Inspection on 20/11/08 for Gordon House

This inspection was carried out on 20th November 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Gordon House 27/11/06

Gordon House 04/11/05

Gordon House 11/08/04

Gordon House 26/04/04

Gordon House 28/01/04

Extracts from inspection reports are licensed from CQC, this page was updated on 29/01/2009.

CARE HOME ADULTS 18-65 Gordon House Belmont Grove Liverpool Merseyside L6 4EH Lead Inspector Daniel Hamilton Unannounced Inspection 20th November 2008 09:30 Gordon House DS0000025106.V373066.R01.S.doc Version 5.2 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 Gordon House DS0000025106.V373066.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 Adults 18-65. 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. Gordon House DS0000025106.V373066.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gordon House Address Belmont Grove Liverpool Merseyside L6 4EH 0151 260 9022 0151 260 9022 gordonhouse@c-i-c.co.uk www.c-i-c.co.uk. Community Integrated Care 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) David George Bruce Sara Elin Taylor Care Home 20 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (20) of places Gordon House DS0000025106.V373066.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N, to service users of the following gender: Either; whose primary care needs on admission to the home are within the following categories: Mental disorder, excluding learning disability or dementia - Code MD. The maximum number of service users who can be accommodated is: 20. Date of last inspection Brief Description of the Service: Gordon House is owned and managed by Community Integrated Care (Registered Provider) and is a single storey building which houses 20 service users with long term enduring mental health illness. The service has two Registered Managers who are both experienced psychiatric nurses. All service users have their own bedroom. Shared communal spaces include a well-maintained garden, lounge areas, kitchen and dining room. Service users are encouraged to maintain their independence and to follow a lifestyle in accordance with their own choices and preferences. Psychiatrists, general practitioners, community psychiatric nurses, social workers and family support the people living in the Gordon House. The service users are encouraged to take up paid jobs, attend day centres, or follow educational programmes. Information on the service is available from the office and the care home fees currently range from £425.80 to £451.00. Gordon House DS0000025106.V373066.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means that the people using the service experience good quality outcomes. This unannounced inspection took place over one day and lasted approximately 8.5 hours. A partial tour of the premises took place and observations were made. Two care files were examined and a selection of staff and service records were also viewed. Reference was also made to information provided by the management team in the form of a pre-inspection ‘annual quality assurance self-assessment.’ The two registered managers, three staff and five service users were spoken with during the inspection. Prior to the visit, survey forms were also distributed to a number of service users in order to obtain additional views and feedback about the service. All the core standards were assessed and previous requirements and recommendations from the last inspection in November 2006 were reviewed. What the service does well: Gordon House presented as a warm and friendly environment in which to live. Service users spoken with during the visit confirmed they were satisfied with the standard of care provided. Comments received included: “The staff are helpful and friendly”; “I like it here. Staff do whatever they can and will bend over backwards for you” and “The managers and staff are very nice and helpful.” The service had developed a care planning system to ensure the needs of the people using the service were identified and planned for. Care plans outlined how the health, personal and social care needs of the people using the service were to be met and the management and staff team demonstrated a good understanding of the needs of the people using the service. The service users were supported to keep in contact with family and friends and to access their local communities to participate in a range of recreational, leisure and social activities of their choice. Service users were encouraged to exercise choice and control over their lives and to take responsible risks as part of an independent lifestyle. Gordon House DS0000025106.V373066.R01.S.doc Version 5.2 Page 6 Systems had been developed to ensure complaints were listened to and acted upon and policies and procedures were in place to ensure an appropriate response to suspicion or evidence of abuse. One service user reported: “If anyone has a problem you can speak to Dave or Sara and they’ll sort it.” Staff had access to induction, ongoing training and development opportunities and formal supervision to ensure they were supported to undertake their roles effectively. The service was managed by two experienced Registered Mental Nurses who were registered with the Commission for Social Care Inspection. A quality assurance system had been developed to ensure the views of residents were obtained each year and audits were undertaken periodically to monitor standards and health and safety within Gordon House. What has improved since the last inspection? What they could do better: There was one requirement made following this visit, which concerned the condition and cleanliness of a carpet in a corridor within the home. This must be replaced to ensure the area is clean and homely for service users. Furthermore, a planned programme of the refurbishment of the vanity units should be completed, to improve the standard of accommodation. It is also recommended that copies of the Statement of Purpose or Service User Guide be displayed in the reception area of the home, so that people can access information on the service more easily. Gordon House DS0000025106.V373066.R01.S.doc Version 5.2 Page 7 Two service users’ files were examined during the visit and both did not contain an assessment of needs. Each service user file should be checked to ensure it contains an assessment of needs and assessments should be updated to ensure equality and diversity issues are considered as part of the assessment process. This will help the service to undertake a more holistic assessment of needs. The controlled drugs cabinet should also be secured to the wall using the correct fixing method, to ensure compliance with the Misuse of Drugs (Safe Custody) Regulations 1973. 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. Gordon House DS0000025106.V373066.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Gordon House DS0000025106.V373066.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. Prospective service users have access to sufficient information to make an informed decision on the suitability of the service and whether it can meet their needs. EVIDENCE: A Statement of Purpose and Service User Guide had been developed in a standard format to provide information on the service provided at Gordon House. The information was detailed and provided all the necessary information required under Schedule 1 of the Care Home Regulations 2001. A separate brochure containing information on Gordon House and the Registered Provider (Community Integrated Care) was also in the process of being developed and was available for reference in the office. The management team confirmed that the service would produce the information in alternative formats, subject to individual need. The service was recommended to display information on the service in the reception area of the home, to ensure it is more accessible to the people using the service and their representatives. Gordon House DS0000025106.V373066.R01.S.doc Version 5.2 Page 10 Gordon House does not take referrals directly as an ‘accommodation group’, organised by Liverpool Primary Care Trust, is responsible for referring the details of people who meet the eligibility criteria for mental health services to available providers on a monthly basis. Upon receipt of referral records, a member of the management team makes arrangements to contact the prospective service user to undertake an assessment of need. This enables the service to determine whether the needs of the person can be met at Gordon House. The pre-admission information is then used to form an initial care plan, which is reviewed shortly after admission. Two service user files were viewed during the visit. Copies of pre-admission assessment information completed by the service could not be located, however mental health assessment reports and review information completed by health care professionals was available for reference. Copies of the ‘Assessment document for new referrals to Gordon House’ was viewed on other files and advice was given on how the assessment document could be further developed in order to ensure an holistic assessment of needs. Service users are encouraged to visit Gordon House as often as they wish before deciding whether to move in. Many of the service users are able to move on to independent living after a period of rehabilitation. Gordon House DS0000025106.V373066.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. The assessed and changing needs of the people using the service is taken into consideration in the planning of the service, to promote and safeguard independence and wellbeing. EVIDENCE: A sample of two service user files were viewed during the visit. Each file contained a detailed care plan, which had been produced by the management team or a senior staff member upon admission of each service user. Care plans viewed outlined the individual needs, objectives and staff instructions on the action required to meet the physical, mental health, personal and social care needs of the people using the service. Care plans had been kept under regular review and had been signed by service users. Gordon House DS0000025106.V373066.R01.S.doc Version 5.2 Page 12 Discussion with the people using the service and staff confirmed service users were encouraged to make decisions about their lives and to take responsible risks associated with the normal aspects of daily life. Staff were available, when required, to offer care and support and it was evident that the people using the service maintained a positive and friendly relationship with the management and staff team. A range of risk assessments had been completed and kept under review to address environmental, health, daily activities, community presence, individual and moving and handling risks. Supporting documentation including daily report, health care records, accident and incident forms and weight records were also maintained. Gordon House DS0000025106.V373066.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality outcome in this area is good. This judgement has been made using available evidence, including a visit to the service. Meals, activities and routines are flexible and varied. This enables the people using the service to have choice and control over their lives. EVIDENCE: The people living at Gordon House are supported to follow their preferred routines and lifestyle. Service users are encouraged to take part in appropriate therapeutic activities including: further education, the development of daily living and employment skills and paid or voluntary work. The people using the service are also supported to have a holiday away from Gordon House and to maintain contact with family and friends. One service user stated; “My Dad comes every Friday to see me.” Gordon House DS0000025106.V373066.R01.S.doc Version 5.2 Page 14 An activities programme is organised on a weekly basis with the people using the service. The programme is flexible to enable service users to exercise choice and control. Activities on offer during the week of the inspection included: a ladies morning, drive and lunch out, bingo session, Christmas shopping, cinema, walk around park, trip to city centre and bowling. Service users were observed to access the community independently during the visit and the service had a designated activities budget and the use of a mini-bus. Comments received from service users included: “I like to take the dogs for a walk and see the Everton games”; “I’ve been to Blackpool and Butlins for holidays and I went to the pictures with staff yesterday” and “I like going on day trips to Southport.” Previous inspection records confirmed service users were entered on the electoral roll and encouraged to exercise their right to vote either in person with staff support if needed, or by postal voting. The Annual Quality Assurance Assessment (AQAA) also detailed that service users were able to access advocacy support and the local Citizens Advice Bureau for information on general and financial issues. The service had a two-week rolling menu plan in place, which detailed a choice of wholesome and nutritious meals. The management team reported that menus were planned in advance with the people using the service and prepared in the main kitchen. Gordon House is also equipped with a rehabilitation kitchen and service users have access to a rehabilitation budget so that they can learn or maintain their cooking skills or prepare a meal for themselves or visitors. There is tea and coffee available throughout the day for service users and visitors to help themselves, and there is a nicely furnished communal dining area where the people using the service can eat and socialise. Feedback received from service users regarding the meals was generally positive. Comments included; “We have a choice of food”; “The food is very nice” and “I can’t complain about the meals. They are generally OK.” Gordon House DS0000025106.V373066.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. The people using the service receive support with their mental and physical healthcare needs in order to ensure a positive outlook and healthy lifestyle. EVIDENCE: The people living at Gordon House required different levels of assistance with their personal and health care. The management and staff team demonstrated a good understanding of the individual needs and preferences of the people using the service and a commitment to the promotion of independent living skills. Examination of health care records confirmed service users had access to general practitioners and other health care professionals subject to individual need. It was noted that some people had refused to attend routine health care appointments and advice was given regarding care planning processes in this respect. Gordon House DS0000025106.V373066.R01.S.doc Version 5.2 Page 16 The Annual Quality Assurance Assessment for the service detailed that staff had access to a policy on the control, storage, disposal, recording and administration of medicines. Local policies had also been produced for selfadministration, leave medication and general storage and medication. The management team reported that only registered nurses were designated to administer medication and that staff received in-house training on policies and procedures. An identification system had been established to help minimise administration errors and a record of staff authorised to administer medication, together with sample signatures was available for reference. Medication was stored in a trolley, which was bolted to a wall when not in use. A fridge was also in place to store medication requiring refrigeration and records of the fridge and room temperature were maintained. There were no controlled drugs in the home at the time of the visit, however a metal cabinet was in place to store controlled drugs if prescribed. Advice was given regarding the correct fixing of the metal cabinet to the wall, to ensure compliance with the Misuse of Drugs (Safe Custody) Regulations 1973. A sample of Medication Administration Records (MAR) were viewed and no issues of concern were noted. Action had been taken in response to recommendations made following a random pharmacy inspection during May 2008. Gordon House DS0000025106.V373066.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. Service users and their representatives can be confident that any complaints will be taken seriously and that systems are in place to protect service users from abuse. EVIDENCE: The Registered Provider (Community Integrated Care) had developed a corporate complaints policy and a complaints procedure for Gordon House had been produced which included the contact details of the Commission for Social Care Inspection. A copy of the complaints procedure was displayed in the reception area and on a notice board in a communal kitchen area for service users to view. The Annual Quality Assurance Assessment (AQAA) for the service detailed that no complaints had been received in the last 12 months. Likewise, the Commission for Social Care Inspection had received no complaints about Gordon House. Feedback received from the people using the service confirmed they understood how to complain about the service. For example, one service user reported; “If anyone has a problem you can speak to Dave or Sara and they’ll sort it.” Gordon House DS0000025106.V373066.R01.S.doc Version 5.2 Page 18 Examination of the complaints record for Gordon House revealed that one complaint had been received by the Registered Provider (Community Integrated Care) from a resident in Gordon House since the AQAA was completed. The complaint concerned a sum of money that had been reported as missing from a resident’s room and the resultant decision of the Registered Provider not to reimburse the loss, as there was no evidence to suggest that a crime had been committed. Records showed that the Registered Provider had developed an adult protection procedure and a whistle-blowing policy. A copy of the Liverpool City Council Inter-Agency Adult Protection Procedures was also available in Gordon House for staff to reference. The AQAA detailed that there had been no adult protection referral or investigations in the last 12 months and this was confirmed in discussion with the management team. At the time of the visit the service did not have a training matrix. Records of staff training were maintained using an electronic system. The management team reported that all staff had completed abuse training as part of their induction and ongoing training updates. Staff spoken with during the visit demonstrated a satisfactory understanding of their duty of care to protect vulnerable people and how to recognise and respond to suspicion and/or evidence of abuse. Gordon House DS0000025106.V373066.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality outcome in this area is adequate. This judgement has been made using available evidence, including a visit to the service. The standard of the environment is improving, however some areas remain in need of refurbishment to ensure the people living in Gordon House benefit from a homely, comfortable and safe environment. EVIDENCE: The Registered Provider (Community Integrated Care) employed a central maintenance officer who was responsible for organising maintenance and repairs to the premises and a contract gardener was employed to maintain the grounds. Jobs in need of attention and/or hazards were recorded in a maintenance book. Since the last visit, the communal toilets and bathrooms had been upgraded and the heating in the lounge used by smokers had been improved. Furthermore, the communal areas had been redecorated, new pictures had been fitted throughout the home and the quiet room had been re-furbished. Gordon House DS0000025106.V373066.R01.S.doc Version 5.2 Page 20 On the day of the visit the premises appeared clean and tidy and generally well maintained. A team of five part-time domestic staff were employed to keep the building clean and a part-time laundry assistant worked five days per week. It was noted that the vanity units in some bedrooms viewed were in need of refurbishment and the carpet in a hallway required replacement, as it was dirty and worn. Communal lounges and the dining room were nicely decorated and furnished with comfortable furniture. There was also a rehabilitation kitchen to help service users maintain or develop their cooking and daily living skills with assistance from staff as required. Service users’ rooms viewed had been decorated and personalised to their own choice. Please refer to the ‘Brief Description of the Service Section’ for more information on the premises. The Annual Quality Assurance Assessment (AQAA) for the service detailed that policies and procedures had been developed for communicable diseases and infection control and to safeguard health and safety. Gordon House DS0000025106.V373066.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality outcome in this area is good. This judgement has been made using available evidence, including a visit to the service. Systems have been established to ensure staff are appropriately recruited and trained for their roles. This ensures the people using the service are protected and in safe hands. EVIDENCE: Gordon House had a team of two job-share Registered Managers, two parttime care managers, four Registered Mental Nurses and 13 support workers. At the time of the visit the service had a vacancy for one full-time care support worker. The present staffing levels ensure service users’ needs are met and that their lifestyles and social activities are promoted. Service users spoken with during the visit reported that the standard of care provided by staff was good. For example, comments from three service users included: “The staff are helpful and friendly”; “I like it here. Staff do whatever they can and will bend over backwards for you” and “The managers and staff are very nice and helpful.” Gordon House DS0000025106.V373066.R01.S.doc Version 5.2 Page 22 Discussion with the management team and examination of the staff rota confirmed that five staff (including a Registered Mental Nurse) were on duty during the day from 7:45am to 2:15pm and four staff (including a Registered Mental Nurse) on duty from 2:15pm until 8:30pm. During the night there were three staff on duty (including a Registered Mental Nurse) from 8:15pm until 8:00am. The Annual Quality Assurance Assessment (AQAA) detailed that the Registered Provider (Community Integrated Care) had a policy on recruitment, including redundancy, and that satisfactory pre-employment checks had been completed for all new staff. Recruitment was co-ordinated by the Registered Provider’s Human Resources Department. The Management team reported that four staff had commenced employment at Gordon House since the last visit. The recruitment records pertaining to the four staff were viewed and confirmed that staff had been correctly recruited and vetted to safeguard the welfare of the people using the service. The Annual Quality Assurance Assessment (AQAA) for the service did not contain information on staff training and qualifications and this information could not be obtained from the Skills for Care website during the visit due to technical reasons. The management team reported that the service employed four qualified Registered Mental Nurses (not including the two registered managers) and seven additional staff had completed a National Vocational Qualification (NVQ) in Care at level 2 or above. Therefore, 11 staff (57.9 ) of the staff team were qualified to NVQ level 2 or above and a further three staff were working towards the award. The Registered Provider had a training department, which delivered certain core training. The organisation had also developed a ‘CIC academy e-learning system’ which covered induction training; core skills part 1, 2 and 3; Safety at Work; Food Hygiene; Person Centred Learning; First Aid; Moving and Handling and Communicating Effectively. Practical training was also provided for Moving and Handling, First Aid and Basic Food Hygiene. Additional training was coordinated on a regular basis and a training bulletin was sent out to the service by the training department every three months. Staff spoken demonstrated a satisfactory understanding of the principles of good care practice and the needs of the people they cared for. Staff also confirmed that they had received induction, undertaken various training courses and received supervision during their employment with Community Integrated Care. Gordon House DS0000025106.V373066.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence and by visiting the service. Management and administration systems have been developed to ensure the service operates efficiently and in the best interests of the people living in Gordon House. EVIDENCE: Mr David Bruce and Ms Sara Taylor are registered with The Commission for Social Care Inspection as the joint Managers of Gordon House. Ms Taylor has managed the service since 1998 and Mr Bruce became the joint manager in 2003. Both the managers are qualified Registered Mental Nurses and Mr Bruce has completed the NVQ level 4 Registered Managers Award. At the time of the visit Ms Taylor was working towards this qualification. Discussion with the Gordon House DS0000025106.V373066.R01.S.doc Version 5.2 Page 24 management team and examination of training records confirmed both the managers had continued to undertake periodic training and development to maintain and update their knowledge, skills and competence in the field of mental health and general management. Feedback received from staff via discussion and surveys confirmed the managers were supportive and approachable. For example, one staff member reported; “Both home managers are extremely supportive and regularly provide ongoing advice and feedback. They are non-judgemental, fair and generous with their time to meet the needs of staff as well as service users.” Likewise, another member of staff reported: “Gordon House is a well managed home. It has a high standard of care which is met by all”. The management team were observed to engage with the people using the service in a positive manner and service users were observed to receive support and assistance throughout the visit as and when required. Service users spoken to on the day of the visit also spoke highly about the Management team and staff. A Service Manager continued to undertake monthly visits to Gordon House on behalf of the Registered Provider in accordance with Regulation 26 of the Care Home Regulations 2001. This involved carrying out an audit of all aspects of the service including staffing, care standards, medication, staff records, staff training, managing resources, food hygiene, hygiene and cleanliness, health and safety, maintenance, communication and quality. Systems had been developed to ensure audits of policies and procedures and an annual quality review were undertaken. Furthermore, team and resident meetings were co-ordinated on a bi-monthly basis and minutes maintained. Annual surveys were also sent out from head office to service users and/or their relatives asking for their views of the home and service provided (where practicable). The results of the survey had been summarised and the management team reported that they planned to include the summary in the service user guide. Information received via the Annual Quality Assurance Assessment (AQAA) for the service confirmed policies and procedure had been developed on Health and Safety. Likewise, the dataset section of the document confirmed that equipment in the home had been serviced and/or tested. Gordon House DS0000025106.V373066.R01.S.doc Version 5.2 Page 25 Fire records were viewed during the visit and confirmed that the fire alarm system had been tested each week and that the emergency lighting and external lighting had been tested on a monthly basis. Records were also in place to confirm that day and night staff received fire instruction training at the recommended intervals. Records had been maintained to confirm health and safety checks had been completed, which included the testing of the hot water outlets. A hazard and fire risk assessment had also been completed for the environment. Gordon House DS0000025106.V373066.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 2 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Gordon House DS0000025106.V373066.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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 YA24 Regulation 23 Requirement The worn and dirty carpet in the corridor must be replaced, to ensure the people using the service benefit from a homely and clean environment. Timescale for action 20/01/09 Gordon House DS0000025106.V373066.R01.S.doc Version 5.2 Page 28 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 YA1 Good Practice Recommendations Copies of the Statement of Purpose or Service User Guide should be displayed in the reception area of the home so that people can access information on the service more easily. Each service user file should be checked to ensure it contains an assessment of needs. Furthermore, assessments should be updated to ensure equality and diversity issues are considered. This will help to ensure an holistic assessment of needs. The controlled drugs cabinet should be secured to the wall using the correct fixing method, to ensure compliance with the Misuse of Drugs (Safe Custody) Regulations 1973. A planned programme of the refurbishment of the vanity units should be completed, to improve the standard of accommodation. A training matrix should be developed to help provide an overview of the training completed by staff. 2 YA2 3 4 4 YA20 YA24 YA35 Gordon House DS0000025106.V373066.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection NW Area Office 3rd Floor, Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Gordon House DS0000025106.V373066.R01.S.doc Version 5.2 Page 30 - 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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