Inspection on 02/08/05 for Gorse Hill

This inspection was carried out on 2nd August 2005.

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

Gorse Hill 23/01/07

Gorse Hill 17/01/06

Gorse Hill 05/01/05

Gorse Hill 16/06/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Gorse Hill 2 Stephenson Drive Burnley Lancs BB12 8AJ Lead Inspector Julie Playfer Announced 2 August 2005 9.30 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 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 Stationary 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. Gorse Hill F57 F07 S55145 Gorse Hill V229113 2.8.05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Gorse Hill Address 2 Stephenson Drive Burnley Lancs BB12 8AJ 01282 438916 01282 831457 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Voyage Ltd inc Thelma Turner Homes Ms Dawn Ashton 10 LD 10 Category(ies) of Learning Disability registration, with number of places Gorse Hill F57 F07 S55145 Gorse Hill V229113 2.8.05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service must at all times, have a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 2. The staffing of the home should be a minimum of 1 (one) staff member to 2(two) service users during the day and 1(one) waking watch and 1(one) sleep in member of staff at night Date of last inspection 5th January 2005 Brief Description of the Service: Gorse Hill is registered with the Commission for Social Care Inspection as a care home for adults (aged 18 –65) with learning disabilities. The home provides accommodation for up to 10 people of both sexes. The rooms are all single occupancy and there are small ‘flats’ available which provide the opportunity for more independent living. These flats contain a sleeping area, sitting area, bath/shower room and kitchen. The communal areas of the home include a large sitting dining area, a smaller lounge, a quiet lounge, a kitchen, crafts room and a ‘smoking’ room. The laundry and ironing rooms may be used with staff supervision. The home is surrounded by gardens and has a patio/ barbeque area with a large water feature. Gorse Hill is situated on the Burnley to Padiham Road with nearby bus stops to both towns. There are a variety of shops and other amenities nearby. A local park is within easy walking distance.There is a minibus available for trips to shops and supermarkets and other less easily accessible amenities. Gorse Hill F57 F07 S55145 Gorse Hill V229113 2.8.05 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and took place over eight and half hours on 2nd August 2005. The previous inspection was carried out on 5th January 2005. No additional visits have been made to the home since the last inspection. On the day of inspection there were 7 residents accommodated at the home. Information was obtained from staff records, care records and policies and procedures. The inspector also spoke to the residents, the staff on duty and the registered manager. A partial tour of the premises was also undertaken. What the service does well: What has improved since the last inspection? Since the last inspection the written information provided for residents had been updated to include details about the services and facilities available in the home and the arrangements for dealing with complaints. The contract/terms and conditions and the policies on confidentiality had also been updated. A behaviour analysis form had been completed for all residents; this document provided a useful overview of all action plans relating to the management of behaviour. Gorse Hill F57 F07 S55145 Gorse Hill V229113 2.8.05 Stage 4.doc Version 1.30 Page 6 Appropriate arrangements had been put in place for storage of controlled drugs. A record medication received into the home had been introduced and there were no omissions seen on the medication administration record. The registered manager had implemented monthly management checks to see how systems were working in the home for instance the review of care plans. To promote the health and safety of residents the handy person had received training to test portable electrical appliances and specialist equipment had been bought for this purpose. This meant that the safety of all electrical appliances could be tested on admission. 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. Gorse Hill F57 F07 S55145 Gorse Hill V229113 2.8.05 Stage 4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection Gorse Hill F57 F07 S55145 Gorse Hill V229113 2.8.05 Stage 4.doc Version 1.30 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 - 5 Residents were provided with useful and informative information about the services and facilities provided in the home. Resident’s needs were properly assessed and reviewed. EVIDENCE: Since the last inspection the statement of purpose and service users guide had been updated and both documents met regulatory requirements. With the exception of one resident, the service users guide had been distributed and explained to all residents. The resident who had not received a service users guide was new to the home and was given a copy during the inspection. Prior to admission prospective residents’ individual needs were assessed by a social worker. Information was also sought from the previous carer and professional staff as appropriate, for instance a psychologist. The registered manager also visited residents in their previous placements. It was part of usual practice for prospective residents to visit the home prior to making the decision to move in. One resident new to the home said he enjoyed the introductory visit he made with his social worker and said he “liked meeting the staff and having a sandwich”. Following the initial assessment process a letter was sent by the organisation to the resident’s social worker, however, the residents did not receive personal Gorse Hill F57 F07 S55145 Gorse Hill V229113 2.8.05 Stage 4.doc Version 1.30 Page 9 written confirmation to assure them that the home was suitable for meeting their needs. All residents had been issued with a contract/terms and conditions, which had been updated since the last inspection to include details of the notice period. Gorse Hill F57 F07 S55145 Gorse Hill V229113 2.8.05 Stage 4.doc Version 1.30 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 - 10 There was effective use of individual care plans and behaviour management guidelines to ensure the delivery of care and support was consistent. The risk assessment and management arrangements supported residents to take responsible risks, however systems must be developed to ensure residents are fully included in the care planning process. EVIDENCE: The residents had an individual plan, which reflected their health and welfare needs. Detailed instructions were set out for staff to ensure all needs were met. Where necessary, the care plans were supplemented by behaviour management guidelines, which were designed to provide a consistent response to behaviours, which challenged others and the service. The guidelines focussed on positive behaviour and the use of distraction. Since the last inspection a behaviour analysis form had been completed for all residents. This presented an overview of all action plans relating to the management of behaviour. Whilst the registered manager reported that individual care requirements had been discussed with the residents, there was no written evidence that the residents had been involved in the care planning process. Gorse Hill F57 F07 S55145 Gorse Hill V229113 2.8.05 Stage 4.doc Version 1.30 Page 11 It was the practice of the home to support responsible risk taking and policies stated that the role of staff was to facilitate independence wherever possible. Detailed risk assessments and management strategies covered activities indoors and in the wider community and were included on residents’ plans. During conversations with residents it was evident they were consulted both informally and formally and they were able to participate in life in the home. One Residents’ meeting had been arranged since the beginning of the year. From the minutes seen it was evident a wide variety of topics were discussed and contributions had been made by the residents. The residents were supported with their financial affairs and detailed written records were maintained of all transactions. A random check of money deposited with the home for safe keeping corresponded accurately to the records. The home had written guidance for staff relating to the safe-keeping of information in accordance with the rights of the residents and the Data Protection Act. Confidentiality of information was also covered in the induction training and reinforced in staff contracts and the General Social Care Council Code of Conduct. A confidentiality statement had been devised since the previous inspection, this had been placed in front of the visitor’s book and given to each member of staff. Gorse Hill F57 F07 S55145 Gorse Hill V229113 2.8.05 Stage 4.doc Version 1.30 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 - 17 Residents were provided with good opportunities to engage in a wide range of appropriate activities and were supported to use community facilities. The residents maintained strong links with their families, which were supported by the manager and staff. Arrangements were in place to ensure the residents participated in the life of the home and their rights were respected. EVIDENCE: The individual plans and care records demonstrated that residents had opportunities to maintain and develop practical life skills. Where necessary tasks had been broken down and achievable goals had been set. Residents had good access to an extensive range of activities both inside and outside the home. Activities outside the home included; bowling, trips to the park, walks in the local area, shopping in Burnley town centre and the use of leisure centres. All residents had an activity schedule, which was freely available in the home. During the inspection one resident showed the inspector his activity schedule, which was very varied and designed around his individual interests. The resident said he enjoyed the activities, particularly the football Gorse Hill F57 F07 S55145 Gorse Hill V229113 2.8.05 Stage 4.doc Version 1.30 Page 13 and athletics. Staffing levels were reviewed at regular intervals, which enabled residents to pursue individual leisure interests. The residents were supported to maintain relationships with their families and where necessary the staff assisted with transport. One resident was away with his family at the time of the visit. The residents had unrestricted access to the home and grounds. The residents were also able to use their room at any time should they wish to spend some time in private. The registered manager maintained an individual record of meals served to residents, which included variations served to the main menu. The residents said they liked the meals and there was always plenty to eat. Meals were provided three times a day and a range drinks and snacks were available at all times. However, there were no desserts listed on the main menu and one resident remarked on a comment card that “there could be more choice/variety” of food. Gorse Hill F57 F07 S55145 Gorse Hill V229113 2.8.05 Stage 4.doc Version 1.30 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 - 20 The residents’ healthcare needs were identified and met. Personal support was provided in a manner, which respected the residents’ rights to privacy and dignity. The accuracy of medication records must be improved in order to safeguard the residents. EVIDENCE: The residents’ individual care plans set out the personal support each resident required and provided details of how this support was to be delivered. Staff told the inspector the routines were flexible and were primarily designed to meet the needs of the residents and their plans for the day. Healthcare needs were appropriately assessed and were included in the care plan. There was evidence to indicate the residents had access to NHS services and the advice of specialist services had been sought as necessary for example Psychology. Whilst the registered manager had a copy of a manual for care homes produced by the pharmacist, there were no specific policies and procedures relating to the management of medication in the home. Appropriate records were maintained of receipt, administration and disposal of medicines. Since the last inspection arrangements had been put into place for the storage of controlled drugs. However, the controlled drugs register was not accurate and Gorse Hill F57 F07 S55145 Gorse Hill V229113 2.8.05 Stage 4.doc Version 1.30 Page 15 the medication administration record (MAR) indicated one drug had not been administered in line with prescription label. There was no record on the MAR sheet that the frequency of the administration had been changed or when it had been changed. It was also noted that handwritten entries on the MAR sheet had not been witnessed and signed by two members of staff. The manager had carried out weekly audits of the medication and all staff designated to administer medication had received accredited training. Gorse Hill F57 F07 S55145 Gorse Hill V229113 2.8.05 Stage 4.doc Version 1.30 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22-23 Residents were provided with appropriate and sufficient information should they wish to raise a concern. The internal procedure relating to the protection of vulnerable adults must be updated to ensure a proper response to any allegation of abuse or inappropriate practice. EVIDENCE: It was part of usual practice in the home for the registered manager and staff to listen to and act on the views and concerns of residents before they developed into problems and formal complaints. This was achieved during daily conversation and one to one discussion with residents and their key workers. The complaints procedure was included in the service users guide and was verbally explained to residents as necessary. The procedure had been updated since the last inspection to include the assurance that residents and their families would not be victimised for making a complaint. The residents were familiar with the complaints process and had used it to voice their views. The registered manager had maintained a record of complaints along with details of the investigation and outcome. There were letters on file to indicate the complainant had received feedback. A copy of “No Secrets in Lancashire” (The Joint Strategy for the Protection of Vulnerable Adults) was available, along with a specific procedure setting out the required response in the event of any allegations or suspicion of abuse. However, the procedure designated the responsibility to instigate the adult protection procedures to the operations manager rather than the registered manager. This is contrary to the Care Homes Regulations 2001, under which this responsibility is seen as the role of the registered person. All staff had received adult protection training. Gorse Hill F57 F07 S55145 Gorse Hill V229113 2.8.05 Stage 4.doc Version 1.30 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 - 30 The residents were provided with a spacious, comfortable, safe and wellmaintained home. EVIDENCE: Gorse Hill is a large detached house set in it’s own grounds. It is located in a residential area approximately one and a half miles from Burnley town centre. The bedrooms are all single occupancy, with some rooms taking the form of small flat, with kitchen and living areas. All bedrooms have an ensuite bathroom. Communal space is provided in a large sitting dining room, a smaller lounge, a quiet lounge, kitchen and a crafts room. All rooms provide facilities in excess of the National Minimum Standards. The bedrooms had been decorated and furnished according to personal taste. One resident said he “liked” his room and thought it was “nice”. Residents were able to bring in personal belongings, many of which were displayed in their rooms. Residents were able to use their rooms at any time, should they wish to spend time pursuing their own activities. As such, the activities plans incorporated free time for them to fill as they pleased. One resident said he liked to watch DVD’s and videos in his room. The home had a good standard of cleanliness in all areas. Gorse Hill F57 F07 S55145 Gorse Hill V229113 2.8.05 Stage 4.doc Version 1.30 Page 18 The grounds were well-maintained and provided plenty of space for any outdoor activities such as football. Gorse Hill F57 F07 S55145 Gorse Hill V229113 2.8.05 Stage 4.doc Version 1.30 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 - 36 The recruitment and selection of new staff must be improved to safeguard the welfare of the residents. Good arrangements were in place for the induction of staff. The wide range of staff training opportunities gave the staff a good understanding of their role and the needs of the residents. However, the systems in place to support staff on an individual basis should be improved. EVIDENCE: Staff had been issued with a job description, which was commensurate with their role as part of the recruitment process. The care records demonstrated that staff were familiar with their own knowledge and skill limitations and knew when it was appropriate to involve someone else with more specific expertise, for instance a doctor or psychologist. From discussions with staff during the inspection, it was evident they had a good understanding of the residents’ needs and knew the residents’ well. Staff referred to the residents in respectful terms and were observed to interact in a positive and pleasant way. The staffing levels were above the minimum levels identified on the certificate of registration. The level of staffing in place was determined by the needs of the residents and contractual agreements. Gorse Hill F57 F07 S55145 Gorse Hill V229113 2.8.05 Stage 4.doc Version 1.30 Page 20 The recruitment and selection procedure of new staff was underpinned by the organisation’s Equal Opportunities Policy. However, whilst it was noted two written references were on file, a reference had not always been sought from previous employment with vulnerable adults and children. With the exception of one new member of staff all files contained a recent photograph. Appropriate police checks had been carried out and obtained prior to employment. Staff had received induction training which was the equivalent to “Skills for Care” (formerly TOPSS) training. This training was supplemented with additional training on the management of challenging behaviour. Each member of staff had a training assessment and profile and there was an overall training development plan for the staff team as a whole. It was evident staff had access to a broad range of training courses, however, none of the staff had received equal opportunities training. At the time of the inspection four staff had completed NVQ level 2 and a further two staff were working towards NVQ 3. This equated to 22 of the care staff were trained to NVQ level 2. Staff meetings were held on a regular basis with records indicating that six meetings had been held in the last 12 months. The meetings gave the staff the opportunity to share experiences and develop teamwork. The staff received supervision, but had not had six supervision sessions in the last year and none of the staff had received an appraisal. Gorse Hill F57 F07 S55145 Gorse Hill V229113 2.8.05 Stage 4.doc Version 1.30 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 -43 The absence of an integrated quality monitoring system meant that the service was not able to fully demonstrate it was meeting the needs of the residents. The management approach promoted positive relationships between the staff and residents and the overall atmosphere was open and friendly. Appropriate policies and procedures were in place to safeguard the health and safety of the staff and residents. EVIDENCE: The registered manager had the overall responsibility for the management of the home and had a job description, which reflected the aims and objectives of the home. The manager had completed the Registered Manager’s Award in May 2005 and had also undertaken periodic training to update her knowledge and skills. The management approach was consultative and there were systems in place to consult both staff and residents. Relationships within the home were positive and staff spoke about the residents with respect. Gorse Hill F57 F07 S55145 Gorse Hill V229113 2.8.05 Stage 4.doc Version 1.30 Page 22 Since the last inspection the registered manager had introduced a monthly audit to monitor systems within the home, for instance the review of care plans. However, an annual development plan based on continuous selfmonitoring had not been developed. Satisfaction questionnaires were distributed every month in order to consult the residents, however at the time of the inspection the overall results had not been collated and residents had not received any feedback. Satisfaction surveys had not been distributed to residents, their families/representatives or professional staff involved with the residents. There was a full set of policies and procedures, which had been signed and dated by the registered manager. The registered manager maintained a number of records, however, not all staff records were complete and in accordance with the Regulations. Staff received health and safety training, which included moving and handling, food hygiene, first aid and fire safety. Documentation was seen during the inspection which, confirmed gas and electrical systems were serviced at regular intervals. To minimise the risk of scalding all water outlets were fitted with preset valves. Window restrictors and radiator covers were fitted as appropriate. The fire log demonstrated staff and residents had participated in regular fire drills. Since the last inspection the handy person had received training and equipment had been purchased to facilitate the testing of portable appliances. The home had public and employers liability insurance cover in place against loss or damage to the assets of the business and business interuption costs. A business and financial plan was not available for the forthcoming year. Gorse Hill F57 F07 S55145 Gorse Hill V229113 2.8.05 Stage 4.doc Version 1.30 Page 23 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 2 3 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 4 4 4 4 4 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 2 Standard No 31 32 33 34 35 36 Score 3 2 3 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Gorse Hill Score 3 3 1 x Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 2 3 2 F57 F07 S55145 Gorse Hill V229113 2.8.05 Stage 4.doc Version 1.30 Page 24 yes Are there any outstanding requirements from the last inspection? 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 3 Regulation 14 Requirement The registered person must confirm in writing to prospective residents that having regard to the assessment the home is suitable for meeting their needs. The residents must be fully invovled in the care planning process. Timescale for action Immediate and ongoing from the date of inspection. Immediate and ongoing from the date of inspection. Immediate and ongoing from the date of inspection. 1st September 2005 2. 6 15 3. 17 16 Varied desserts must be offered to residents and listed on the main menu. 4. 20 13 5. 20 13 Specific policies and procedures must be devised in respect to the management of medication. These must cover all aspects of the receipt, recording, storage, handling, administration and disposal of medicines. The controlled drugs register must be accurate at all times. Immediate and ongoing from the date of inspection. Page 25 Gorse Hill F57 F07 S55145 Gorse Hill V229113 2.8.05 Stage 4.doc Version 1.30 6. 20 13 7. 20 13 8. 23 12 9. 34 18, 19 schedule 2 (as amended 2004) 10. 36 18 The medication administration record must accurately reflect the prescribers instructions. Any changes in these instructions must be clearly documented on the record. Handwritten entries on the medication administration record must be signed and witnessed by two members of staff. Previous timescale of immediate - not met. The procedure relating to the protection of vulnerable adults must be amended to clearly state that in the event of any suspicion or allegations of abusive practice the registered manager must instigate the adult protection procedures. All records and documentation relating to the recruitment of new staff must be collated and maintained in line with the requirements of the Regulations. This includes obtaining a written reference from a persons last period of employment, which involved work with children or vulnerable adults of not less than three months duration. Staff must receive individual supervision sessions a minimum of six times a year. Immediate and ongoing from the date of inspection. Immediate and ongoing from the date of inspection. 1st September 2005 Immediate and ongoing from the date of inspection. 11. 39 24 12. 41 17 and 19 schedule 2 (as amended) An annual development plan must be produced based on a systematic cycle of planning, action and review and based on outcomes for residents. The regsitered person must ensure all recrords specified under Schedule 2 (as amended July 2004) are collated and maintained for all staff working in the home. Previous timescale Immediate and ongoing from the date of inspection. 1st October 2005 Immediate and ongoing from the date of inspection. Page 26 Gorse Hill F57 F07 S55145 Gorse Hill V229113 2.8.05 Stage 4.doc Version 1.30 of immediate, not met. 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. Refer to Standard 35 32 36 39 Good Practice Recommendations All staff should receive equal opportunities training, including disability equality training, race equality and antiracisim training. 50 of care staff should be trained up to NVQ level 2 by 2005. All staff should have an annual appraisal with their line manager to review performance against job description and agree career development plans. The results of surveys should be collated and published and made available to residents, their representatives and other interested parties including the CSCI. Further to this the registered manager should also seek the views of family, friends and stakeholders in the community on how the home is achieving its aims for residents. A financial and business plan should be devised for the home and the service, which is open to CSCI inspection and reviewed annually. 5. 43 Gorse Hill F57 F07 S55145 Gorse Hill V229113 2.8.05 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Unit 4 Petre Road Clayton-le-Moors Accrington BB5 5JB 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 Gorse Hill F57 F07 S55145 Gorse Hill V229113 2.8.05 Stage 4.doc Version 1.30 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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