Inspection on 23/01/07 for Gorse Hill

This inspection was carried out on 23rd January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Gorse Hill 17/01/06

Gorse Hill 02/08/05

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 Lancashire BB12 8AJ Lead Inspector Mrs Julie Playfer Key Unannounced Inspection 23rd January 2007 09:15 Gorse Hill DS0000055145.V315014.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 Gorse Hill DS0000055145.V315014.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. Gorse Hill DS0000055145.V315014.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gorse Hill Address 2 Stephenson Drive Burnley Lancashire BB12 8AJ 01282 438916 01282 831457 gorsehill@voyage.freeserve.co.uk 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) Voyage Ltd inc. Thelma Turner Homes Mrs Catherine Veronica Plaskowski Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Gorse Hill DS0000055145.V315014.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for ten service users in the category of LD Learning Disability (under the age of 65 years) 17th January 2006 Date of last inspection 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 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. The home has a statement of purpose and service users guide, which informs the current and prospective residents about the services and facilities available at the home. According to information submitted by the home the scale of fees was £1165 per week plus additional charges in line with the residents’ needs. An additional fee of £35 per hour was charged for transport. Gorse Hill DS0000055145.V315014.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Gorse Hill on 23rd January 2007. During the visit the inspector looked at written information including policies, procedures and records, spoke to the residents, registered manager and staff and conducted a partial tour of the premises. As part of the inspection process the inspector used “case tracking” as a means of gathering information. This process allows to the inspector to focus on a small group of people living at the home. Prior to the inspection comment cards were sent to the home. 6 completed cards were received from the residents’ relatives/visitors. The registered manager also completed a questionnaire about the home. At the time of the inspection there were 8 residents accommodated in the home, with one person in hospital. What the service does well: The admission process was well managed. Prospective residents were fully involved in the transition plans and were offered a wide range of introductory visits to the home. The residents’ needs were properly assessed and professional and specialist advice was sought as necessary. Appropriate care and support was provided effectively to ensure the residents’ needs were met and there was a consistent approach to any difficult behaviours. The residents pursued a wide range of individual activities both inside and outside the home. This enabled the residents to participate in the life of the home and gave them the opportunity to meet other people. One resident said, “it’s a good place to live, I like it”. The residents had access to an effective complaints procedure which ensured they were listened to and their concerns were acted upon. The residents were provided with a spacious, well-maintained and safe home, which was decorated and furnished to a good standard. The residents were able to personalise their rooms and create an individual space, in line with their choice and interests. Staff were provided with a broad range of training opportunities, which gave them an understanding of the needs of the residents. Relationships in the home were positive and the atmosphere was open and friendly. Gorse Hill DS0000055145.V315014.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 DS0000055145.V315014.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Gorse Hill DS0000055145.V315014.R01.S.doc Version 5.2 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 the following standard(s): 1, 2, 4 and 5 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. The admission process was well managed. The residents’ needs were fully assessed and they had access to a range of information suitable for their needs. EVIDENCE: Written information was available for residents in the form of a statement of purpose and service users guide. Both documents had been updated in line with the changes in the registered persons. A resident spoken to confirmed she had received a personal copy of the service users guide. Since the last inspection, a short overview of the services and facilities available at the home had been devised, in order to provide succinct information for the current and prospective residents. An informational DVD had also been produced to provide residents with a visual presentation of the home. All the residents had lived in the home for sometime and there had been no new admissions since the last inspection. However, the registered manager explained that a prospective resident was in the process of being admitted to the home. It was evident this person’s needs had been assessed by a Social Worker and the registered manager. Transitional plans indicated that the prospective resident had visited the home on various occasions to meet the Gorse Hill DS0000055145.V315014.R01.S.doc Version 5.2 Page 9 other residents and staff. The plans had been reviewed at regular intervals in line with the needs and wishes of the person. The established residents had been issued with a written contract/statement of terms and conditions. Gorse Hill DS0000055145.V315014.R01.S.doc Version 5.2 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 the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The residents’ individual needs were addressed and they were supported to participate in all aspects of life in the home. EVIDENCE: The case tracking process demonstrated that each resident had an individual plan, which reflected their health and welfare needs. Guidance was set out for staff to ensure all needs were met. 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. The registered manager had also produced an overview of the care plan and behaviour management guidelines to provide staff with a quick and easy reference. However, there was no evidence to indicate that the residents had participated in the care planning process or contributed to their care plan. It was also noted that one care plan had not been reviewed or updated for sometime. The registered manager explained that a new care planning format Gorse Hill DS0000055145.V315014.R01.S.doc Version 5.2 Page 11 was due to be implemented shortly, which amalgamated much of the existing paperwork into one comprehensive document. It was the practice of the home to support responsible risk taking and policies and procedures supported this ethos. Detailed risk assessments and management strategies covered activities indoors and in the wider community and were included in the residents’ care plan documentation. During conversations with the residents, it was evident, they were consulted informally and formally and they were able to participate in the life of the home. One person said “I like to talk to my keyworker about things”. Residents meetings were held in the home and it was evident a wide variety of topics were discussed. The residents fully contributed to the agenda and discussions and hence it was advised these meetings are held on a more frequent basis. 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. Gorse Hill DS0000055145.V315014.R01.S.doc Version 5.2 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 the following standard(s): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents were able to make choices about their life style and were supported to develop their life skills. 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 a range of activities both inside and outside the home. Activities outside the home included the use of leisure centres, shopping in Burnley town and walks in the local area. Since the last inspection, three residents had enjoyed extended weekend breaks away from the home to various destinations. The residents were supported and encouraged to devise individual activity plans, in order to build self esteem and provide structure to their day. The plans were flexible to allow each person to make alternative arrangements and develop activities of their choice. One resident explained he Gorse Hill DS0000055145.V315014.R01.S.doc Version 5.2 Page 13 had several diverse outdoor interests, which were fully supported by the manager and the staff team. Staff were allocated to work with each resident and staffing levels were reviewed at regular intervals to enable each resident to pursue their individual activities. At the time of the inspection, three residents were attending vocational courses at local colleges. One person spoken to said she really enjoyed her course. The residents were supported to maintain relationships with their families and where necessary staff assisted with transport and accompanied residents on journeys. The residents were also able to use the home’s telephone to speak to their families. All six relatives/visitors who completed a comment card prior to the inspection indicated that they felt welcome in the home and five people were satisfied with the overall care provided. One person commented, “my son seems very happy there. The staff are polite and very amicable. We are very happy with his standard of care”. The residents had unrestricted access to the homes and grounds. The residents were also able to use their room at any time should they wish to spend time in private. All the residents had been issued keys for their bedroom doors and residents were seen using their keys during the visit. The home followed a weekly menu, which provided the residents with a choice of food at each mealtime. Meals were provided three times a day and a range of drinks and snacks were available at all times. An emphasis had been placed on healthy eating and as such fresh fruit and salad was always freely available. The residents said they liked the meals describing them as “good” and “alright” and confirmed there was always plenty to eat. However, one person said the meals were not very varied and she would like to discuss different options at the next residents’ meeting. The record of meals provided was maintained on an individual basis, however, it was noted that this record had not always been completed. Gorse Hill DS0000055145.V315014.R01.S.doc Version 5.2 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 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 health and personal care that the residents received was based on their individual needs. EVIDENCE: The residents’ individual plans set out the personal support each resident required and provided details of how this support was to be delivered. All personal care was provided in the privacy of the residents’ own bathroom facilities. The staff told the inspector that 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 plans. A separate record was made of medical appointments and work had begun to implement individual health action plans. There was evidence to indicate the residents had access to NHS services and the advice of specialist services had been sought as necessary. There was a set of policies and procedures in respect of medication and appropriate records were maintained of receipt, administration and disposal of Gorse Hill DS0000055145.V315014.R01.S.doc Version 5.2 Page 15 medicines. The home operated a monitored dosage system for the administration of medication dispensed into blister packs. It was noted the controlled drugs register was complete and up to date and all staff designated to administer medication had received accredited training. Appropriate record keeping had been established, however, it was noted that written protocols were not in place for all variable dose medication and medication prescribed “as necessary” and an additional member of staff had not checked hand written entries on the medication administration record. Gorse Hill DS0000055145.V315014.R01.S.doc Version 5.2 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 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. The residents were able to express their concerns and had access to an effective complaints procedure. Written procedures and practice protected the residents from abuse and neglect. EVIDENCE: It was part of usual practice for the registered manager and staff to listen to act on the views and concerns of the residents before they developed into problems. To this end the manager operated an “open door” policy, which enabled staff and residents to discuss any issues whenever they wished. The complaints procedure was included in the service users guide and was verbally explained to residents as necessary. Each resident had a personal copy of the guide. The procedure was written in an accessible format and met with regulatory requirements. The residents were familiar with the complaints process and had used it to voice their concerns. 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 complainants had received feedback. The home had received two complaints since the last inspection. Five relatives/visitors who completed comment cards were not aware of the home’s complaints procedure. The registered manager therefore offered to send a copy of the procedure to all the residents’ relatives. 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 Gorse Hill DS0000055145.V315014.R01.S.doc Version 5.2 Page 17 the required response in the event of any allegations or suspicion of abuse. The staff were aware of the procedure and had received appropriate training. The staff also had access to a whistle blowing procedure. Gorse Hill DS0000055145.V315014.R01.S.doc Version 5.2 Page 18 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 the following standard(s): 24, 25, 26, 27, 28 and 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. The physical layout of the home enabled the residents to live in a safe, comfortable and well maintained environment, which encouraged independence. EVIDENCE: Gorse Hill is a large detached house set in it’s own grounds. It is located in a residential area approximately one and half miles from Burnley town centre. The bedrooms are single occupancy, with some rooms taking the form of a 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 provided facilities in excess of the National Minimum Standards. The bedrooms had been decorated and furnished according to personal taste. The residents spoken to said they liked their rooms, which they thought were comfortable and warm. Residents were able to bring in personal belongings, many of which were displayed in their rooms. The furnishings and fittings were domestic in character and of a good standard throughout. Appropriate Gorse Hill DS0000055145.V315014.R01.S.doc Version 5.2 Page 19 arrangements were in place to carry out repairs and maintenance. Since the last inspection, one bedroom had been redecorated by a resident, with the help of the handyman. The grounds were well-maintained and provided plenty of space for any outdoor activities. The home had a good standard of cleanliness in all areas seen and was free from offensive odours. Arrangements were in place for the residents to do their own laundry. Gorse Hill DS0000055145.V315014.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The recruitment and selection procedures were thorough and ensured the protection of the residents. Staff were well trained and skilled to meet the needs of the residents. However, the systems in place to support staff should be improved. EVIDENCE: Staff had been issued with a job description, which was commensurate with their role, as part of the recruitment process. From discussions with the staff during the inspection, it was evident they had a good understanding of the needs of the residents and knew the residents well. Staff referred to the residents in respectful terms and were observed to interact in a positive and pleasant way. It was noted that one relative/visitor who completed a comment card indicated there were not always sufficient staff on duty. However, from viewing the staff rota, it was evident there were always at least four staff on duty to provide care and support for seven residents. The registered manager confirmed that the level of staffing in place was determined by the needs of the residents and contractual arrangements. Gorse Hill DS0000055145.V315014.R01.S.doc Version 5.2 Page 21 The recruitment and selection procedure for new staff was underpinned by the organisation’s Equal Opportunities Policy. The recruitment process included completion of an application form, face-to-face interview, obtaining two written references and a POVA first and CRB check. The file of one member of staff was inspected. This showed that the procedures had been followed and all relevant details had been obtained. Staff had received induction training, which covered the “Skills for Care” standards. 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 the staff had access to a broad range of training courses. At the time of the inspection, eighteen members of staff had achieved NVQ level 2 or above. This equated to 85 of the staff team, which was an increase of 52 since the last inspection. Consultation with staff was ongoing and handover arrangements had been maintained. However, staff meetings had not been held on a regular basis. Records also indicated that whilst staff had received an appraisal of their work performance, they had not received regular staff supervision. Since the last inspection, the senior staff had received training to enable them to carry out formal supervision of the care staff. Gorse Hill DS0000055145.V315014.R01.S.doc Version 5.2 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The management approach promoted positive relationships between the staff and the residents and the overall atmosphere was open and friendly. Systems were in place to monitor and develop the quality of the service and the health and safety of the residents was promoted and protected. EVIDENCE: Since the last inspection, the new manager has registered with the Commission. At the time of the visit the registered manager was working towards the Registered Manager’s Award, which was due for completion in Autumn 2007. The registered manager has 14 years experience of working in various residential settings. Gorse Hill DS0000055145.V315014.R01.S.doc Version 5.2 Page 23 The management approach was consultative and there were established systems were in place to consult staff and residents on an ongoing basis. Relationships within the home were positive and staff spoke to and about the residents with respect. The registered manager had continued to develop the quality assurance systems, to ensure there was continuous monitoring of the service. A report was made every month and submitted to the Operations Manager. In addition, satisfaction questionnaires had been distributed to the residents, their relatives and their funding authorities in August 2006. However, the results for the surveys had not been collated and the residents had not received specific feedback about the outcome of the surveys. An annual development plan based on the outcomes of the monitoring processes had been produced, which identified the planned developments for the service. Staff received health and safety training, which included moving and handling, food hygiene, first aid and fire safety. The 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 and the fire system was tested on a regular basis. Appropriate arrangements were in place to record any accidents or incidents in the home. The registered manager had formulated risk assessments for all safe working practice topics. Gorse Hill DS0000055145.V315014.R01.S.doc Version 5.2 Page 24 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 4 2 3 3 X 4 4 5 3 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 4 25 4 26 4 27 4 28 4 29 X 30 3 STAFFING Standard No Score 31 3 32 4 33 2 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 4 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 3 2 X X 3 X Gorse Hill DS0000055145.V315014.R01.S.doc Version 5.2 Page 25 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 YA6 Regulation 15 (1) (2) Requirement The residents must be fully involved in the care planning process to ensure they know their assessed and changing needs are reflected in their individual plan. Timescale for action 01/03/07 2. YA17 17 (2) Sch 4 (13) 3. YA20 13 (2) The service user plans must be reviewed with the residents and updated at least every six months or in line with changing needs, to ensure the staff have up to date information about the residents’ needs. The record of food provided must 23/01/07 be fully completed for all residents in order to clearly demonstrate that the diet provided for the residents is wholesome and nutritious. To minimise the potential for 23/01/07 error an additional member of staff must sign and witness any handwritten entries on the medication administration record. Written protocols must be devised for the administration of all variable dose and medication prescribed “as necessary”. DS0000055145.V315014.R01.S.doc Version 5.2 Page 26 Gorse Hill 4. YA36 18 (2) (a) Staff must receive individual supervision sessions a minimum of six times a year. (Previous timescale of immediate – not met). 23/01/07 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. Refer to Standard YA33 YA37 YA39 Good Practice Recommendations Regular recorded staff meetings should take place (minimum of six per year). The registered manager should achieve an NVQ level 4 in both Management and Care. The results of surveys should be collated and published and made available to residents, their representatives and other interested parties including the CSCI. Gorse Hill DS0000055145.V315014.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park 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 DS0000055145.V315014.R01.S.doc Version 5.2 Page 28 - 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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