Inspection on 23/05/06 for Goole Hall

This inspection was carried out on 23rd May 2006.

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

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

Other inspections for this house

Goole Hall 21/05/08

Goole Hall 22/05/07

Goole Hall 07/08/06

Goole Hall 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 Ms Anne-Marie Foster Key Unannounced Inspection 23rd May 2006 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.V296799.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.V296799.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 Mrs Patricia Ann Hopkins 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.V296799.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th June 2005 Brief Description of the Service: Goole Hall is a privately owned care home that is registered to care for and accommodate 28 older people, including those with dementia. The home is owned by Heltcorp Limited, a company that owns other care homes in Yorkshire. The home is accommodated in a Georgian manor, situated in extensive and well-maintained grounds 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. There are various outside areas where service users can choose to sit out. The home is not close to local amenities but is on a bus route. There is a car park to the rear of the premises. Current fees range between £286.00 and £333.30 per week. Goole Hall DS0000061976.V296799.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on May 23rd 2006.The inspector was assisted by the registered manager and one senior carer. The inspector spoke to four members of staff, two relatives and 8 service users. A visiting community psychiatric nurse was spoken with. The care records of four service users were looked at, and the files of three staff were inspected along with other documentation including policies and procedures. Surveys were sent to 10 relatives and friends of service users, and also a pre inspection questionnaire was sent to the homes manager, the information that was returned is used during the inspection process. A tour of the premises was made, including service users rooms the kitchen the laundry and communal areas. What the service does well: What has improved since the last inspection? Staff have completed their medication training, but there are further improvements to be made in the staff training area, and service users would benefit from this, and be better supported and cared for. The recruitment of staff appears robust, and each staff file inspected contains the required documentation, the information on the protection of vulnerable adults has now been passed on to the care staff enabling them to understand and follow procedures that are in place, the complaints log has been reinstated all of this meaning that the service users are better protected from abuse. Goole Hall DS0000061976.V296799.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Goole Hall DS0000061976.V296799.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 Goole Hall DS0000061976.V296799.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to this service. Service users have their needs assessed before moving into the home, so that they can be assured that their needs can be met, though the service user information could be improved to provide more detail, which will enable the prospective client to make an informed choice. Service users who are admitted for intermediate care are assessed by the manager and are helped to return to independence. EVIDENCE: The manager, along with the senior carers is involved in the pre admission assessment, to ensure that no service user, whose needs cannot be met, moves into the home. One service user who was staying for intermediate care said that the staff were helping to rehabilitate her “I am being well looked after”. The manager produces a service users guide and statement of purpose and makes this available to prospective clients; this guide should include a copy of the complaints procedure and other service users views of the home in order to help them make an informed choice. Goole Hall DS0000061976.V296799.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The service user’s health personal and social care needs are not set out well, and service users are not protected by the homes medication policy. EVIDENCE: The home does benefit from a stable, mature group of staff, who were seen to work in a calm, unhurried fashion, and a family member who was present during the inspection was positive in her comments about the staff “they are helpful and kind”. One relative said that staff were helpful and supportive to her and the family whilst their mother was close to death. Care plans inspected, however were not filled in effectively. Out of the five care plans inspected two did not have the important admission information such as medical history, medications, GP’s name. Only one of the five care plans had been reviewed this year, though the recommendation interval is at least once a month. A care plan, which did refer to the wishes of the service user upon dying, did not accurately reflect that this service user was extremely Goole Hall DS0000061976.V296799.R01.S.doc Version 5.2 Page 10 poorly; instead the care plan suggested that this person was up and about. A care plan for a service user with pressure sores was not reviewed regularly; this ineffective care planning puts the service user at risk of their care needs not being met. The home does not have a detailed controlled drugs policy, and there is no controlled drug register, meaning an ongoing audit is not taking place between administrations of controlled drugs; this does not comply with the Misuse of Drugs (safe custody) Regulations 1973. The homes medication trolley, whilst locked, is left by the front entrance for the whole day and is then returned to the medication room at the end of the day, there is a potential risk from theft, damage or overheating and the trolley should be returned to the medication room after administrations, or stored in a cool place, securely attached to a wall. Goole Hall DS0000061976.V296799.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users enjoy their daily life, and are able to exercise choice, however there is a lack of organised activities, meaning that social, cultural, religious, and recreational needs are not satisfied. EVIDENCE: Service users are able to receive visitors at any time, and the rooms that were inspected were individualised with the service users possessions meaning the service user is helped to exercise some choice and control. The meal at the time of the inspection looked appetising, the dining room is laid out in a very pleasant manner, and the meal was served in an unhurried fashion, allowing the lunch to be an enjoyable experience. One service user, whose first language is not English spoke to me about food from her own country, and went on to say that the food in the home was “very good, very appetising”. There is an alternative to the main meal, and the cook is eager to find out any likes or dislikes that the residents may have, along with any special dietary needs, meaning that an appealing menu is offered. The home does not employ an activities organiser, and no plan of activities is available. The manager said that a variety of activities such as skittles or entertainers is offered, but there Goole Hall DS0000061976.V296799.R01.S.doc Version 5.2 Page 12 is nothing to reflect that these are enjoyed in the care plan, and so it is unclear if the home meets the social, cultural, religious or recreational needs of the residents. Those service users with dementia need particular consideration when planning activities. Goole Hall DS0000061976.V296799.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from revised complaints and protection system and so are better protected from abuse than previously. EVIDENCE: The complaints policy is simple and clear and a new complaints book has been started, two complaints have been investigated by the manager in a timely fashion meaning that service users and their families can be confident that their complaints will be taken seriously and acted upon. The Policy and procedure information for the protection of the vulnerable adult has been passed on to all staff now, raising their awareness with regard to the detection and reporting of abuse, and one staff member asked, reports that she is aware of the protection policies and procedures. The registered manager is responsible for the handling of service users monies, and there are clear records that support a safe system including receipts/ running totals and a safe for storage of cash, these were inspected and found to be satisfactory. Goole Hall DS0000061976.V296799.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 ,21 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There were some hazards found, and the home was not clean on the day of the inspection meaning that service users were not living in safe and comfortable surroundings. EVIDENCE: The upstairs sash windows pose a danger to service users and staff as they can be pushed right up without restriction, though this was to be addressed immediately on the day of inspection with the maintenance manager about to fix up restrictors. There are no domestic staff employed currently in the home meaning that the care staff have to do the cleaning; this is not acceptable, and it was evident on the day that the carers do not have time to manage the cleaning. The upstairs bathroom was in a very untidy state with razors, toiletries, and service users prescribed creams left lying about, along with other items that were not meant to be in the bathroom, resulting in a loss of privacy and dignity to service users. The upstairs toilet near room 20 should be Goole Hall DS0000061976.V296799.R01.S.doc Version 5.2 Page 15 refurbished, as this is not usable in its current state. There were toiletries in the upstairs bathroom with no names on which suggests that these are used communally for everyone, service users should have their own personal toiletries in order to reduce any chance of cross infection. Three bedrooms downstairs were smelled of urine, and there was evidence of a pool of urine all around one toilet .The carers had not managed to start any cleaning at this point which was 10.30am. There are still no locks to service users rooms, which was highlighted in the last inspection report, although this has been discussed with the provider and is being looked into, this means privacy and dignity is not upheld for the service users. There is still no separate sink in the laundry for staff to wash their hands, and staff are still sluicing laundry in the sink. This has been discussed and there are plans to improve the laundry, pending planning permission, however service users are vulnerable to cross infection until this is addressed, and practices are improved. Goole Hall DS0000061976.V296799.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst service users are generally in safe hands, there is a lack of qualified staff with NVQ2 qualification in care, which means that care needs might not be met effectively. EVIDENCE: The home has a robust recruitment policy, and also a low turn over of staff, meaning that service users are protected from the employment of unsuitable people. The 4 staff files inspected all contained the documentation required by regulation; two good references, CRB checks and employment history check, meaning that service users are protected by the homes recruitment policy. Staff receive basic induction training for fire safety, first aid, moving and handling, infection control, dementia awareness, food hygiene awareness, but would need to have a regular training plan. Only 25 of the carers have NVQ training against the recommended minimum of 50 . There is evidence that staff do not receive the minimum of three paid training days per year, and a staff training and development programme is not available, this will affect the quality of care delivered. Goole Hall DS0000061976.V296799.R01.S.doc Version 5.2 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a home that is run by an experienced manager, however there are areas that must be improved. EVIDENCE: An experienced manager runs the home, though there have been no plans to support the manager in continuing with the NVQ 4 qualification. Recently, much of the administration work that the previous owners and deputy used to be responsible for has been left to the manager to take on, meaning that she has a greater load of administration work than previously and is therefore unable to fully meet all of her responsibilities in a satisfactory way. Goole Hall DS0000061976.V296799.R01.S.doc Version 5.2 Page 18 Health and safety systems and policies are in place; water temperatures were good, safe working practices relating to fire safety/ first aid and food hygiene were observed. Electrical system checks, and regular servicing of gas boilers were noted and the Health and Safety Inspection report was seen plus the Environmental Health Inspection has just been carried out – all contributing to the safety and welfare of staff. There is no real quality assurance system in place, although the cook does question the service users about their likes and dislikes, the home would benefit from residents and relatives meetings and service user surveys and from seeking the opinions of other visitors like GP’s district nurses, community psychiatric nurses etc- this would enable the home to measure its success in meeting its aims and objectives. Staff supervision has lapsed again, which was highlighted at the last inspection. Out of 5 staff files inspected, no one had supervision this year and one had not had supervision since 2004, even though there should be supervision at least 6 times per year. This could lead to staff being unclear of good care practices, policy and procedures and career development needs. The staff do not have a room to take their breaks in, although the cloakroom cupboard where they hang their coats is used, also the managers office is very small –its size makes it unsuitable for its purpose. The attic is used for storage of incontinence pads, however the attic is unkempt and in a dilapidated state; and each of the available rooms is cluttered with old equipment, the stairs are hazardous to staff meaning that staff are not safeguarded. Goole Hall DS0000061976.V296799.R01.S.doc Version 5.2 Page 19 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 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X 1 X X X X 1 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 1 x 2 Goole Hall DS0000061976.V296799.R01.S.doc Version 5.2 Page 20 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. 2 Standard OP7 Regulation 15 12 Requirement The registered person must ensure that care plans are accurate and comprehensive. Window restrictors must be put into place to prevent the sash windows upstairs being opened fully to prevent risk of falling. The upstairs bathroom must be kept clean and tidy. Toiletries must be stored appropriately in the service users own room and not used communally. Laundry facilities must meet required standards for disinfection and there must be hand-washing facilities for staff to prevent cross infection. (Previous timescale of 31/03/06 not met) A cleaner/cleaners must be employed as soon as possible There must be a training and development plan in place for staff. (Previous timescale of 28/02/06 not met) Timescale for action 01/08/06 23/05/06 OP19 3 OP21 23 01/08/06 4 OP26 23 23/05/06 5 OP30 18 & 19 31/07/06 Goole Hall DS0000061976.V296799.R01.S.doc Version 5.2 Page 21 6 OP34 25 The registered person must ensure that the home has a business and financial plan that is open to inspection and reviewed annually. (Previous timescale of 31/03/06 not met). The registered person shall ensure that staff working at the home are appropriately supervised at least 6 times per year. 31/07/06 7 OP36 18 31/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP1 Good Practice Recommendations The service user guide should contain a copy of the complaints procedure and have expressions of service users views of the home. Service users care plans must be reviewed regularly i.e. at least once a month. The provider should persist in his efforts in sourcing suitable locks for service users rooms. Communal toiletries must not be used. The registered person must ensure that the changing needs of the service users is reflected in the plan of care especially with regard to dying and death. A plan of organised activities should be drawn up, with particular consideration for those service users with dementia. The recreational and leisure activities enjoyed by the service users should be recorded in their plan of care. The registered person shall make arrangements for the recording handling and safe administration of controlled drugs, and that a controlled drugs register is used. There should be an action plan in place to address the need for a minimum of 50 of care staff to achieve NVQ level 2 in care. Care staff should receive a minimum of three paid days training per year. DS0000061976.V296799.R01.S.doc Version 5.2 Page 22 OP8 OP10 OP11 OP12 6 7 OP9 OP27 OP30 Goole Hall 8 9 OP31 OP33 10 OP38 The registered manager should be supported in order to complete NVQ level 4. The registered provider must develop a quality assurance system to self-monitor the homes progress and success. This should include seeking the views of service users, their families and other visitors involved with the home The staff room and the manager’s office are too small to suit their purpose, the attic area is hazardous, and the provider should draw up a plan for improvement, so that the welfare of staff is promoted and protected. Goole Hall DS0000061976.V296799.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Goole Hall DS0000061976.V296799.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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