Inspection on 22/05/07 for Goole Hall

This inspection was carried out on 22nd May 2007.

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 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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Goole Hall Swinefleet Road Old Goole Goole East Yorkshire DN14 8AX Lead Inspector Eileen Engelmann Key Unannounced Inspection 22nd May 2007 09:30 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 Goole Hall DS0000061976.V340564.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. Goole Hall DS0000061976.V340564.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 vacant post 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 Goole Hall DS0000061976.V340564.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th August 2006 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. There are beautiful views from inside and outside the home. Accommodation is provided over two floors in single and double rooms; fifteen of these rooms have en-suite facilities. The home is accessible to all service users via the provision of a passenger lift and ramps. 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 30/04/07 within the Pre-Inspection Questionnaire indicates the home charges fees of £286.80 to £333.30 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. Goole Hall DS0000061976.V340564.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home is currently recruiting for a manager and in the meantime Morag Dewar, Operations manager, and Lesley Wilson, acting manager, is offering the staff managerial support. For the purposes of this report Morag Dewar is named as the manager throughout. This unannounced visit was carried out with the provider, manager, staff and residents of Goole Hall. The visit took place over 1 day and included a tour of the premises, examination of staff and resident files and records relating to the service. Two of the staff on duty and several of the residents were spoken to; their comments have been included in this report. Information was gathered from a number of different sources before the inspector visited the home. Questionnaires were sent out to relatives, residents and staff and their written response to these was good. The inspector received 8 back from relatives (57 ), 2 from staff (20 ) and 14 from residents (100 ). The provider completed a pre-inspection questionnaire and returned this to the Commission within the given timescale. Since the last key inspection in August 2006 a further random visit was made in January 2007. In August 2006 the East Riding of Yorkshire Council Social Services Team expressed concerns about the care within the home and following discussions a temporary stop on placing Dementia Care residents within the home was made to allow staff time to undertake training and develop the necessary skills and knowledge to look after this category of resident. A number of meetings with the manager and provider have taken place since this time and progress is being made although this is hampered by the lack of a permanent manager within the home. Monitoring visits from the Social Service Team continue to be carried out, although these may become less frequent in the future as the service improves and resident care gets better. After the last visit in January 2007 the Commission for Social Care Inspection issued a warning letter to the provider to improve the service and meet a number of outstanding requirements and recommendations. A timescale of 1st April 2007 was given for this to be completed by. Failure to comply could result in enforcement action being taken against the Provider. At this visit it was seen that the manager and staff have worked extremely hard to improve the documentation within the home, staff practices have got better and the service has moved forward and been brought up to date. The majority of the requirements and recommendations made at the January visit have now been met and work is progressing to achieve others. Goole Hall DS0000061976.V340564.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Goole Hall DS0000061976.V340564.R01.S.doc Version 5.2 Page 7 The home must improve the statement of purpose and service user guide and make sure people living in the home and their relatives have easy access to a copy. People living in the home said that the staff are very good at talking to them and they felt comfortable talking about the service and their needs. The people working in the home do not always write down what care each person living in the home needs to make their life and health better. They should be talking to the residents more to find out what they like and how they want to be looked after. This helps the residents to have choice in how they are cared for and helps them stay as independent as possible. People working in the home have to get better at writing down the medication coming into the home and being given to the people living there, or else people may become ill. People who are in charge of running the home have to be given training around keeping people safe from harm, this helps them understand how to look after individuals and speak up if they think anything is wrong. The person who owns the home must make sure the people living in the home have nice rooms to stay in and that anything that is broken or worn out is replaced with something new. The person who owns the home must make sure there are enough people working in the home to take residents to hospital if they fall ill in the night, and still have enough people to look after the rest of those who live in the home. People working in the home need to go to training sessions to make sure they are able to look after the people living in the home and give them the right kind of care. The person who owns the home must make sure that people who work in the home do checks to make sure they are doing things right and that people living in the home are getting the care they need. The inspector would like to thank everyone who completed a questionnaire and/or took the time to talk to her during this visit. Your comments and input have been a valuable source of information, which has helped create this report. Goole Hall DS0000061976.V340564.R01.S.doc Version 5.2 Page 8 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. Goole Hall DS0000061976.V340564.R01.S.doc Version 5.2 Page 9 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 Goole Hall DS0000061976.V340564.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 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. All residents undergo a full 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 by the service. EVIDENCE: At the last visit a requirement was made for the responsible individual to produce an up to date statement of purpose and service users guide, which is made available to residents and their families. 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 is in the process of ensuring sufficient copies are available in the home for any resident or relative 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 in available in a clear print version: although a larger print document can be produced on request. The service user guide combines Goole Hall DS0000061976.V340564.R01.S.doc Version 5.2 Page 11 pictures and words to make the document more meaningful for the residents in the home. The statement of purpose requires some small adjustments to meet the criteria of Regulation 4 including • • • • Qualifications of staff Information about the review of care process in the home A copy of the Complaints policy and procedure. Information on the arrangements for residents regarding meeting their religious needs. The service user guide requires some additional information within it to meet the criteria for Regulation 5. This includes • • • • • • Information on the range of charges for additional extras A copy of the complaints policy and procedure A copy of the homes terms and conditions for residency A copy of the inspection report Information on the resident’s views of the home The name and address of the Commission for Social Care and Inspection, and contact details. The provider was busy making some of these changes throughout the visit. Comments from the surveys shows that the majority of residents received sufficient information to make an informed choice about the service before accepting the placement offer. One relative said ‘the staff were very helpful during our first visit and throughout the decision making process’. In the last report (January 07) a requirement was made for the registered person to provide a contract or statement of terms and conditions to all residents. This has now been met. The accountant for the home has issued every resident or their representative with a new, up to date contract/statement of terms and conditions for them to read: sign and return a copy to the home. Each resident has their own individual file and four of those looked at have a full needs assessment from Social Services completed within them. The manager said she and a senior care assistant go out to see potential residents and complete a needs assessment before a placement is offered. The information from the assessment process is used to formulate the individuals care plan. One relative said that ‘Goole Hall’s risk assessment process has identified various issues and actions needed to improve my relative’s quality of life, including obtaining specialist equipment’. This was a requirement in the January 2007 report and is now met. Goole Hall DS0000061976.V340564.R01.S.doc Version 5.2 Page 12 Since the visits in August 2006 and January 2007 the manager has made sure that staff attend training and development sessions to improve their knowledge and skills. This has resulted in a more positive attitude from the staff and comments from the surveys show that residents and relatives have noticed a big improvement in the care practices and service. Individuals said they receive good care and support by staff, who now listen to their views and take action as necessary. Staff are always available to give help and assistance where needed, and one person said ‘the staff always inform us on the condition of our relative and never make decisions without consultation with us’. The staff training files and the training matrix show that the home has not yet obtained the Skills for Care Induction package for all new staff to go through an induction before starting work, but the home has a basic training programme in place. Information from the files and matrix indicates that not all of the staff are up to date with their mandatory safe working practice training, but more sessions are booked within the next few months and the manager is positive a rolling programme can be achieved by the end of 2007 that gives everyone a chance of attending. Staff members on duty were knowledgeable about the needs of each resident and had a good understanding of their specific problems/abilities and the care given on a daily basis. Information from the Pre-Inspection Questionnaire completed by the manager and discussion with the residents, indicates that all of the residents are of a white/British nationality. The home does accept individuals with specific cultural or diverse needs following a needs assessment being completed. 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. The home employs one staff member from overseas. Discussion with the staff indicates they work well together as a team and they consider their support to each other as a main strength in the progress being made to improve resident care. The employment records show that the manager is using a selective approach to recruitment; ensuring new staff have the right skills and attitude to meet the needs of the residents. Residents are unable to make a choice of staff gender when deciding who they would like to deliver their care, as the home only employs female staff at the moment. The manager has recruited male staff in the past, but a lack of suitable applicants makes it difficult at this time. She said that she would discuss the lack of staff choice with potential residents during the needs assessment process. The home does not accept intermediate care placements so standard six is not applicable to the service provided. Goole Hall DS0000061976.V340564.R01.S.doc Version 5.2 Page 13 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The quality of the record keeping for care plans and medication must be improved to ensure the needs of the residents are met and their health and safety protected. EVIDENCE: A requirement made in the last visit (January 2007) was for the responsible individual to ensure that Care plans are more comprehensive in their detail, include specific risk assessments and information, and contain input from the resident and/or their representative. It was seen at this visit to be partly met. Staff still have problems identifying what information each section of the problem sheets should contain and work must be done to build their skills in this area. However, the staff are including information about the abilities of the residents to be independent within the plans and this is an aspect of good practice and must be encouraged and developed further. Goole Hall DS0000061976.V340564.R01.S.doc Version 5.2 Page 14 It is recommended that the manager continue giving staff training on Care Planning so they have the necessary skills and knowledge to produce care plans of a high quality. Individual care plans are in place for all residents and set out the health and personal care needs identified for each person. Four of the plans looked at have been evaluated on a monthly basis and any changes to the care being given is documented and implemented by the staff. Risk assessments around daily activities of living have been carried out and are recorded, where appropriate, within the individual resident’s plan. The care plans are basic and need to include detailed information about the needs and expectations of the residents, social aspects of care and the care being given on a daily basis. There is little evidence that the residents are able to contribute to their care plan on a regular basis other than at the yearly reviews held with the Funding Authority: although some staff are including the residents and their views in the monthly reviews of care. This is a positive aspect of the plan, which should be encouraged and built on. Areas where the plans could be improved include • • • • • • Having a photograph of each resident in their own file Staff only creating a problem/ability sheet where there is evidence that a resident requires help to achieve a goal and making sure that all these sheets are dated and signed by the staff member writing them. Staff not leaving gaps when writing the daily report and sign in full instead of initialling their entry. Resident views and choices must be clearly documented in the plan and signatures from the resident/relative obtained to show it has been read and agreed by the individuals concerned. Staff must make sure that all the paperwork is completed on admission including information around religion and marital status. Risk assessments on falls, moving and handling and nutrition must be consistently completed for all residents and reviewed on a regular basis. Discussion with the manager indicates she is aware of the above issues and is working with the staff to improve the care plans further. At the visit in January 2007 two requirements were made for the responsible individual to acquire a set of weighing scales for use in the home so that staff will be able to weigh service users as part of the nutritional screening plan, and to ensure that for all individuals nutritional screening is undertaken on admission and subsequently on a periodic basis, a record maintained of nutrition, including weight gain or loss, and appropriate action taken. These have been met. The home has purchased a new set of weighing scales that residents can stand upon. These are appropriate for everyone in the home to use, except for one individual, and the staff said they have no concerns about the weight or nutritional health of this individual. Staff are now weighing people living in the Goole Hall DS0000061976.V340564.R01.S.doc Version 5.2 Page 15 home on a monthly basis, the majority of individuals have nutritional risk assessments in their care plans, which are being reviewed regularly, and dietician advice is being sought if there are concerns about anyone’s nutritional health. Two residents 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. Information from the Pre-Inspection Questionnaire indicates that there are no people living in the home with a pressure sore. However, there is a need for all residents to be assessed, by a person trained to do so, to identify those individuals who are at risk of developing pressure sores and for staff to make sure the appropriate intervention is recorded in the care plan. Discussion with the staff indicated they would ask the District Nurses for advice if they have any concerns about a resident’s well being. The home has developed new policies and procedures for medication since the last visit and risk assessments for medication self-administration were seen in the four care plans looked at during this visit. All individuals, whose assessments were looked at, are unable to undertake this task so staff do this for them. Discussion with the staff indicates that seven of them are in the process of doing their medication training with Selby College and this is helping them to be more confident and knowledgeable about this aspect of practice. 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. At the time of this visit there were no controlled drugs in the home. Checks of the medication records showed that overall these are well maintained and kept up to date, however there were a few areas in which they could be improved. These included • Where staff are hand writing medication onto the sheets (transcribing), they are not following best practice. Staff must include the amounts of medication received or brought forward, and have two staff sign the entry to indicate they have both witnessed that the information on the sheet is correct. Staff must ensure they sign every time that they give out medication. It was seen that there were a few missing signatures. Where medication is in bottles or tubes (such as eye drops) the staff should make sure they date the container when it is opened and discard it after 28 days. Medication in the trolley had been dated, but some kept in a resident’s room had not. • • It is recommended that the manager audit the medication charts weekly to ensure staff are completing these correctly. Goole Hall DS0000061976.V340564.R01.S.doc Version 5.2 Page 16 Residents and relatives commented that they were extremely satisfied with the care being given at the home. Individuals felt that their privacy and dignity is being respected and they are able to express their views and opinions about their care. Two individuals said they were very happy living in the home and were satisfied with the care they received, one commented ‘the care provided is second to none, and the staff are excellent’. Relatives were very positive about the home meeting the needs of their family members. One person said ‘the staff really care for the people living in the home, they keep you up to date with any problems, telephone you when needed and make us welcome every time we visit’. Another individual said ‘the staff provide great care, even when under a lot of pressure. My relative is always kept clean and nicely dressed, her weight has improved and staff are always kind, considerate and friendly’. Goole Hall DS0000061976.V340564.R01.S.doc Version 5.2 Page 17 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. Residents are provided with choice and diversity in the meals provided by the home. Individual wishes and needs are catered for and people have the option of where, when and how they participate in eating activities. EVIDENCE: There has been an outstanding requirement, for improvements to the social side of life for the residents in the past three reports with given timescales for change as 08/10/06, 30/11/06 and 01/04/07. At this visit it was seen that things are improving and more appropriate activities are being provided. A group of residents were enjoying a lively game of dominoes in the main lounge this morning and they said that this was something they did on a regular basis. Two residents were walking around the grounds of the home under the discreet eye of a member of staff to ensure they did not go too far away from the main house, and others were sat around the home chatting, watching television or enjoying a cigarette in the smoking lounge at the front of the building. There is a list of activities on display in the entrance hall and observation during the day indicated residents do read this or ask staff what is Goole Hall DS0000061976.V340564.R01.S.doc Version 5.2 Page 18 on it for the morning or afternoon sessions. Discussion with the staff indicates that although there is no activity co-ordinator in the home, they have the time and capacity to do activities with the residents on a regular basis. The manager has recently booked activity sessions with an outside group who provide movement and activity programmes designed to meet the needs of those with cognitive or memory impairment. At the last session the person doing these activities noted what the residents enjoyed doing, what their abilities were and future sessions will be built around this knowledge. Residents said they enjoyed the event and looked forward to more taking place. Little information is documented in the care plans about individual wishes and needs regarding social and emotional care. The manager must take action to improve this area of practice. Discussion with the residents indicates that they have good contact with their families and friends. Everyone spoken to said they were able to see visitors in the lounge or in their own room and there is an open visiting policy in place. Relatives made positive comments about the home in the survey responses, one person said ‘the friendly atmosphere makes the place, the staff all seem to care about the residents and are patient and understanding with those whose memories are poor’, ‘residents receive a lot of care and attention at all times’. Other relatives said ‘as a family we feel that Goole Hall is a caring home for the elderly. The staff are kind and considerate and the care is excellent’. Information from the residents’ files indicates that there are a number of individuals who follow different spiritual faiths, including Methodist, Catholic and Church of England. Discussion with the residents showed that they do not want to go to church on a regular basis, but those expressing a wish to do so are assisted by the staff to attend local services. Discussion with two residents showed that they are offered choice in their daily lives and have a satisfactory awareness of their rights. Advocacy information is available in the home and it is in the Service User Guide. There is no evidence that residents are encouraged to access the advocacy services and it is recommended that the manager discuss these options with the residents. Information from the Pre-inspection Questionnaire indicates that none of the residents handle their own financial affairs, but have family who deals with this. Residents are satisfied that they can access their personal allowances when needed. Residents said that the home encouraged them to bring in small items of furniture and personal possessions to decorate their bedrooms. 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 home has a large and spacious dining room where residents 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 Goole Hall DS0000061976.V340564.R01.S.doc Version 5.2 Page 19 prompts. A member of staff sits at each table during lunch and the meal is a sociable and relaxed event. All residents spoken to were full of praise for the quality and quantity of the meals provided at the home. Comments received indicated the residents are offered a good choice of food and there were plenty of drinks and snacks in between the main meals. Goole Hall DS0000061976.V340564.R01.S.doc Version 5.2 Page 20 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements are needed to the complaints recording system and the staff training around safeguarding of adults, to ensure individual’s views are heard and dealt with appropriately and they are kept safe from abuse. EVIDENCE: The complaints policy is displayed in the entrance hall of the home, and comments from the residents and relatives indicate that the majority of them know how to make a complaint and are confident that the manager will listen and take appropriate action, where necessary, to resolve their issues. One relative said ‘the complaint process was made clear to me during my initial fact finding visit to the home’. The manager could not find the complaints record/book during this visit. This must be in place and kept up to date to show where complaints have been made; by whom and what investigation and action the manager took to resolve the issues. The staff on duty displayed a good understanding of the safeguarding of adults procedure and four residents spoken to said they ‘felt safe at the home’. Since the East Riding of Yorkshire Social Service Team made a temporary stop on making dementia referrals to the home in August 2006, the staff in the home have undergone training around safe guarding of adults, dementia care and Goole Hall DS0000061976.V340564.R01.S.doc Version 5.2 Page 21 challenging behaviour. Individuals spoken to said they are more confident about dealing with different types of behaviour and relatives have commented how good the staff are at handling and defusing stressful and confrontational situations. Observation of the staff at work showed they have a calm and friendly approach to the residents, which results in a relaxed atmosphere and residents who are amiable and enjoy life in the home. Discussion with the staff indicates they know that there is a referral process for the home to use if they have any concerns about an individual’s well being, but the staff were not sure what to do, saying ‘I would pass this on to the manager’. As the home does not have a permanent manager in place at the moment it is important that the senior staff are given training and knowledge of how to make referrals to the adult protection team. Goole Hall DS0000061976.V340564.R01.S.doc Version 5.2 Page 22 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager and provider have a good understanding of the areas in which the home needs to improve. Planning must be put into place to set out how this improvement is going to be resourced and managed with the minimum disruption to the lives of the residents. EVIDENCE: At the last visit to the home in January 2007 a number of requirements were made around the environment. These included • 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. At this visit this still is outstanding and it was discussed with the manager how this could be achieved. Observation of the home showed that redecoration and DS0000061976.V340564.R01.S.doc Version 5.2 Page 23 Goole Hall • • • • refurbishment was ongoing, but not documented. The requirement will remain in this report. The responsible individual must review the suitability of the small gate at the top of the stairs leading down to the lower floor, and carry out a risk assessment; considering that there are a number of residents with dementia in the home who could potentially fall over the top. Work to complete this was done very quickly after the last visit in January 2007 and the requirement is met. The responsible individual must ensure that the bathing facilities are kept in a good state of repair and equipment within them is clean and hygienic. Door locks must be fitted to all facilities, and repairs to the toilet fans undertaken. Observation of the premises showed that this work has been completed and the requirement is met. The responsible individual must ensure the residents are provided with a clean and comfortable bed and clean bed linen. Bedroom furniture with missing handles must be repaired or replaced. 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). Checks of the bedrooms showed new bed linen has been provided and furniture handles have been replaced. Some rooms have been provided with a lockable drawer, but others have not. Discussion with the provider indicated that these rooms would have a lockable drawer when the furniture is replaced as part of the rolling programme of renewal within the home. The requirement is not completely met and will remain in part on this record. The responsible individual must ensure that laundry facilities meet the required standards with an impermeable floor and readily cleanable walls with crumbling plaster repaired. Observation of the laundry room showed this requirement has been met. The home is accommodated within a large Georgian mansion set in its own grounds and situated on the outskirts of the Port town of Goole. Residents have bedrooms and living space on three floors accessed by a passenger lift and stairs. Discussion with the provider and manager indicates there is a future programme of planned renovation and renewal for the accommodation and facilities within the home. There remain a number of areas that need attention and these include • • • New beds must be purchased for a number of the rooms, as the divan style beds in place are old, worn and not suitable for the residents. The stair carpet going down to the basement floor is stained and dirty and should be replaced. Room 11 on the basement floor is empty at the moment. This room has a large locked cupboard just inside the door, which is used by the staff as a linen store for the whole floor. This is not acceptable if the room is DS0000061976.V340564.R01.S.doc Version 5.2 Page 24 Goole Hall • • • • • • • to be used as a bedroom and the responsible individual must consider the future use of the room or the cupboard. The bathroom on the basement floor level does not have a towel rail, toilet roll holder, soap dispenser, paper towel holder or waste bin within it. The responsible individual must make sure these are provided as soon as possible. A number of rooms have frayed emergency pull cords: these should be replaced. A number of rooms do not have towel rails in their en-suite facilities these should be provided. Two double rooms on the basement floor are empty, they do not have privacy curtains or screens in place and the responsible individual should make sure these are in place if more than one person occupies the rooms. There are a number of empty rooms around the home and the domestic staff should make sure that these are kept clean of cobwebs, dust and dirt so staff can show prospective residents the rooms. Room 1 on the basement floor has a radiator in the en-suite, which needs a cover over it to make sure the resident is protected from risk of burns. The Yale lock on the fire door leading out to the ramp exit needs to be removed in order for the fire door to be used effectively in case of an emergency. The above issues were discussed with the provider and manager who assured the inspector the work would be done over the next few months. 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. Staff say that there is sufficient moving and handling equipment within the home to meet the needs of the residents and this includes two fixed bath hoists, a manual hoist, slide sheets and a turntable. The majority of the residents are independently mobile or can walk with assistance, however for one or two individuals a moving belt would be useful and the provider should consider purchasing this equipment. Residents have use of two lounges, the one at the back is non-smoking and both areas are provided with televisions and comfortable furnishings. All areas were seen to be clean, tidy and odour free and comments from the residents indicates that they are very satisfied with the hygiene and cleanliness of the home. One individual said ‘the home is warm and welcoming. I feel totally at ease here’. Goole Hall DS0000061976.V340564.R01.S.doc Version 5.2 Page 25 Two residents spoken to were very pleased with their individual rooms and said that they had ‘brought in a number of personal possessions to make them feel more homely’. The environment is clean, warm and comfortable and no malodours were present. Comments from the residents show that the home is clean and they are satisfied with the laundry service provided by the home. Goole Hall DS0000061976.V340564.R01.S.doc Version 5.2 Page 26 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. 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. Improvements to the standards of staff Induction and Training must be made to ensure the staff have a good understanding of their roles and responsibilities, and have the skills and knowledge to meet the needs of the residents. EVIDENCE: Comments from relatives, residents and staff indicate that there has been a huge improvement in the way staff work together and share duties. This has impacted on the time management of tasks and resulted in everyone being much happier about the staffing levels within the home. Staff said there is sufficient staff on duty to meet the residents needs and they have the opportunity to spend ‘quality time’ talking to individuals and doing activities. Individuals are using a team approach to care and there is a good working atmosphere at the home. Comments from the relatives and residents praised the staff; one individual said ‘the staff are excellent, they work hard to make the home comfortable for the residents’. At the moment there are 13 residents living at the home, with two care staff on duty in a morning plus the manager, three care staff in the afternoon and two care staff at night. Observation of the staff showed that the home is busy, but well organised. Goole Hall DS0000061976.V340564.R01.S.doc Version 5.2 Page 27 Concerns were raised that night staff do not have any formal on call cover, so if a resident is ill and needs to go to hospital they potentially would either go on their own or leave only one staff member in the home. The staff said that they usually would call another member of staff in from home, but this is relying on the good nature of the staff to come in. The registered person must make sure that there is sufficient staff available to provide emergency cover for the home on a twenty-four hour basis. The home does not have an induction programme for new starters and the registered provider must make sure that this is provided and meets the standards of Skills for Care. Only 25 of the staff have completed an NVQ 2 or 3, although other staff members are going through the training. The home should try to achieve 50 of care staff with this qualification by the end of June 2008. The home has a recruitment policy and procedure that the manager understands and uses when taking on new members of staff. Checks of four staff files showed that police (Criminal Records Bureau) checks, written references, health checks and past work history are all obtained and satisfactory before the person starts work. Storage of the information within the files is not consistent and the manager should ensure they are all brought up to date and introduce a standard format that can be easily audited as part of the quality assurance system. Since the last two visits in August 2006 and January 2007 the home has been putting together a mandatory safe working practice training programme. Information in the staff training files indicates uptake of training has been patchy over the past 12 months and the manager must make sure that everyone attends. A monitoring system should be put in place to assess the skills and knowledge of the staff, and determine how successful the training has been. Fire safety, safe handling of medications and moving and handling training is booked for June and July 2007 and the provider and manager are aware of the importance that this training is undertaken and completed by all staff. A rolling programme of training must be in place by the end of September 2007. Goole Hall DS0000061976.V340564.R01.S.doc Version 5.2 Page 28 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38. 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. The manager has a clear development plan and vision for the home, which she has effectively communicated to the residents, staff and relatives. EVIDENCE: There is no registered manager in post at the home and this has been the case for some time. The provider is actively recruiting for a suitable person to fill the post and is hopeful that a successful candidate will be found soon. Morag Dewar and Lesley Wilson are providing interim management support for the staff, and between them offer full time cover for the home. 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. Sustaining the improvements to the quality of care within the home will depend on a permanent individual being in post, who Goole Hall DS0000061976.V340564.R01.S.doc Version 5.2 Page 29 has the necessary skills and training to take on the role and responsibilities of being the registered manager. The requirement for the responsible person to recruit a suitable person to the position of manager will remain in this report. There is no quality assurance or quality monitoring system in place at the home. Discussion with the manager and provide 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. This was a requirement in the last report and will remain in this one. After the last visit in January 2007 a warning letter was sent to the Provider from the Commission for Social Care Inspection. It asked that the Provider take urgent action to comply with a number of requirements that had not been met in the previous three to four reports. Failure to comply within the given timescale of 01/04/07 could result in enforcement action being taken. During this visit it has been seen that action has taken place to address the requirements, not all have been completed but sufficient progress has been made to comply with the contents of the letter. Checks of the financial records showed that residents 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 resident, the provider updates these each week. Information from the manager indicates that the majority of the residents 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. Each resident has their own zipped plastic wallet with money, receipts and transaction book within it. Only the provider has access to the safe where the money is kept although staff do have access to a cash float where money can be given to the residents when the provider is not in the home. Checks of the money held in the home showed it to be accurate and balanced with the pocket money books. It was discussed with the provider that the records of transactions would be better recorded in a bound book or books to prevent the chance of pages being removed or lost. An audit of the monies should also be undertaken by an outside agency to ensure all practices are correct and safe. The requirement made at the January 2007 visit for the responsible individual to keep a record of financial accounts, and the homes charges to residents, within the home at all times has now been met. Checks of the maintenance certificates and contracts found that the majority are up to date and in place. The gas safety certificate was due for renewal in January 2007 and discussion with the provider indicated that the contractor is booked to check the system. The provider should fax the certificate to the Commission for Social Care Inspection when this work is completed. Goole Hall DS0000061976.V340564.R01.S.doc Version 5.2 Page 30 The fire risk assessment was last reviewed in 2004: the provider must make sure this is brought up to date as soon as possible. Fire drills are taking place but the person responsible is no completing the correct paperwork, the provider must make sure this is done. Fire training for staff is overdue and the provider booked this for 01/06/07 during this visit. Accident books are being completed, but staff are filing the reports in the care plans without making a record of events. This makes auditing the accident records difficult and it is recommended that the manager look at a developing a more efficient method of filing and recording of accidents. Regulation 37 reports are being sent into the Commission for Social Care Inspection as required. The provider is completing a regulation 26 report on a monthly basis and copies of these are kept within the home. The manager has completed generic risk assessments for a safe environment within the home. Risk assessments were seen regarding fire, moving and handling, bed rails and daily activities of living. These requirements were made at the January 2007 visit: for the responsible individual to ensure that risk assessments are carried out for all safe working practice topics, and that significant findings of the risk assessment are recorded. All accidents, injuries and incidents of illness or communicable disease are recorded and reported. These requirements have now been met. Goole Hall DS0000061976.V340564.R01.S.doc Version 5.2 Page 31 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 3 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X 2 2 X 2 2 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 2 X X 2 Goole Hall DS0000061976.V340564.R01.S.doc Version 5.2 Page 32 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 responsible individual must produce an up to date statement of purpose and service users guide, which is made available to residents and their families. Timescale for action 01/10/07 2. OP4 12 3. OP7 15 The registered person must be 01/10/07 able to demonstrate the homes 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. The responsible individual must 01/10/07 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 DS0000061976.V340564.R01.S.doc Version 5.2 Page 33 Goole Hall 4. OP8 12(1) 5. OP9 17(1)(a) any). The registered person must 01/10/07 ensure that where residents are identified as having or being at risk of developing pressure sores then appropriate intervention is recorded in their plan of care. This is so residents receive the correct care and treatment to protect their health and wellbeing. The registered person must 01/10/07 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. 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. 01/10/07 6. OP12 16 (2)(m n) 7. OP16 17(2) 8. OP18 13(6) 9. OP19 23 The manager should ensure that 01/10/07 a record is kept of all complaints made and this includes details of investigation and any action taken. The registered provider must 01/10/07 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. The responsible individual must 01/10/07 ensure that a programme of routine maintenance and renewal of the fabric and decoration of the premises is DS0000061976.V340564.R01.S.doc Version 5.2 Page 34 Goole Hall produced and implemented with records kept (given timescale of 01/04/07 was not met). 10. OP19 23(1)(2) (a) 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. 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). The responsible individual must make sure that radiators are guarded or have guaranteed low temperature surfaces, to protect the residents from risk of burns. 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. 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. The registered provider must ensure that there is a training programme in place that ensures staff fulfil the aims of the home DS0000061976.V340564.R01.S.doc 01/10/07 11. OP24 16, 23 01/10/07 12. OP25 13(4)(a) (c) 01/10/07 13. OP27 18(1)(a) 01/10/07 14. OP28 18(1) 01/10/07 15. OP30 18(1)(a) (c) 01/10/07 Goole Hall Version 5.2 Page 35 16. OP31 8 and meet the changing needs of the residents. Specialist training on the elderly and diseases relating to old age must be included in the training programme. The responsible individual must recruit a suitable person to the position of manager (given timescale of 01/04/07 was not met). 01/10/07 17. OP33 24 18. OP38 23(4)(c) The responsible individual must 01/10/07 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 (given timescales of 08/10/06, 30/11/06 and 01/04/07 were not met). The responsible individual must 01/10/07 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 well being. 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 The responsible person should ensure that copies of the statement of purpose, service users guide and current inspection report are available on request, and consider how the documents can be displayed safely and securely DS0000061976.V340564.R01.S.doc Version 5.2 Page 36 Goole Hall within the home. 2. OP7 The manager should continue to provide staff with care plan training and report writing skills to assist them in completing and developing the records within the home. Transcribed medications should have two staff signatures on the MAR chart to indicate that the information written down has been checked and is accurate. The manager should audit the medication charts weekly to ensure they are completed correctly. Where medication is in bottles or tubes (such as eye drops) the staff should make sure they date the container when it is opened and discard it after 28 days. The responsible individual should establish whether service users would like to develop links with the local community The manager should make sure that residents and relatives are aware of advocacy services in the community and discuss residents’ rights and options with individuals as needed. The bathroom on the basement floor should be provided with a towel rail, toilet roll holder, soap dispenser, paper towel holder and waste bin. En-suite facilities in the bedrooms should be provided with towel holders. The responsible individual should consider purchasing a moving belt to aid in the moving and handling of some of the residents. 50 of care staff should achieve an NVQ 2 by the end of June 2008. Storage of the information within the staff employment files is not consistent and the manager should ensure they are all brought up to date and introduce a standard format that can be easily audited as part of the quality assurance system. A monitoring system should be put in place to assess the skills and knowledge of the staff, and determine how successful the training has been. The responsible individual should make sure that the records of transactions is recorded in a bound book or books to prevent the chance of pages being removed or lost. An audit of the monies should also be undertaken by an outside agency to ensure all practices are correct and safe. The provider should fax the Gas Safety certificate to the Commission for Social Care Inspection when this work is completed. DS0000061976.V340564.R01.S.doc Version 5.2 Page 37 3. 4. 5. 6. 7. OP9 OP9 OP9 OP13 OP14 8. OP21 9. 10. 11. OP22 OP28 OP29 12. 13. OP30 OP35 14. OP38 Goole Hall 15. OP38 The manager should look at a developing a more efficient method of filing and recording of accidents. Goole Hall DS0000061976.V340564.R01.S.doc Version 5.2 Page 38 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Goole Hall DS0000061976.V340564.R01.S.doc Version 5.2 Page 39 - 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. 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