionals, including the reason for the visit. Goole Hall J53_s61976_Goole Hall_v226217_140605_Stage 4.doc Version 1.30 Page 11 The recording of the administration of medication, storage of medication and medication policies and procedures are satisfactory. However, staff that administer medications must undertake accredited training to ensure that they are administering medications safely. This training has been booked with a local provider, but they are unable to commence the training until later in the year. The registered manager has informed the inspector (following the inspection) that another provider has been found who is able to start this training sooner. There are satisfactory arrangements in place for the administration, recording and storage of controlled drugs. None of the current service users have chosen to self-medicate but the registered manager informed the inspector that lockable storage would be provided if this were needed. The inspector recommends that a lockable storage facility is provided in every bedroom, as this could also be used for the storage of valuables and money. Goole Hall J53_s61976_Goole Hall_v226217_140605_Stage 4.doc Version 1.30 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 standard(s) 14 Support offered to service users enables them to exercise choice and control over their lives. EVIDENCE: Discussion with service users and relatives/friends evidences that service users are supported and encouraged to exercise control over their lives. Service users are offered a choice about where to spend their day and how to spend their day. Service users are taken out by friends and relatives and visitors to the home are encouraged. Service users and their representatives are informed about available advocacy services. Policies and procedures record that access to information is facilitated for service users, in accordance with the Data Protection Act 1998. Service users are supported to handle their own financial affairs for as long as they are able to do so. A list of possessions brought into the home by service users is now recorded – these were seen in individual records. Goole Hall J53_s61976_Goole Hall_v226217_140605_Stage 4.doc Version 1.30 Page 13 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 standard(s) 16 The home has a satisfactory complaints system with some evidence that service users feel that their views would be listened to and acted upon. The use of a complaints log would enable any complaints to be monitored effectively. EVIDENCE: There is a satisfactory complaints procedure in place and this is displayed in the home and is also attached to the service user’s contract. There is a ‘niggles’ book in use to record minor niggles and comments, mainly from staff. Complaints are recorded in individual records and the inspector recommends the use of a complaints log, as this enables complaints to be monitored effectively. However, there have been no formal complaints made to the home or to the Commission for Social Care Inspection in the last year. Service users and relatives spoken to said that they were aware of the complaints procedure and feel confident that any complaints would be listened to and dealt with effectively. Goole Hall J53_s61976_Goole Hall_v226217_140605_Stage 4.doc Version 1.30 Page 14 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 standard(s) 22, 24 and 25 Service users live in safe and comfortable surroundings that offer good views of the open countryside. Mobility equipment is provided that enhances independence for service users and ensures that they are assisted safely. The suitability of the premises and provision of disability equipment to meet the needs of service users cannot be confirmed in the absence of an assessment by a suitably qualified person. There are no locks on bedroom doors and this could compromise the privacy and feeling of security for service users. EVIDENCE: There has been no assessment by a suitably qualified person to evidence that the premises are equipped to meet the needs of current service users. The owners are in the process of applying for planning permission to extend the premises and have said that they will arrange an assessment when the building work is due to commence. There is now suitable equipment in place to ensure that service users can be assisted to take a bath safely, and grab rails and other mobility equipment is provided throughout the premises, both in communal and private areas. A new higher safety gate has been fitted at the top of the stairs to the basement level and this has increased the safety of Goole Hall J53_s61976_Goole Hall_v226217_140605_Stage 4.doc Version 1.30 Page 15 the stairway. Service users have access to all areas of the home, inside and outside, via the provision of a passenger lift and ramps. Private accommodation is comfortable and well furnished. Some service users spend most of the day in their rooms and others just use their bedrooms to sleep in. Furniture provided for service users reflects what the bedroom is used for, and service users have been asked which items of furniture they would like. Bedrooms have been personalised depending on the choice of service users. Only one bedroom door has had a lock fitted – bedroom doors must be lockable and service users must be offered a key. No service users have asked for a lockable storage facility in their rooms and the registered manager said this would be provided on request. However, this should be provided in all bedrooms. Screening is available in double rooms. All bedrooms offer access to sunlight and the dining room has several large windows overlooking open countryside. All areas of the home are centrally heated and heating can be controlled in a service user’s bedroom. All radiators have now been fitted with guards. The inspector observed that water temperatures in baths are taken every time service users are assisted with a bath and these temperatures are recorded. Goole Hall J53_s61976_Goole Hall_v226217_140605_Stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28 and 30 There is a need for NVQ training to be more consistent to ensure that staff achieve this award within given timescales. Individual training records evidence that staff have the knowledge to carry out their role effectively, but a specific training and development programme would enhance training records by detailing the strengths and needs of the staff group as a whole. EVIDENCE: Four or five staff have achieved NVQ Level 2 in Care and other staff have asked to enrol for this training. Some staff that have achieved NVQ Level 2 in Care hope to continue with NVQ Level 3. NVQ training has ‘come to a halt’ as the home’s current training provider has run out of funds and the registered manager intends to explore the possibility of using another training provider. There are no agency staff and no trainees employed at the home. Staff do not undertake foundation training – it is expected that all staff will enrol on NVQ Level 2 in Care following their induction training. The inspector recommends that any staff that do not wish to undertake NVQ Level 2 in Care should undertake foundation training. Individual training records are held for staff. These evidence that induction training takes place and that ‘core’ training such as health and safety, fire safety, food hygiene and moving and handling takes place. There is no training and development plan in place so there is no overall picture of the training strengths and needs of the whole staff group, and no evidence that National Training Organisation workforce training targets can be met that will Goole Hall J53_s61976_Goole Hall_v226217_140605_Stage 4.doc Version 1.30 Page 17 meet the changing needs of service users. Staff are currently undertaking Dementia care training. Goole Hall J53_s61976_Goole Hall_v226217_140605_Stage 4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 34, 35, 36 and 38 The home is managed by an experienced, competent person. There was no business and financial plan to be examined on the day of the inspection so it is not possible to confirm that service users are safeguarded by financial procedures. Service users personal finances managed by the home are done so safely. Staff have formal supervision and this gives them the opportunity to meet with a manager on a one to one basis. There are systems in place to ensure that the health, safety and welfare of service users is protected and promoted. EVIDENCE: The registered manager has the experience and skill to manage the home. She keeps her practice up to date – she has recently attended fire training with other members of staff. NVQ Level 4 in Care and Management is ongoing but the same problems are being experienced as recorded in the previous section, i.e. the training provider has run out of funds. Goole Hall J53_s61976_Goole Hall_v226217_140605_Stage 4.doc Version 1.30 Page 19 The quality assurance system has now been fully implemented. Another service user survey has taken place and the inspector examined the results of the last two surveys that were displayed on the notice board. Staff meetings and resident’s meetings take place, and a relative attended the most recent resident’s meeting. Staff informed the inspector that they always feel able to discuss concerns with the manager and are free to discuss any issues at the staff meeting. There was no business and financial plan at the home available for inspection. The inspector did see a summary of the home’s accounts and these indicate that the home is a viable business. There is appropriate insurance cover in place - evidence of this was seen by the inspector. Monies held on behalf of service users are stored securely. Records were examined for those finances handled by the home on behalf of service users. These were found to be well recorded and the balances of cash held were accurate. There are appropriate policies and procedures in place that inform staff about the safety of service user monies. There is now a good staff supervision system in place. This includes the registered manager observing a task undertaken by the staff member – this task and other relevant areas are then discussed at the subsequent supervision meeting. The home is ‘on target’ to meet the requirement for staff to have six supervision meetings per year. All equipment is well maintained by the home – the passenger lift and three mobility hoists have been serviced recently. There is a landlord’s gas safety certificate in place and the electrical installation has been tested. All fire tests (in house and by a qualified contractor) are in place and up to date. There is a general risk analysis in place to record safe working practices. Health and safety training is undertaken by staff on a regular basis. The inspector did not see any evidence that there are systems in place to control the risk of Legionella. Goole Hall J53_s61976_Goole Hall_v226217_140605_Stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 x COMPLAINTS AND PROTECTION x x x 2 x 2 3 x STAFFING Standard No Score 27 x 28 2 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 2 x 3 1 3 3 x 3 Goole Hall J53_s61976_Goole Hall_v226217_140605_Stage 4.doc Version 1.30 Page 21 Yes 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 9 Regulation 12, 13 & 17 25 Requirement Staff that administer medication must undertake accredited training (previous timescale of 10.4.04 not met). The registered person must ensure that the home has a business and financial plan that is open to inspection and reviewed annually (previous timescale of 10.5.04 not met). Timescale for action 31.8.05 2. 34 31.7.05 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 22 Good Practice Recommendations The registered person should arrange for a suitably qualified person to assess the premises and facilities to ensure that the needs of service users have been addressed. Bedroom doors must be fitted with a lock so that new service users can immediately be offered a key to their door. Bedrooms should be provided with lockable storage space. Training must continue to ensure that 50 of staff achieve NVQ Level 2 in Care by the end of 2005. There must be a staff training and development plan for J53_s61976_Goole Hall_v226217_140605_Stage 4.doc Version 1.30 Page 22 2. 24 3. 4. 28 30 Goole Hall 5. 6. 7. 31 38 16 the home that meets NTO targets and ensures that staff can fulfil the aims of the home. The registered manager must continue with training to ensure that NVQ Level 4 in Care and Management is achieved by the end of 2005. There should be evidence that the risk from Legionella is controlled. A complaints log should be used. Goole Hall J53_s61976_Goole Hall_v226217_140605_Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Goole Hall J53_s61976_Goole Hall_v226217_140605_Stage 4.doc Version 1.30 Page 24 - 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!