Inspection on 22/02/06 for Gorsefield Residential Home

This inspection was carried out on 22nd February 2006.

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 but made no statutory requirements on the home.

Other inspections for this house

Gorsefield Residential Home 24/08/09

Gorsefield Residential Home 09/09/08

Gorsefield Residential Home 10/09/07

Gorsefield Residential Home 29/09/06

Gorsefield Residential Home 17/08/05

Gorsefield Residential Home 30/03/05

Gorsefield Residential Home 03/11/04

Gorsefield Residential Home 25/02/04

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

CARE HOMES FOR OLDER PEOPLE Gorsefield Residential Home 306 High Lane Burslem Stoke-on-trent Staffordshire ST6 7EA Lead Inspector Peter Dawson Unannounced Inspection 22nd February 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Gorsefield Residential Home DS0000008233.V284480.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Gorsefield Residential Home DS0000008233.V284480.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Gorsefield Residential Home Address 306 High Lane Burslem Stoke-on-trent Staffordshire ST6 7EA 01782 577237 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) Mr David John Hood Mrs C Bhalla, Mrs Janet Hood Mrs Shirley Grainger Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17), Physical disability over 65 years of age (5) of places Gorsefield Residential Home DS0000008233.V284480.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th August 2005 Brief Description of the Service: Gorsefield is situated on the main road in High Lane, close to Burslem and directly on a bus route allowing easy access for visitors. The home is a large detached property which has been extended and provides good spacious accommodation. The building and location are quite impressive, well presented and well maintained. There are attractive gardens to the front and rear with good parking facilities. Accommodation for residents is on 2 floors with shaft lift access to the first floor. On the ground floor there are 2 lounges, separate dining room, kitchen and 5 single bedrooms, there is an assisted bathing facility also on this floor. On the first floor there are 10 bedrooms, 2 are shared rooms and have en-suite facilities, some with shower. On this floor there are 2 bathrooms, one has assisted facility. There are separate toilets, office and storage facilities. There is a small lounge/recessed area with kitchenette, allowing space to receive visitors. The home provides accommodation for up to 17 older people 5 of whom may have a physical disability. There is presently no registration for dementia or mental health care. There has been staff training in this area of work and application is being made to the Commission additional categories. Gorsefield Residential Home DS0000008233.V284480.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. There were 15 people in residence (including 1 in hospital) at the time of the unannounced inspection. All residents were seen and spoken to. All had positive comments about care provision and the facilities at Gorsefield. The only negative comments related to the lack of activities in the home, which has been expressed before. A relative of a long-stay resident was seen and spoken to and stated his total satisfaction with the care provided for his mother at Gorsefield (she later endorsed the view). He said that he was a regular visitor and kept informed of any changes in the health or welfare of his mother. He was seen to be welcomed into the home by staff and had relaxed and humorous exchanges with staff members. The inspector was impressed with the care provided to a confused resident who constantly wandered. He had been carefully risk assessed and provided with bed guard and protective headgear after having several falls resulting in head injuries. The home had taken the initiative to provide the headgear which had been risk assessed and discussed agreed and signed by the relative. The risks had been significantly reduced. Health care awareness is high in this home. There were again many examples of early referrals to health care professionals and good co-working with those professionals. Application must be made for increase in categories of registration. This is required to cover a person recently admitted out of category and also some deterioration in other residents. Several requirements of the last report have not been met. Some have been subject to 2 previous requirements. This area of non-compliance is of concern and will be monitored closely by the Commission. This applies to staff recruitment procedures which must be strengthened to protect residents. Gorsefield Residential Home DS0000008233.V284480.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Annual fire training must be provided for all staff (date arranged). Broken handle on bedroom window identified must be replaced. Provide immediate means of communication between waking and non-waking members of night staff. CRB checks must be obtained for all existing and for all new staff prior to employment. The effectiveness of the call system must be urgently reviewed. The call alert in ground floor bedroom must be operational at all times. Application to the Commission must be made for additional categories of registration. Gorsefield Residential Home DS0000008233.V284480.R01.S.doc Version 5.1 Page 7 All medication must be signed for at the point of administration. All staff should be provided with contracts of employment. Provide appropriate facility to distribute medication in the home. For ease of use and to provide safety. 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. Gorsefield Residential Home DS0000008233.V284480.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Gorsefield Residential Home DS0000008233.V284480.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1–5 There is adequate information available to allow prospective residents to make a conscious choice of home. Appropriate pre-admission procedures are followed. Standards relating to Choice of Home were met. EVIDENCE: The home has a statement of purpose and service users guide. All residents have been given a copy and there are copies in the home available for visitors. The documents provide adequate information relating to the services provided by the home. Funded residents are provided with contracts by sponsoring local authorities. Self-funding resident are reported now to be provided with contracts following requirement made (not seen/checked). Gorsefield Residential Home DS0000008233.V284480.R01.S.doc Version 5.1 Page 10 All funded residents are subject to Care Management assessments prior to admission. The home always completes an assessment prior to admission in the persons current environment. Wherever possible pre-admission visits to the home for prospective residents are offered/arranged. A person recently admitted had spent a period of respite care in the home prior to admission, allowing objective assessment and giving prior knowledge to the person allowing experience to make a decision upon the suitability of the home. Relatives are always invited to the home separately or together with the prospective resident. Gorsefield Residential Home DS0000008233.V284480.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 - 10 Care plans are adequate and currently being further reviewed and revised by the Manager. There is evidence of early identification and referrals of health care concerns. Two requirements are made in relation to medication. From observations and discussions with residents they felt that they are treated with respect and that their dignity is upheld. EVIDENCE: Care plans were sampled and seen to be generated from assessed need. Information is in 2 forms one for daily use giving basic information required for care and more detailed information to supplement that information. Care plans are satisfactory. The Manager now has allocated management time each week when she is not required to engage in hands-on care on the rota. This has allowed her time to review and re-write some of the care planning information. The work continues but is a positive move. Gorsefield Residential Home DS0000008233.V284480.R01.S.doc Version 5.1 Page 12 Risk assessments are in place and are good. They are reviewed monthly together with care plans and always reviewed following falls. The inspector was particularly impressed with the risk assessment relating to a resident who has some confusion and wanders regularly both day and night, having many falls and sustaining several head injuries. There is a risk assessment for this man for bed guards and for protective headgear (cycling helmet) to reduce the effect of falls. Both risk assessments are discussed with and signed by the relative and reviewed on an ongoing basis. The home are presently seeking a more suitable means of head protection having contacted specialist hospital and other services. The person is closely monitored at all times by staff. A resident spoken to indicated that she had fallen 2 days prior to the inspection, sustaining painful neck/head. There had been a review of the risks to her and she was visited during the inspection by the Physiotherapist (seen by the inspector), who was to provide an exercise programme to staff for the person and she was to obtain a smaller framed walking frame. This was an example of swift referral to health care professionals where there are concerns. A resident with severe spine curvature whose food intake reduced due to inability to swallow, was referred to the speech and language specialist. No physical issues were identified and the home continues to ensure that appropriately prepared food is available and also drinks constantly available. District Nurses are visiting currently only in relation to ongoing blood and other checks. There are no pressure area management problems in the home at this time. The Continence Advisor had been requested to visit following sudden incontinence of a resident. Advice and aids were provided. Key-workers are allocated to all residents. A requirement was made at the time of the last inspection for regular weighing of residents. All are now weighed monthly and weekly if there are particular concerns about weight. All weights are recorded. A resident admitted some months ago and seeming to fall into the DE (Dementia) category is still subject to reviews with the Care Management Team. The Consultant Psychiatrist has recently visited the person and the outcome is not known. The home are advised to obtain a copy of the Consultants letter/report via the social worker or GP. Her formal diagnosis and treatment needs should be known to the home to ensure they are able to provide the necessary ongoing care. The home does not have category to admit people in DE category - this person should not have been admitted. Gorsefield Residential Home DS0000008233.V284480.R01.S.doc Version 5.1 Page 13 A requirement was made in the last report for the proprietor to request additional category of registration to accommodate this and other persons. This has not been done and is a further requirement of this report. The inspector feels that the home are providing the necessary care and have the required skills to continue to meet the needs of this person, but formal request for additional categories is conditional. Medication is supplied in MDS form (blister packs) by Boots Chemists. Records were inspected. It was found that Temazepam had been administered as prescribed on 2 occasions but not signed for by staff. Staff are reminded that all medication must be signed for at the point of administration. The manager raised a question regarding the prescribed time (8.30pm) for medication for a resident who demanded the medication at an earlier time. This was discussed and 3 options identified. The Manager will initially discuss with the Pharmacist/GP the importance of the medication at the prescribed times or whether there is flexibility. As outlined and required in the last report the medication is brought from the secure office area on the first floor to the ground floor and administered from a large plastic container, which is heavy, cumbersome and unsafe. The morning medication was openly on display in the dining area whilst being administered during breakfast time. This indicates obvious risks. A suitable medication trolley (transportable in the lift from the first floor) is required but has not been provided. This should be done and the Manager was advised to contact the Pharmacy for help in providing a suitable trolley for storage and transportation. This would increase security of medication and provide ease of use. Gorsefield Residential Home DS0000008233.V284480.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 - 15 There was evidence of chosen lifestyles being accommodated. Activities are a weak area in this home. Staff are aware of this and the basic staffing levels to not assist greatly in that provision. This is the only area of care where the home is weak. Contacts with family and friends are encouraged and promoted as part of care. EVIDENCE: There is no formal activities programme in the home. Staff engage residents in activities as time allows. The responsibilities of providing personal care mean that activities are a lower priority. There is the minimum staffing level in the home which means that there are only 2 staff on duty throughout the waking day. Staff are therefore unable to dedicate specific time to activities. There are armchair aerobics fortnightly and entertainers arranged approximately 2 monthly. Daily activities centre around residents watching TV, reading or chatting in the lounge areas. Last year a group from the Princes Trust visited the home over a week and provided some activities. One resident became interested in jigsaws and continues to enjoy them, evidence seen in the lounge area and his bedroom. Gorsefield Residential Home DS0000008233.V284480.R01.S.doc Version 5.1 Page 15 Staff understand the need to introduce residents to activity they may have previously enjoyed or new ones they will be interested in. Residents and relatives have indicated in direct feedback to the Commission in the past that activities are few. There was evidence of residents accessing their bedrooms as they chose throughout the morning of the inspection. Two residents are prone to wander throughout the day and allowed to do so freely, staff aware of the need to constantly monitor whereabouts. All external doors are now alarmed ensuring safety for those wandering. Records showed that 3 residents are served tea in their bedroom at 6.30 by request, the remainder going to the dining room for breakfast later – breakfast seen being served until around 9.30 a.m. Residents spoken to said that rising times were flexible and individual. Where possible residents go out with visitors. Several go out on a weekly basis. A resident with female friend goes to her home twice weekly collected by family. Visitors see residents in the lounge areas or privacy of bedrooms. Additionally there is an attractive sitting area with kitchenette on the first floor, used by some visitors where drinks can be prepared. All residents spoken to said that they were satisfied with the food provided at Gorsefield. Whilst the printed menus on a 4-week cycle do not give choices of main dishes. These are reported to be always available if preferred. There may be an unrealistic expectation that residents will ask for alternatives - staff must ensure options are readily available without asking. An example given by resident of sweet eaten that she did not like was given to the Manager. Adequate types, quantity and quality of food is provided by the home – there are no shortcomings. The important part is to ensure that residents know the choices on offer. Gorsefield Residential Home DS0000008233.V284480.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 – 18 Standards relating to complaints and protection were found to be met. EVIDENCE: There is a copy of the complaints procedure in the home and available to both residents and visitors. The procedure complies with the requirements of Regulation 22. No complaints have been received by the home or the Commission since the last report. In fact no complaints have been received over the past 3 years. There are clear instructions to staff concerning the reporting of suspected or actual abuse and all have a copy of those procedures which include an outline of the definitions of abuse. A whistle-blowing policy is on the notice board. Gorsefield Residential Home DS0000008233.V284480.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 – 26 There is a good standard environment and good facilities. The home is generally well-maintained. The call system in the home must be checked and reviewed and 2 requirements are made in relation to the system. A requirement is also made in relation to repair/replacement of bedroom window handles. EVIDENCE: Gorsefield provides a good standard environment. Furniture, fittings and equipment are to a good standard. There has been redecoration and refurbishment of the communal areas providing good and pleasing lounge areas which are comfortable and attractive and with good natural light from large windows. The home preserves much of its original character. The dining room is large, well fitted with attractive tables and provides a view of the garden area, the room is conducive with socialisation. Gorsefield Residential Home DS0000008233.V284480.R01.S.doc Version 5.1 Page 18 A visit by Environmental Health Officer last year resulted in requirements being made to the environment. All have been addressed with the exception of two. One was to provide an extractor fan in the smoking area – there are in fact no longer any residents who smoke and the home are therefore now considering the possibility of being a non-smoking home, the extractor would not be needed if that decision were made. The other matter was to make the former pond area safe and there are plans to involve the Princes Trust Group in possibly filling in the pond in the spring/summer. There are adequate bathing facilities in the home with 3 bathrooms, two are assisted. Four bedrooms have en-suite facilities with shower and there are adequate numbers of toilet areas located throughout the building and near to the lounge and dining areas. A sample of bedrooms were seen. All were well furnished, bright and personalised reflecting individual interests. The heating system is good with variable controls in bedrooms. Hot water control safety valves are fitted to all resident outlets. In a ground floor bedroom both opening handles on the window had broken off and it was not possible to open/close the window without difficulty. This should be repaired replaced immediately. The standards of hygiene throughout the home were, as always excellent. A domestic assistant works 24 hours per week in the home. Infection control practices seemed good with adequate required protection readily available. The laundry and kitchen were not inspected on this visit. The call system in the home gives cause for concern: The system appears to have two separate alert systems, one connected directly to the main call system control. There is also a stand-alone call alert which seems to service 2 toilet areas on the ground floor. In one of the toilet areas mentioned the call system was not working and this must be repaired immediately. A resident said she was unable to use the call system in her bedroom as there was no longer an extension cable attached. This was checked and found to be correct. An extension must be provided in the bedroom area to ensure the system is readily available at all times. A requirement is made in relation to this. Additionally the home must check in all bedroom and lounge areas to ensure there are adequate extension cables attached. This applies also to the lounge areas where the call alerts are at the entrance and there are no extensions attached. The system is not being used in the lounge areas and this is not acceptable, particularly considering the staffing levels in the home. Gorsefield Residential Home DS0000008233.V284480.R01.S.doc Version 5.1 Page 19 The main control boxes to the call system (one on each floor) is the central point for the audible alert. It is not possible to hear the alert from the dining room and front lounge area. This must be addressed swiftly to ensure that the call alert system can be heard clearly in all parts of the home to ensure the safety of residents. Gorsefield Residential Home DS0000008233.V284480.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 – 30 The home is staffed to the required minimum standard but this does not give flexibility beyond basic requirement needs. Staff recruitment procedures in the home are poor. CRB checks are still outstanding for existing staff and since the last report CRB check has not been obtained for a new member of staff. Staff have still not had written contracts. These areas of non-compliance must be urgently addressed to ensure the protection of residents. Annual fire training for all is also required. NVQ training does not comply with the required levels at 2005 and training should be stepped-up. EVIDENCE: The staffing continues at the required level. This is the minimum staffing level required for this home - 2 staff are on duty throughout the waking day and one night care worker and one person sleeping in on-call at night time. The overall dependency levels in the home are low to medium. The Deputy Manager has recently returned from long-term sick leave allowing the Manager now to work one day supernumerary. Gorsefield Residential Home DS0000008233.V284480.R01.S.doc Version 5.1 Page 21 She is now able to carry out her management duties on one day each week without the responsibility of hands-on care. Already she has worked upon extending the care planning information and reviewing the plans in general. This is a positive start. Additional staffing at peak times would be helpful particularly in relation to residents with higher dependency needs, also staff would have more time to spend on activities with residents. There are still outstanding CRB checks required for existing staff, although a further requirement was made in relation to this in the last report. This has not been done. Additionally checks of staffing on this visit revealed that a new member of staff had not had the required CRB/POVA check prior to employment and this is still outstanding. A further requirement is therefore made in relation to CRB checks. This must be actioned immediately. Also it was found that no references had been obtained for the new member of staff. Two written references must always be obtained prior to employment. Two previous recommendations to provide all staff with contracts of employment has not been actioned. It is a further recommendation of this report. NVQ training commenced in 2005 only and two members of staff are presently involved in training. The home did not meet the required standard of 50 of NVQ trained staff by 2005. There was staff training in Moving & Handling, medication administration, food hygiene and Health & Safety in 2005. A requirement to provide annual fire training was made at the time of the last report. Although this has not been done training is arranged for March 2006. Gorsefield Residential Home DS0000008233.V284480.R01.S.doc Version 5.1 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 – 33 and 36 - 38 The Manager provides good and positive leadership in the home and is keen to maintain standards of care. Good and positive working relationships were observed between staff and residents. There is regular staff supervision. Previous requirements have been carried out in relation to staff training. Annual fire training is still required but a date arranged. The call system must be reviewed to ensure safety of residents as identified in standard 22. An immediate means of communication between the two night staff (one sleeping-in on call) must be addressed. The equipment has apparently been purchased but not installed. A further requirement is made in relation to this. Gorsefield Residential Home DS0000008233.V284480.R01.S.doc Version 5.1 Page 23 EVIDENCE: The Manager is competent to manage the home although she does not have the Registered Managers Award. There are positive relationships between residents and staff and good staff commitment to resident care. There is regular supervision of all staff. The Manager has recently been able to work 1 day each week supernumerary (not on rota) allowing her time to spend on her other management duties. She has commenced a review of the care planning format/information. Whilst the Manger has clear responsibility for all aspects of care in the home, she does not have control over financial matters. That rests with the proprietors. The majority of requirements made in this report have some financial implications and therefore must be addressed by the proprietors. Although there are no residents meetings, the Manager has regular “face to face” discussions with all residents as a means of ensuring quality assurance. Records seen were adequate and complied with the requirements of the regulations. Fire records were inspected and all checks and servicing of equipment had been carried out together with regular fire drills. Annual fire training has not been provided, as required for all staff but a date has been arranged for March 2006. Food hygiene, moving & handling and health & Safety training has been carried out in the past year. Risk assessments relating to the building and fire have been completed and risk assessments in relation to all resident activity have been provided in care planning information and are regularly reviewed. A nighttime there is a waking night care assistant and one-person sleeping-in and on call. There is no means of the waking night care worker contacting the person sleeping-in without having to visit the room. A requirement was made in the last report to provide a means of instant communication with the person sleeping-in. Apparently a phone system has been purchased but still not installed at this date. A further requirement is made in relation to this. There could easily be an urgent situation where contact between the 2 night care workers is vital. Gorsefield Residential Home DS0000008233.V284480.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 1 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x x 3 3 2 Gorsefield Residential Home DS0000008233.V284480.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP29 Regulation 19 Requirement CRB checks must be completed for all staff. - (This was a requirement of the last two reports- timescale not met) Handle on window in bedroom identified must be replaced. Provide immediate means of communication between waking and non-waking night staff. (requirement of the last report not met). Provide annual fire training for all staff. (requirement of the last report not met) Review call system. Ensure alerts are audible in all areas and residents have access to the call system at all times. Call alert in ground floor toilet area must be operational at all times s Application must be made for additional categories of registration to cover people with mental health needs. All medication must be signed for at the point administration. Timescale for action 23/02/06 2. 3. OP19 OP38 23(2)( c) 12(1) 31/03/06 28/02/06 4. 5 OP38 OP22 23(4) 23(2)( c) 31/03/06 31/03/06 6 7 OP22 OP14 23(2)( c) CSA 2002 23/02/06 23/02/06 8 OP9 13(2) 23/02/06 Gorsefield Residential Home DS0000008233.V284480.R01.S.doc Version 5.1 Page 26 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. Refer to Standard OP29 OP9 Good Practice Recommendations Provide written contracts of employment for all staff (previous recommendation) Provide appropriate facility to distribute medication (previous recommendation) Gorsefield Residential Home DS0000008233.V284480.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Gorsefield Residential Home DS0000008233.V284480.R01.S.doc Version 5.1 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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