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 7th August 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.V307597.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.V307597.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 *** Post Vacant *** Care Home 28 Category(ies) of Dementia - over 65 years of age (28), Old age, registration, with number not falling within any other category (28) of places Goole Hall DS0000061976.V307597.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 23rd May 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. The home is owned by Heltcorp Limited; 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. Current fees range between £286.00 and £333.30 per week as at 1/5/2006. Goole Hall DS0000061976.V307597.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced site visit took place on August 7th 2006, we revisited the home as a result of information received about levels of care, poor care practices and lack of support for care staff. The site visit and took place over 6 hours; the senior carer on duty was available to assist the inspector. Information used in the inspection process was gathered from a variety of sources including notifications of events or illnesses sent into The Commission for Social Care Inspection, comments from relatives, service users, staff, and social services, also the care files of 5 service users were inspected, and staff files were inspected. Observations were made on the day of care practices and of how the staff interacted with the service users. A tour of the home was made including service user’s rooms, communal areas, the kitchen and laundry. What the service does well: What has improved since the last inspection? What they could do better:
There were concerns in each area of inspection. Choice of home The registered provider should improve the information available to prospective service users about the home, its aims and objectives and how it provides for the needs of people with dementia, so that people can make an informed choice about choosing the home for their care. Goole Hall DS0000061976.V307597.R01.S.doc Version 5.2 Page 6 Each service user should have a written contract/statement of terms and conditions in their files. The pre admission assessment process has broken down, and the home is relying on social services to provide an assessment, however this isn’t always possible, and the providers need to develop a strategy where a suitably trained member of staff is able to assess prospective service users so that no service user moves into the home without their needs being assessed. Health and personal care The registered provider and staff need to ensure that service users have an accurate individualised plan of care, with personal and social needs set out; as this provides the basis for the care to be delivered. The provider must review the medication system and ensure that the medicine trolley is secured when not in use, and also comply with the Royal Pharmaceutical Society guidance on the administration of controlled drugs, in order to protect service users by robust, safe medication procedures. The registered provider must review the use of the toilet in the main hallway, as service user’s right to privacy is compromised in this area. Daily life and social activities There is a lack of organised activities, particularly stimulating ones that service users enjoy, or activities tailored to suit the individual capabilities of the service user; the registered provider must review the situation in order be able to offer the chance of a more satisfying lifestyle within the home. Complaints and protection The complaints procedure must be available to all service users and their relatives, and staff must be trained with regard to abuse awareness so that the service users can be better protected by a robust complaints and protection system. Environment The registered provider must draw up a plan of improvement to address the poor state of the path leading up to the home, in order to protect service users, staff and visitors from harm. For service users to be able to enjoy the outside space the registered provider needs to make available suitable seating and also review the need for an appropriate fence to keep people safe. The registered provider must persist in his attempts to provide suitable locks for service users rooms in order to be able to offer individuals privacy. The laundry issues remain outstanding and the home must have a laundry floor that is impermeable and easily washable walls plus a separate hand washing sink so that risks of cross infection are reduced. The carpet outside the kitchen is worn and sticky and must be replaced. Goole Hall DS0000061976.V307597.R01.S.doc Version 5.2 Page 7 Staffing Staff morale is low as staff are working long hours whilst the home is short staffed and without a manager, staff training and supervision has lapsed and therefore service users are at risk of their needs not being met as the numbers and skill mix of staff are low and staff are not supported. Management The provider must persist in their attempts to recruit a suitable manager, so that management responsibilities can be redeveloped e.g. quality assurance, staff supervision, health and safety issues, so that the home can be run in the best interests of the service users. The registered provider must provide The Commission of Social Care Inspection with details and /or certificates of the most recent checks of the boiler service electrical system check storage of water to guard against legionella check, also the registered provider must conduct an immediate fire alarm test and continue to test according to the home’s policy after that, in order to promote and protect the health safety and welfare of staff and service users. 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.V307597.R01.S.doc Version 5.2 Page 8 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.V307597.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 The outcome in this area is poor. There is insufficient available information about the home for prospective service users, and the pre admission assessment process has broken down, this could lead to people being admitted whose needs then cannot be met. This judgement has been made using available evidence including a visit to this service EVIDENCE: The home does not offer enough information to prospective service users; there is no available service users guide, statement of purpose, or up to date inspection report, and particularly the home does not say how it provides for the needs of people with dementia, this does not assist people in making an informed choice about the home. The inspector could not find a contract, which sets out terms and conditions and fees in the service users files. The preadmission assessment process has broken down since the registered manager left, and none of the care staff are able to go out to assess peoples needs, the home is relying on a social services care plan as a form of assessment, however this is not always available and therefore could lead to service users being admitted out of category, and whose needs then cannot be met by the home.
Goole Hall DS0000061976.V307597.R01.S.doc Version 5.2 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is poor. Whilst service users agree that they are cared for by a dedicated team of staff, lack of care planning and an unsafe medication system does not allow the health and personal care needs to be met fully. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Those service users that were able to speak with the inspector were eager to praise the staff and remark on their dedication, also one visitor and one care manager reported that the staff work very hard in a calm and respectful way, despite being under pressure due to the inadequate numbers of staff available. The care planning system has broken down and out of five care plans inspected in detail, three service users had no care plans at all and two service users had inadequate care plans that did not mention important facts relating to their health care needs. Care staff are not confident about care planning and support and training in this area. The lack of a detailed plan of care could result in care staff overlooking and being unaware of important health, personal and social needs and result in harm to service users. Whilst there is no registered manager in the home, one senior carer reported that she is
Goole Hall DS0000061976.V307597.R01.S.doc Version 5.2 Page 11 confident enough to make referrals to local community health services when necessary in order to maintain service users health (e.g. GP or district nurse). This will help to ensure access to basic health care services in order to meet health care needs but mat be insufficient in more complex situations. One service user who was extremely underweight due to illness had no nutritional assessment in place in the plan of care, all admissions should have this screening done, along with a periodic review, including analysing weight gains or losses, so that appropriate action can be taken early if a problem becomes evident. The medication trolley is still not locked in an appropriate way, this was a problem identified at the previous inspection, and the trolley must be securely attached to the wall when it is left in the downstairs hall and then locked away in the medicines room when not in use. The controlled drugs system needs to be reviewed; in particular a bound register with numbered pages should be used to record the running balance of controlled drugs after each administration, this is necessary in order to safeguard both staff and service users best interests. Whilst staff were observed working courteously and respectfully during the day, using the preferred term of address with service users and knocking before entering rooms, the toilet in the main hallway has no lock or vacant/engaged signage it also has a door that opens outward into the hall, where many service users like to sit. The inspector noted that use of this toilet became quite a public affair with staff and service users commenting on the smells coming from the toilet, staff and the providers need to make a review of this toilet’s use in order to ensure that service user’s dignity and rights to privacy are upheld. Goole Hall DS0000061976.V307597.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is adequate. A limited range of activities are available, however these are not tailored to the individuals needs meaning that the home does not fully satisfy the service user’s social, cultural and recreational needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a lack of organised activities and community contact, in particular individualised activities which relate to the service users likes and dislikes and current abilities are not available due to shortages of staff. The home does not employ an activities organiser, and hobbies are not recorded in care plans, and so service users do not have enough opportunities to participate in stimulating, motivating activities and their recreational needs are not met. Service users are able to have visitors throughout the day, and they are made welcome by the staff in the home. Service users have some choice through the day and have several areas in which to sit and can choose their daily routine, which is kept as flexible as possible by care staff, and so service users are helped to exercise choice and control over their lives. Goole Hall DS0000061976.V307597.R01.S.doc Version 5.2 Page 13 The lunchtime meal was observed and this was served in the pleasant dining room in a calm and unhurried fashion, with care staff assisting as necessary at the tables, the meal was enjoyed, and the cook was available during the day to establish likes, dislikes and choices and to encourage one gentleman with a poor appetite, also care staff were seen during the day helping people to take sufficient fluids, and fresh fruit was offered in appealing portions to everyone as an afternoon snack, and it was evident that service users received a wholesome, appealing balanced diet in pleasing surroundings. Goole Hall DS0000061976.V307597.R01.S.doc Version 5.2 Page 14 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 and 18 Quality in this outcome area is poor. Service users are not safeguarded by an available complaints policy, and staff need more training with regard to abuse awareness. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home does not display a copy of the complaints procedure and the home does not display the contact details for The Commission for Social Care Inspection in case any service user or relative or staff wish to make a complaint. There is no copy of the complaints procedure available in service users files. Two service users were not sure whom they would make a complaint to, and the inspector could not find a complaints log to see if there had been any recent complaints. The home therefore is not protecting the service users with a robust complaints procedure that is available to everyone. Staff do not receive sufficient training, and whilst the new multi - agency document on adult protection has arrived at the home, this has not been cascaded to staff. Also staff have recently been verbally and physically challenged by a resident with dementia and have difficulty dealing with this. Staff need to have dementia awareness training and need the support of the providers so that they are safeguarded, and also to ensure that service users are protected and cared for appropriately. Goole Hall DS0000061976.V307597.R01.S.doc Version 5.2 Page 15 The Commission for Social Care Inspection has received two complaints about the home since the last inspection of 23rd May 2006 and has investigated these during this inspection of 7th August 2006, and found that in the area of shortage of staff the complaint was upheld in the area of poor care practices the complaint was partially upheld. Goole Hall DS0000061976.V307597.R01.S.doc Version 5.2 Page 16 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24 and 26 Quality in this outcome area is poor. The home is comfortable and clean, however improvements need to be made to ensure the safety of staff and service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Whilst the lawns to the home are well maintained the path leading up to the home is crumbling, hazardous and unfit for residents use and in particular for those in wheelchairs, as it would compromise their safety. There is a lack of garden furniture and also the garden is not enclosed leading straight on to the main road into Goole, and so service users cannot sit out and enjoy the garden comfortably, and they are not safeguarded by an appropriate fence. Whilst there are only two bathrooms, the staff say that they have sufficient bathing facilities and manage to offer several baths during the week to each service user or as they wish, the home should make available one assisted bath to 8 service user so that there are enough bathing facilities. Service users
Goole Hall DS0000061976.V307597.R01.S.doc Version 5.2 Page 17 do not have locks to the doors of their rooms that are suited to their capabilities; this has been identified as an issue at the last two inspections. The privacy of the service user is not assured. Clear signage to bedroom doors would be useful, in particular to those service users with dementia in order to assist them in identifying their room. The home was found to be clean and two new domestics have been employed, and are working hard to raise the standard of cleanliness, however the laundry policy needs to be reviewed so that soiled laundry is transported in red bags, and the laundry room still needs to be improved as identified at the last two inspections, with an impermeable floor and readily cleanable walls, plus separate sink for staff to wash their hands in, as this will reduce the risks to service users of cross infection. The carpet outside of the kitchen is worn and sticky and needs replacing, as it is hazardous and unpleasant. Goole Hall DS0000061976.V307597.R01.S.doc Version 5.2 Page 18 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 poor. Service users are cared for by a dedicated hardworking team of staff, however, the home is short staffed, and since the manager resigned staff are not supported. A lack of sufficient approved training for staff results in the care needs of service users not being met by either the numbers or skill mix of staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service users spoken with were eager to praise the staff “ they are dedicated and hardworking” “ we have everything we need”. One social services care manager told the inspector that the staff team were a stable group of dedicated care workers who cared very much about the service users, and she felt that service users were well cared for, also one visitor reported to the inspector how well the staff looked after his mother, but he felt that staff were not supported and had to work long hours. The inspector observed the staff working in a calm, respectful way and noted that they had a good rapport with each other and with service users and were very much focused on their welfare. However the home is currently short staffed and so carers are being asked to work extra duties and long hours. There is also a lack of appropriate training and no training programme available, and so service users needs are not met by the numbers and skill mix of staff.
Goole Hall DS0000061976.V307597.R01.S.doc Version 5.2 Page 19 There are less than 50 of care staff with the NVQ2 certificate in care, and with no manager or deputy manager the service users lack available qualified staff to care for them and staff have no support access to advice within the home when complex issues arrive The files of five staff members were inspected with regard to recruitment procedures and the documents required by regulation were all found to be in order with two good written references and Criminal Record Bureau checks in place, and so service users are protected by a robust recruitment policy and practices. There is no staff training programme in place other than induction training, resulting in staff lacking in confidence, and being poorly equipped with the necessary skills that would enable them to deliver improved care to service users, for example in relevant areas such as: dementia /challenging behaviour /adult abuse awareness. Goole Hall DS0000061976.V307597.R01.S.doc Version 5.2 Page 20 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): 31,33,35,36 and 38 Quality in this outcome area is poor. Service users live in a home that does not have a manager, staff are not supported by the area manager and the safety of people in the home is not protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Whilst the providers are using an agency to advertise the managers post no one has been selected as yet for the post, also the home has no deputy manager and no administrative staff in place in the home. The area manager calls to the home several times per week, however staff feel they do not get the support that they require and staff morale is low. The home still does not have a quality assurance system in place, which was identified as a problem at the last inspection, the home should seeks the views of those that are using the service, and of their relatives and other stakeholders in the wider community e.g. care managers district nurses, also there are no residents
Goole Hall DS0000061976.V307597.R01.S.doc Version 5.2 Page 21 meetings or opportunity for relatives to express their views, make comments or complaints, and so the home is not able to monitor its quality its progress or to measure any success in meeting its aims and objectives. Service users cannot now access their monies on a daily basis, since the registered manager left, only the area manager has the keys to access this money which meant that the inspector could not check the records for these monies, and also that service users have to wait until the area manager visits in order to access their cash. Staff supervision, identified as a problem at the last inspection has lapsed completely, staff should receive supervision at least six times per year and it is an opportunity for the home to ensure that employment policies and procedures, the philosophy of the home, are passed on to staff and then put into practice, without this supervision staff are lacking in confidence and support. The inspector could not find evidence to show that the fire alarm test had been carried out since the registered manager left in June, and other safety certificates could not be found to evidence that the inspections and safety checks had been done that were necessary since the last inspection; electrical system, wiring and equipment check, boiler service check and storage of water temperature to prevent legionella check, and the inspector could not therefore gather the evidence which shows that the providers ensure compliance with relevant health and safety procedures and legislation to protect both service users and staff. Goole Hall DS0000061976.V307597.R01.S.doc Version 5.2 Page 22 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 1 1 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 2 X 2 X X 2 X 1 STAFFING Standard No Score 27 1 28 1 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 1 1 X 1 Goole Hall DS0000061976.V307597.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Goole Hall DS0000061976.V307597.R01.S.doc Version 5.2 Page 24 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 OP2 Regulation 5 (b, c) Requirement Service users must have a contract/ statement of terms given to them, and available in the their file. No service user should move in to the home without an assessment, which shows that the home can meet their needs. The provider must ensure care staff are assisted with regard to written care plans, and risk assessments must be in place to safeguard service users. (Previous timescale of 1/8/06 not met) The medicine trolley must be attached to a wall when stored in the hall, and when not in use must be locked away in the medicines room. The provider should ensure that a variety of suitable activities are organised which are enjoyed by and match the capabilities of the service user. The provider must ensure that the complaints policy and procedure is available to all service users and their representatives and this should display the contact details for The Commission for Social Care Inspection. Timescale for action 08/09/06 3 OP3 14 (1) (a) 08/09/06 4 OP7 15 09/08/06 5 OP9 13 (2) 09/08/06 6 OP12 16 (2)(m n) 08/10/06 7 OP16 22 (5)(6)(a) 08/10/06 Goole Hall DS0000061976.V307597.R01.S.doc Version 5.2 Page 25 8 OP19 23 (2)(b)(o) 9 OP26 23 10 OP27 OP28 OP30 18(1) 18(1) (c) 11 12 OP31 OP33 8 24 13 OP35 12 14 15 OP36 OP38 18 (2) 23 (4)(c) (i) The provider must make a review of the state of the path leading from the car park up to the home, which is in need of repair, and also review the safety of the open gardens with regard to service users with dementia, and take steps to make these safe. The provider must ensure that laundry facilities meet the required standards with an impermeable floor readily cleanable walls and a hand wash sink for staff. (Previous timescale of 31/3/06 not met) The provider must ensure that service users needs are met by the numbers and skill mix of staff. A manager and more care staff need to be recruited and existing staff need to be supported and offered appropriate training. The provider must persist in recruiting a suitable manager as soon as possible The provider must revise the quality assurance system at the home in order to seek the views of the service users, their family and representatives, and other stakeholders as to whether the aims and objectives of the home are being met The provider should ensure that any service users monies and written records of transactions are available for inspection. The provider should make arrangements to ensure that staff have adequate supervision The provider must take immediate action to conduct a fire alarm test and maintain testing at regular intervals thereafter.
DS0000061976.V307597.R01.S.doc 08/10/06 08/10/06 08/10/06 07/08/06 08/10/06 14/08/06 08/10/06 09/08/06 Goole Hall Version 5.2 Page 26 13 The provider must supply copies of certification to show that the following checks have been carried out by suitably competent individuals; Electrical wiring Portable appliance testing Boiler service Storage of water temperatures to guard against legionella 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 OP2 Good Practice Recommendations The providers must offer clear information about the home to prospective service users in the form of a statement of purpose and service users guide, and this should be made available in the home. The provider must support the staff so that they can be confident about making decisions regarding service users health care needs, and the need to make referrals to allied health care professionals. The provider should make a review of the use of the downstairs hall toilet, which is situated in a public area and has no lock or signage, and the door opens out into the hall, as the service users right to privacy is compromised. The provider should establish whether service users would like to develop links with the local community The provider should ensure that staff have sufficient training and information with regard to protecting service users from abuse. The provider should review the bathroom facilities as the home has an insufficient number of assisted baths for the number of service users. The provider must persist in his attempts to provide suitable locks for service users rooms. 2 OP8 3 OP10 4 5 6 7 OP13 OP18 OP21 OP24 Goole Hall DS0000061976.V307597.R01.S.doc Version 5.2 Page 27 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
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