Inspection on 21/05/08 for Goole Hall

This inspection was carried out on 21st May 2008.

CSCI found this care home to be providing an Good service.

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 22/05/07

Goole Hall 07/08/06

Goole Hall 23/05/06

Goole Hall 14/06/05

Goole Hall 28/10/04

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Goole Hall Swinefleet Road Old Goole Goole East Yorkshire DN14 8AX Lead Inspector Eileen Engelmann Key Unannounced Inspection 21st May 2008 09:00 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 DS0000061976.V364352.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. DS0000061976.V364352.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Goole Hall Address Swinefleet Road Old Goole Goole East Yorkshire DN14 8AX 01405 760099 01405 760099 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) Heltcorp Limited Manager post vacant Care Home 28 Category(ies) of Dementia - over 65 years of age (28), Old age, registration, with number not falling within any other category (28) of places DS0000061976.V364352.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd May 2007 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. Heltcorp Limited owns the home; a company that owns other care homes in South Yorkshire. The home is accommodated in a Georgian manor, surrounded by open countryside on the outskirts of Goole. Accommodation is provided over two floors in single and double rooms; fifteen of these rooms have en-suite facilities. The home is accessible to people with mobility problems by the provision of ramps to the side of the building and a passenger lift to the upper floors. 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. Information about the home and its service can be found in the statement of purpose and service user guide, both these documents are available from the manager of the home. A copy of the latest inspection report for the home is also available from the manager. Information given by the provider on 21/05/08 indicates the home charges fees of £300.00 to £346.50 per week based on the dependency levels of the individual. There are no additional charges other that those for hairdressing, private chiropody treatment, toiletries and newspapers/magazines, and a list of prices for these can be obtained from the manager. DS0000061976.V364352.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that the people who use this service experience Good quality outcomes. The home has just finished recruiting for a manager and until this person is in post (June 2008) Morag Dewar, Operations manager, is offering the staff managerial support. For the purposes of this report Morag Dewar is named as the manager throughout. Information has been gathered from a number of different sources over the past 12 months since the last visit to the service, this has been analysed and used with information from this visit to reach the outcomes of this report. This unannounced visit was carried out with the provider, manager, staff and people using the service. The visit took place over 1 day and included a tour of the premises, examination of staff and people’s files, and records relating to the service. Informal chats with people living in the home, relatives and staff took place during this visit; their comments have been included in this report. Questionnaires were sent out to a selection of relatives, people living in the home and staff. Their written response to these was adequate. We received 1 back from relatives (10 ), 4 from staff (40 ) and 6 from people using the service (60 ). The manager completed an Annual Quality Assurance Assessment and returned this to the Commission within the given timescale. What the service does well: All of the people living in the home were positive about the home and like living there. Individuals told us that ‘the home excels at making people feel as though they are in their own home. They make visitors very welcome and the staff are very patient and kind to us’. Staff are hard working and do their best to meet the needs of those people living in the home. People and relatives who spoke to us said ‘the staff make sure everyone is cared for according to their needs. They offer people help and support if they need assistance, but respect the wishes of people who like to be more independent’. DS0000061976.V364352.R01.S.doc Version 5.2 Page 6 People being cared for have good access to professional medical staff and are able to access external services such as dentists, opticians, physiotherapists, chiropody and dieticians, so their health is looked after and they are kept well. People living in the home said they are offered a good choice of meals and they enjoyed the quality of food. Specific wishes are catered for and they have plenty to eat and drink throughout the day. One person told us ‘ the food is excellent, we are offered plenty of choice and the quality of the meals is fantastic’. 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. The summary of this inspection report can be made available in other formats on request. DS0000061976.V364352.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 DS0000061976.V364352.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 and 6. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People wanting to use the service undergo a needs assessment and are given sufficient information about the home and its facilities prior to admission, to enable them to be confident that their needs can be met. EVIDENCE: At the last visit in May 2007, a requirement was made ‘The responsible individual must produce an up to date statement of purpose and service users guide, which is made available to people using the service and their families’. Checks at this visit show this has been partly met. The information in the statement of purpose and service user guide has been reviewed and is available in two separate documents. The provider has ensured sufficient copies are available in the home for any person who wishes to have one, and for staff to have spare copies for individuals making enquiries about future placement in the home. The statement of purpose is available in DS0000061976.V364352.R01.S.doc Version 5.2 Page 9 a clear print version: although a larger print document can be produced on request. The service user guide combines pictures and words to make the document more meaningful for the people living in the home. The statement of purpose requires some small adjustments to meet the criteria of Regulation 4 including • • • Qualifications of staff A copy of the Complaints policy and procedure. Information on the arrangements for people regarding meeting their religious needs. The service user guide requires some additional information within it to meet the criteria for Regulation 5. This includes • • • A copy of the homes terms and conditions for residency A copy of the inspection report Information on people ’s views of the home The provider was busy making some of these changes throughout the visit. The people and relatives we spoke to said they received sufficient information to make an informed choice about the service before accepting the placement offer. These individuals have also received a contract/statement of terms and conditions from the home. Each person has his or her own individual file and the funding authority or the home, before a placement is offered to the individual, completes a need assessment. The four files looked at during this visit were for funded individuals. The home develops a care plan from the assessments, identifying the individual’s problems, needs and abilities using the information gathered from each person and their family. Information is gathered during the assessment around issues of equality and diversity, such as age, disability, gender, sexuality, race and religion/beliefs and this is put into the care plan. Discussion with the manager indicated she goes out to assess individuals who have expressed an interest in coming into the home, and each person is given information about the service and life in the home. At present the manager said she gives a verbal offer of placements, and it was discussed that she should make this a more formal written practice. DS0000061976.V364352.R01.S.doc Version 5.2 Page 10 People using the service and relatives are very pleased with the care and support given by the staff, they said ‘the staff are caring and friendly and everyone is well looked after’ and ‘the home provides a good service’. Information from the Annual Quality Assurance Assessment and discussion with the manager and people living in the home indicates that all of the people are of white/British nationality, and everyone is currently of Church of England or Catholic faith. The home does accept people with specific cultural or diverse needs and everyone is assessed on an individual basis. Discussion with the manager indicated that the home looks after a number of people from the local community, although placements are open to individuals from all areas. Checks of the staffing rotas and observation of the service showed that the home employs all white/British, female staff, except for the handyman. Discussion with the manager indicates that this is due to a lack of suitable applicants and that an equal opportunities policy is used when employing staff. Staff members on duty were knowledgeable about the needs of each person they looked after and had a good understanding of the care given on a daily basis. Discussion with three people showed that they were satisfied with the care they receive and have a good relationship with the staff. One person said ‘these girls are great, nothing is too much trouble for them, we do not have to wait to get any help we need and staff are very kind and look after us well’. A requirement was made in the May 2007 report that :‘The registered person must be able to demonstrate the home’s capacity to meet the assessed needs of individuals admitted to the home, ensuring that staff individually and collectively have the skills and experience to deliver the services and care that the home offers to provide’. Checks at this visit show this has been met. Information from the training files and training matrix indicates that the majority of staff are up to date with their basic mandatory safe working practice training, or they are booked onto training in 2008. The home is registered with us to accept placements for people with dementia and the manager is aware of the need to introduce more robust staff training around dementia and challenging behaviour to ensure the staff are able to meet people’s needs. In 2007, 61 of the care staff attended training around Alzheimer’s disease and challenging behaviour, and an update of this course is booked for all staff in June 2008. The home does not have any intermediate care beds and therefore standard six does not apply to this service. DS0000061976.V364352.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 and 10. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health, personal and social care needs of the people living in the home are clearly documented, and are being met by the service and staff. The staff have a good understanding of people’s support needs. This is evident from the positive relationships, which have been formed between the staff and people using the service. EVIDENCE: A requirement made in the May 2007 report was that ‘The responsible individual must make sure that the resident’s care plan sets out in detail the action which needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the resident are met. The care plan must be drawn up with the involvement of the resident or their representative in a form that they can understand and be agreed and signed by the resident if capable and/or their representative (if any)’. Checks at this visit show that this has been met. DS0000061976.V364352.R01.S.doc Version 5.2 Page 12 Since the last visit in May 2007 46 of the care staff have received training in writing the care plans and record keeping. This has resulted in improved documentation of the care being given. The care of four people was looked at in depth during this visit and included checking of their personal care plans. The content of the plans is basic, easy to follow and on the whole completed to an acceptable standard. It was discussed with the manager that there are a few areas in the care plans that staff need to take more time over and these include • Making sure that all the information areas on the admission sheets are completed in full. Areas not consistently completed are information around religion, wishes regarding death and dying, ethnicity, the person’s life history and personal profile. Personal hygiene sheets must be completed each day Ensuring that care plans are reviewed monthly, including the risk assessments for each person. • • Positive aspects of the plans include risk assessments for moving and handling, nutrition, pressure sore development, falls and individual choices regarding activities of daily living. Weights are recorded monthly, and evidence was seen that staff are contacting outside health professionals for advice and visits were needed. We recommended that the manager carry out a monthly audit of the plans; to ensure the plans are up to date. People who spoke to us are satisfied that the staff give appropriate support and care to those living in the home. People said they are able to make their own decisions about their daily lives most of the time; that staff treat them well and listen and act on what they say. The relatives spoken to said that ‘the staff are extremely conscientious about letting us know how our relative is doing and informs us immediately of anything that affects their wellbeing’. People said that they have good access to their GP’s, chiropody, dentist and optician services, with records of their visits being written into their care plans. They all have access to outpatient appointments at the hospital and records show that they have an escort from the home if wished. Comments from the people and relatives indicate they are satisfied with the level of medical support given to the people living at the home. At the last visit in May 2007 a requirement was made that ‘The registered person must ensure that where residents are identified as having or being at risk of developing pressure sores then appropriate DS0000061976.V364352.R01.S.doc Version 5.2 Page 13 intervention is recorded in their plan of care. This is so residents receive the correct care and treatment to protect their health and wellbeing’. Checks at this visit found this was met. Information given to us in the Annual Quality Assurance Assessment indicates that no one at the home has a pressure sore and there is a good relationship with the District Nurse team who provide staff with advice and help around this area of care. Nutritional risk assessments are completed and the staff weighs everyone on a regular basis. Evidence in the plans show that dieticians are called out if the home has particular concerns about an individual. The medication policy for the home says that individuals can self-medicate if they want to and after a risk assessment has been completed and agreed. All of the people spoken to prefer to have staff administer their medication and the manager confirmed that at the moment there is no one in the home who self-medicates. A requirement in the May 2007 report was that ‘The registered person must ensure that accurate records are kept of all medications, received, administered, leaving the home or disposed of to ensure there is no mishandling. This is to protect the residents’ health and wellbeing and promote their safety’. This has been met. The home uses Lloyds Pharmacy as their medication supplier and has a ‘pop out’ system of medication, plus some boxes and bottles where medication is not suitable for putting into the heat-sealed system. Checks of the medication records show that overall these are well maintained and kept up to date. As a good practice measure we recommended that two staff sign next to transcribed (handwritten) medication instructions. This is to signify they have checked that the instructions contain the right medication name, strength of medication, route to be given, form of medication (tablets, liquid, cream etc.) and when it is to be administered. It is also recommended that the home purchase a controlled drug register to record the Temazepam medication currently in use. At the moment the home is using a small hard backed book. 46 of the care staff completed a safe handling of medication course in September 2007 at the local Selby College, they also receive regular updates from an in-house training pack. DS0000061976.V364352.R01.S.doc Version 5.2 Page 14 People and relative comments show they are very satisfied with the care and support offered by the staff. Chats with people using the service revealed that they are happy with the way in which personal care is given at the home, and they feel that the staff respect their wishes and choices regarding privacy and dignity. Observation of the service showed there is good interaction between the staff and people, with friendly and supportive care practices being used to assist people in their daily lives. DS0000061976.V364352.R01.S.doc Version 5.2 Page 15 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. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are provided with choice and diversity in the meals and activities provided by the home. Individual wishes and needs are catered for and people have the option of where, when and how they participate in both eating and leisure activities. EVIDENCE: In the May 2007 report a requirement was made that ‘The responsible individual must ensure residents’ interests are recorded and they are given opportunities for stimulation through leisure and recreational activities in and outside of the home, which suit their needs, preferences and capacities’. Discussion with people, relatives and checks of the care plans indicates this has been met. The home does not have an activities co-ordinator, but the provider has informed us, through the Annual Quality Assurance Assessment completed in DS0000061976.V364352.R01.S.doc Version 5.2 Page 16 April 2008, that the recruitment of someone to carry out social activities is recognised in their improvement plan over the next 12 months. At the moment staff carry out activities in addition to their caring duties, and we observed people, who live in the home, playing dominoes, going for walks in the grounds of the home and enjoying a cigarette in the smoking lounge. One person was busy drawing/colouring at a table in the dining room and others were sitting and chatting to friends and relatives in the lounges. People told us that they like playing bingo and other in-house games, and the majority felt that there is always something for them to do on a daily basis. There is a list of activities on display in the entrance hall and observation during the day indicated people living in the home do read this or ask staff what is on it for the morning or afternoon sessions. An information poster showed that activity sessions with an outside group who provide movement and activity programmes designed to meet the needs of those with cognitive or memory impairment, is booked for June 2008. This was a popular event at our last visit and people continue to enjoy the sessions. Evidence seen at this visit indicates that people are encouraged to celebrate Christian events such as Birthdays, Easter and Christmas. People have access to the local churches and weekly visits by the Catholic priest are arranged on an individual basis. Staff have improved their recording of people’s personal wishes and choices regarding social activities. This information can be found in the individual care plans and also highlights input from family and friends. Discussion with the people living in the home indicates that they have good contact with their families and friends. Everyone said they were able to see visitors in the lounge or in their own room and they could go out of the home with family. Visitors were seen coming and going during the day, staff were observed making them welcome and there clearly was a good relationship between all parties. Meetings for people using the service and their relatives are held every month; these are used as an opportunity for individuals to express their ideas of what activities they want and to give their feedback on events that have taken place. The manager, cook, and maintenance man also attend the meetings so other issues regarding the home and life within it can be discussed and changes made where necessary. Relatives and visitors to the home are very positive about the service and the staff. Comments made to us on the day of this visit showed a high level of satisfaction. Individuals said that ‘the staff are friendly and welcoming’, ‘my DS0000061976.V364352.R01.S.doc Version 5.2 Page 17 relative is being well looked after and their health is improving’ and ‘ there is a pleasant and inclusive atmosphere in the home’. People spoken to were well aware of their rights and said that they had family members who acted on their behalf and took care of their finances. There is some information and advice on advocacy and this is on display in the entrance hall. Additional information is available in the service user guide. Visitors said they are kept informed of any important issues affecting their friend/relative and felt that staff did a good job of supporting people to live the lives they choose. The manager said she has attended training on the Mental Capacity Act, but there is no evidence that staff have received training around current legislation in equality, diversity and disability matters, such as the Data Protection Act 1998, Disability Discrimination Act and the Mental Capacity Act. The registered person must ensure that staff are able to promote and protect the rights of people using the service through up to date knowledge and awareness of current legislation. The home has a large and spacious dining room where people living in the home and staff sit together and enjoy the midday meal. All people in the home eat a normal diet and there is no one who requires feeding although some do need discreet prompts. A member of staff sits at each table during lunch and the meal is a sociable and relaxed event. Discussion with the cook indicated that she caters for specialist diets as and when required, and this includes diabetic, vegetarian and coeliac. People spoken to were full of praise for the quality and quantity of the meals provided at the home. Individuals told us that ‘the meals are excellent, there is plenty to eat and drink and lots of choice’. Observation of the lunchtime meals showed they were home cooked from fresh ingredients and individual likes and dislikes were catered for regarding food choices, portion size and addition of gravy. DS0000061976.V364352.R01.S.doc Version 5.2 Page 18 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 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Progress has been made to develop the complaints system and people feel that their views are listened to and acted upon. Safe guarding of adult protection training and procedures have improved since the last inspection with clear evidence that people are being protected from abuse. EVIDENCE: A requirement was made in the May 2007 report that ‘The manager should ensure that a record is kept of all complaints made and this includes details of investigation and any action taken’. It was seen at this visit that a complaints book is now in place, and the requirement is met. Checks of the records in the home show that there have been no formal complaints received since the last visit in May 2007, and that the manager deals with any niggles and grumbles on a daily basis. The home has a complaints policy and procedure that is found within the statement of purpose and service user guide. It is also on display within the home. DS0000061976.V364352.R01.S.doc Version 5.2 Page 19 People’s responses showed individuals have a clear understanding about how to make their views and opinions heard and those people spoken to said ‘the manager and staff come round every day to see us and will discuss any problems at this time’. Relatives are aware of the complaints procedure and are confident of using it if needed. Those who spoke to us said that the manager was efficient and effective in answering queries and they were satisfied with her actions. The home has policies and procedures to cover adult protection and prevention of abuse, whistle blowing, aggression, physical intervention and restraint and management of people’s money and financial affairs. A requirement was made in the May 2007 report that ‘The registered provider must make sure that senior care staff are given training and knowledge of how to make a safeguarding of adults referral, to ensure all allegations and incidents of abuse are followed up promptly and action taken is recorded’. This is now met. The staff on duty displayed a good understanding of the safeguarding of adults procedure. They are confident about reporting any concerns and certain that any allegations would be followed up promptly and the correct action taken. The manager understands how to make a safeguarding referral to the appropriate authorities and has a copy of the local policies and procedures to follow in the event of an allegation of abuse being made. 46 of the care staff have received safeguarding of adults training, and discussion with the manager indicates that she plans for all staff to attend updates and refresher sessions on a yearly basis. 61 of the staff have attended training around challenging behaviour and management of dementia, and further courses are booked for 2008. DS0000061976.V364352.R01.S.doc Version 5.2 Page 20 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, 21, 22, 24, 25 and 26. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standard of the environment within this home has improved since our last visit, providing people with an attractive and homely place to live. EVIDENCE: In the May 2007 report a requirement was made that ‘The responsible individual must ensure that a programme of routine maintenance and renewal of the fabric and decoration of the premises is produced and implemented with records kept’. This has been met. During this visit we were provided with an up to date record of the refurbishment, redecoration and repairs carried out within the home in the past 12 months and the work that is planned over the next 12 months. DS0000061976.V364352.R01.S.doc Version 5.2 Page 21 In the May 2007 report a requirement was made that ‘The responsible individual must make sure that all repairs and renewals as highlighted in this report are carried out. This will enable the residents to live in a safe and well maintained environment, which meets their needs and the outcomes of the statement of purpose’. This has been met. Walking around the premises it is clear that the provider has spent time and money on improving the environment. This includes • • • • Funding from the government in 2007/8 has been used to refurbish the communal areas with new carpets, chairs, footstools, dining furniture and redecoration. The lower floor bathroom has been refurbished The attic on the top floor of the home has been converted into an office. In the past 12 months the provider has decorated 18 bedrooms, with 11 of these being fitted with new furniture including a bed, headboard, curtains, lamp, mirror, wardrobe, bedside cabinet, 4-drawer chest and an armchair. All bedrooms have been fitted with two double sockets Each bedroom door has been provided with a door lock using a master key system for safety. 5 bedrooms have had new carpets fitted Bedroom 11 has had the storage cupboard removed from within the room and is being refurbished with new furniture. • • • • On the day of this visit the kitchen received a new fridge; this was highlighted in the recent environmental health report (April 2008) as a requirement. All other issues raised in the report have been actioned by the provider. In the May 2007 report a requirement was made that ‘The responsible individual must ensure the residents are provided with a clean and comfortable bed. Residents must also be provided with lockable storage space for medication, money and valuables and be provided with the key, which he or she can retain (unless the reason for not doing so is explained in the care plan)’. This has been met. The new furniture provided in 11 of the bedrooms includes a new bed and a 4drawer chest with a lockable drawer and the provider told us he intends to complete the refurbishment of all the bedrooms within the next 12 months. In the May 2007 report a requirement was made that ‘The responsible individual must make sure that radiators are guarded or have guaranteed low temperature surfaces, to protect the residents from risk of burns’. This has not been met. DS0000061976.V364352.R01.S.doc Version 5.2 Page 22 Room 1 on the basement floor has a radiator in the en-suite, which needs a cover over it to make sure the person living in the room is protected from risk of burns. Other areas that require attention include • The stair carpet going down to the basement floor is stained and dirty and should be replaced. • A number of rooms have frayed emergency pull cords: these should be replaced. • Upstairs windows were being propped open by ornaments. The handyman should ensure these open and close without the use of inappropriate objects. The home is not purpose built as a care facility, but provides a lift and stairs for access to the three floors offering accommodation and communal living space. There are a number of Georgian features within the rooms including high ceilings and decorative plasterwork. The home is a listed building and this has impact on the amount of repair work and renovation that can be done to the exterior and interior of the premises. The majority of the people using the service are independently mobile or can walk with assistance, and staff told us that there is sufficient moving and handling equipment within the home to meet the needs of the people and this includes two fixed bath hoists, a manual hoist, slide sheets, a turntable and a moving belt. Discussion with the provider indicated that over the next 12 months he plans to convert an unused bathing facility into a ‘wet room’ with shower facilities suitable for use by disabled individuals. This will offer people more choice of bathing facilities and help staff in their care giving. In 2007 the government introduced no-smoking laws with special exemptions for care homes. Goole Hall recognises that some people using their facilities enjoy having a cigarette, and because of this have continued to provide people with a comfortable and spacious smoking room at the front of the property. In line with legislation the home has removed the television and music equipment from the room. We spoke to some individuals and relatives who were not happy with this, and explained that the home is complying with legislation and had gone out of their way to ensure people’s rights have not been compromised. All people living in the home have access to a spacious lounge to the rear of the home, which is a non-smoking environment, and it is provided with a wide screen television, music system and comfortable chairs. All areas were seen to be clean, tidy and odour free and comments from the people spoken to indicates that they are very satisfied with the hygiene and cleanliness of the home. DS0000061976.V364352.R01.S.doc Version 5.2 Page 23 Discussions during this visit indicate that people using the service find the home to be spotlessly clean and are satisfied with the laundry service provided by the home. Staff told us that there is an ample supply of aprons and gloves for personal protection whilst carrying out care duties and infection control policies and procedures are in place. 8 staff members (61 ) are booked onto an infection-control training course with Selby College and are waiting for their enrolment forms before they can start. DS0000061976.V364352.R01.S.doc Version 5.2 Page 24 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): People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff recruitment practises are inadequate and do not promote or protect the health, safety and well being of those people using the service. EVIDENCE: Comments from the people using the service and relatives are on the whole very positive about the staffing levels within the home, and individuals feel that there is a good standard of care being given to the people living in the home. At the time of this visit there were 18 people in residence and the staffing rota showed that the following staffing levels are in use 7:30am to 2:30pm – 3 care staff on duty 2:15pm to 9:15pm – 3 care staff on duty 9:00pm to 7:45am – 2 care staff on duty Discussion with the manager indicates the numbers of staff have been reduced due to the current bed vacancies, but will increase as more people come into the service. Information from the Annual Quality Assurance Assessment, about the number of care staffing hours provided (434), and the dependency levels of the people DS0000061976.V364352.R01.S.doc Version 5.2 Page 25 using the home, was used with the Residential Staffing Forum Guidance and showed that the home is meeting the minimum hours asked for in the recommended guidelines. In the May 2007 report a requirement was made that ‘The responsible individual must make sure that there is sufficient staff available to provide emergency cover for the home on a twenty-four hour basis’. After discussion with the manager it is considered by us that the requirement is met. The manager has told us that it is extremely difficult to provide emergency cover at night should a member of staff need to accompany a person using the service to hospital. The home has approached relatives to ask if they are willing to be telephoned at night and will meet their relative at the hospital. This information is recorded in the care plans. Staff continue to meet people at the hospital if the night time call is to the local hospital, but due to the fact that few of the staff drive it is not possible to do this if the person is taken to other hospitals in the area. The manager said she has discussed the problem with the local social services, who agree that the home is doing the best they can to meet the needs of the people living in the home. In the May 2007 report a requirement was made that ‘The responsible individual must make sure that new starters are registered on a Skills for Care induction programme or equivalent: so residents are looked after by staff who are knowledgeable and confident about their roles and responsibilities’. This has been met. Discussion with the manager and checks of the training files indicate all new staff go through an induction package, which is detailed, but is not the skills for care format. The registered person should ensure the home’s induction matches the criteria of skills for care. 31 of the care staff have completed an NVQ 2 in care or above and seven more individuals are working towards this award. The home should try to achieve 50 of care staff with this qualification by the end of June 2009. The home has a recruitment policy and procedure that the manager understands and uses when taking on new members of staff. During this visit we checked four staff files, two were found to only have one reference. The registered person must ensure that two references are obtained for all new members of staff, one from their last employer and if another professional one is not available then a character reference. The references must be obtained before an individual starts work. DS0000061976.V364352.R01.S.doc Version 5.2 Page 26 The home has a mandatory staff training programme in place and information from the staff training matrix indicates that the majority of the staff are up to date with this or are booked onto refresher training for 2008. The manager is aware of the need to expand the range of training to include sessions on conditions relating to old age, dementia and challenging behaviour. DS0000061976.V364352.R01.S.doc Version 5.2 Page 27 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): People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management team has a clear development plan and vision for the home, which they have effectively communicated to the people living in the home, staff and relatives. EVIDENCE: A requirement in the May 2007 report was that ‘The responsible individual must recruit a suitable person to the position of manager’. This has been met. There is no registered manager in post at the home and this has been the case for some time. The provider has been actively recruiting and a new manager is due to start in post by June 2008. DS0000061976.V364352.R01.S.doc Version 5.2 Page 28 The operations manager is providing daily management support and input to the home and the provider is also visiting regularly. Together they have moved the service forward in the past 12 months, improving the staff training, care documentation, policies and procedures, supervising staff practises and refurbishing the property. Staff have had to learn a lot of new skills and practices within a short space of time and have responded to the introduction of training and personal development with enthusiasm and motivation. The provider and operations manager recognise that sustaining the improvements to the quality of care within the home will depend on a permanent individual being in post, who has the necessary skills and training to take on the role and responsibilities of being the registered manager. In the May 2007 report a requirement was made that ‘The responsible individual must ensure there is an effective quality assurance and monitoring system in place at the home, which seeks the views of the residents and measures the success in meeting the aims and objectives and statement of purpose of the home’. This has been partially met. There is no formal quality assurance or quality monitoring system in place at the home. Discussion with the manager and provider indicates that this is because of the lack of a manager to carry out the necessary audits and monitoring of the practices within the home. A suitable system must be developed and implemented as soon as possible. Meetings for people using the service and their families/friends are held on a regular basis and minutes are circulated to people living in the home. Staff have meetings with the manager and everyone is encouraged to join in with discussions and voice their opinions. People and staff agreed that they are able to express ideas; criticisms and concerns without prejudice and the management team will take action where necessary to bring about positive change. Policies and procedures within the home have been reviewed and updated to meet current legislation and good practice advice from the Department of Health, local/health authorities and specialist/professional organisations. The registered person does spot checks and completes the regulation 26 visits. Feedback is sought from the people using the service and relatives through regular meetings and satisfaction questionnaires. This information must be analysed and put together into an annual development report as part of this process, to highlight where the service is going and/or indicate how the management team is addressing any shortfalls in the service. Checks of the financial records showed that people are able to have personal allowance accounts in the home. These records are hand written and detail the transactions undertaken and the money held for each person, the DS0000061976.V364352.R01.S.doc Version 5.2 Page 29 registered person updates these each week. Information from the manager indicates that the majority of people have a family member or representative who looks after their monies and these individuals make sure the personal allowances are sent/brought into the home. Maintenance certificates are in place and up to date for all the utilities and equipment within the building. Accident books are filled in appropriately and regulation 37 reports completed and sent on to the Commission where appropriate. Staff have received training in safe working practices and risk assessments are in place for fire, smoking and daily activities of living. In the May 2007 report a requirement was made that ‘The responsible individual must make sure that fire safety training is up to date, the fire risk assessment is reviewed and brought up to date and fire drills are recorded properly. This will protect the residents safety and wellbeing’. This has been met. Checks of the fire risk assessment and fire records show that these have been reviewed and updated. 61 of staff attended fire training in 2007 and updates are planned for 2008. DS0000061976.V364352.R01.S.doc Version 5.2 Page 30 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 2 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 3 X 3 2 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 DS0000061976.V364352.R01.S.doc Version 5.2 Page 31 Are there any outstanding requirements from the last inspection? Yes. 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 OP1 Regulation 4, 5, Schedule 1 Requirement The registered person must produce an up to date statement of purpose and service users guide, which is made available to people using the service and their families, and individuals who are interested in coming into the home. So individuals have sufficient information to make an informed decision about the homes ability to meet their needs. (Given timescale of 01/10/07 was not met.) The registered person must ensure that individual’s care plans are kept under review and information within them is completed consistently. So staff have access to up to date information, which helps them provide person centred care and support and meet the individual’s needs. The registered person must make sure that the en-suite radiator in bedroom 1 has a guarded or a guaranteed low DS0000061976.V364352.R01.S.doc Timescale for action 01/08/08 2. OP7 15 01/09/08 3. OP25 13(4)(a) (c) 01/10/08 Version 5.2 Page 32 4. OP29 19(4)(c) temperature surface, to protect the person who uses the room from risk of burns. (Given timescale of 01/10/07 was not met) The registered person must ensure that two references are obtained before appointing a member of staff. 01/09/08 5. OP33 24 This will make sure that the people using the service are protected from risk of harm. The registered person must 01/04/09 ensure there is an effective quality assurance and monitoring system in place at the home, which includes an annual development plan for the home, based on a systematic cycle of planning-action –review, reflecting the aims and outcomes for people using the service. So people can have access to information about where the service is going and how the management team is addressing any shortfalls in the service. 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 OP3 Good Practice Recommendations The registered person should make sure that people interested in using the service, or their representative, receive formal written confirmation that the home, taking into consideration their assessment, is able to meet their needs. This must be given to people prior to their admission. DS0000061976.V364352.R01.S.doc Version 5.2 Page 33 2. 3. OP7 OP9 4. 5. OP9 OP14 6. 7. 8. OP19 OP28 OP28 The manager should carry out regular audits of the care plans; to ensure staff are completing these in full and that risk assessments are reviewed on a monthly basis. The manager should make sure that where staff are hand writing medication onto the sheets (transcribing), there should be two staff signing the entry to indicate they have both witnessed that the information on the sheet (name of medication, strength and administration methods) is correct. The registered person should ensure the home is supplied with a controlled drug register. The manager should enable staff to access training around current legislation in equality, diversity and disability matters, to improve the staffs knowledge and understanding of a person’s individual rights within the care home and out in the community. The registered person should ensure the repairs recommended in this report are carried out within the next 12 months. 50 of care staff should achieve an NVQ 2 by the end of June 2009. The registered person should ensure the home’s induction matches the criteria of skills for care. DS0000061976.V364352.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. Extracts may not be used or reproduced without the express permission of CSCI DS0000061976.V364352.R01.S.doc Version 5.2 Page 35 - 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. 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