Inspection on 29/09/06 for Gorsefield Residential Home

This inspection was carried out on 29th September 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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 22/02/06

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 Key Unannounced Inspection 29 September 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.V310924.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Gorsefield Residential Home DS0000008233.V310924.R01.S.doc Version 5.2 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.V310924.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd February 2006 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 an 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 but no application made to the Commission additional categories. The home is unable to admit people requiring dementia care or those with mental health needs. Gorsefield Residential Home DS0000008233.V310924.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector from 10am – 3 pm. A pre-inspection questionnaire had bee provided by the service. Written feedback to the Commission had been received from 5 residents and 6 relatives. There was an inspection of all areas of the communal areas and a sample of bedrooms. Records relating to the inspection process were readily available and seen as required. All residents were seen and the majority spoken to. A visiting relative was seen and also visiting GP who made very positive comments about the care provided at Gorsefield and staff awareness of health care issues and cooperation in addressing any areas of concern relating to health. Residents made positive comments about the home in verbal and written feedback, although one commented that there were insufficient staff on duty. This view was also expressed by a two relatives also in feedback. The home provides the minimum staffing levels which is adequate for the present (reduced) 11 residents but which is not adequate for increased numbers or increased dependency levels. Staff say they do not have time to engage in activities with residents. This supports the views expressed that the provision on activities in the home are poor. Registration does not include people with dementia care or mental health needs. The providers have been urged to consider extension of registration categories but they had not made an application as suggested. The home is therefore unable to admit anyone with those categories of need at this time. There has been a previoius admission out of stated categories. Positive comments from residents and relatives in written feedback included: “staff are very attentive” and “We are well satisfied with the care for (relative)” Two self-funding residents said that they had not been provided with contracts following admission. This was raised with the provider who had contracts at home and a requirement made to forward copies to the Commission. The environment presents well with sound building and excellent garden area but requirements relating to the environment are not actioned. Two previous requirements are repeated in this report one to repair the call-alert system in ground floor toilet the other to provide a means of communication between waking and non-waking night staff. Both are urgent requirements which must be met and present potential risk to residents. Gorsefield Residential Home DS0000008233.V310924.R01.S.doc Version 5.2 Page 6 A relative complained in written feedback to the Commission that the shared bedroom occupied by a relative had paper hanging from the ceiling (for several months) and the bedroom carpet required replacing. The bedroom was inspected and the situation was as described. Requirements are made in this report relating to this. The home provided excellent care for resident (now deceased) who was at risk due to confusional state/wandering. A letter was seen sent by relatives since his death complimenting the home on the high standards of care and support offered to him. The relatives have donated a new mobile food trolley to the home in his memory. A resident currently bedfast/totally dependent is being provided with a high level of care under the supervision of the Nursing Service. Attention to tissue viability issues – regular turning, inputs of fluid/food are good. Advice was given about recording the quantification of inputs. A good basic standard environment but maintenance not actioned swiftly and non-compliant with requirements. The standard of care is good but the staffing level is minimal only and allows only task-centred care. What the service does well: What has improved since the last inspection? A handle on window in bedroom has been replaced. Fire training has been provided following 2 previous requirements. MAR sheets seen indicated no gaps. Written contracts of employment have been provided for all staff. Gorsefield Residential Home DS0000008233.V310924.R01.S.doc Version 5.2 Page 7 A medication trolley has been supplied by the homes pharmacy, allowing easier and safer transport of medication in the home. The relatives of deceased resident have provided excellent food trolley avoiding use of trays which were not appropriate/safe. 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. Gorsefield Residential Home DS0000008233.V310924.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Gorsefield Residential Home DS0000008233.V310924.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1–5 This quality of this outcome is adequate. This judgement is made using the available evidence and a visit to the service. There is adequate information available for choice of home. Pre-admission procedures are followed wherever possible, this includes assessments and visits prior to admission. Contracts for 2 self-funding residents must be sent to the Commission. EVIDENCE: The home has a statement of purpose/service users guide. All residents are given a coy and there is a copy available in the home for visitors or prospective residents and their families. Funded residents are provided with copies of contracts from sponsoring local authorities. Self funding residents should be given a contract with the home and a previous requirement was made regarding this. A resident in written feedback stated she had not been provided with a contract, another said she had not had one until 20th September 2006. The proprietor was seen and Gorsefield Residential Home DS0000008233.V310924.R01.S.doc Version 5.2 Page 10 copies were at his home not at Gorsefield. He was asked to send a copy of contracts for 2 self-funding residents identified, to the Commission. This is a requirement. The home carries out a pre-admission assessment in the present location of the prospective resident. Prospective residents are always invited to the home for a meal/visit prior to admission. Although offered this does not always take place. A recently admitted resident had not visited the home although her family had and they had not felt it necessary to bring the person to Gorsefield prior to admission. Care Management assessments are obtained for funded residents and this had been obtained for a recently admitted lady. Gorsefield Residential Home DS0000008233.V310924.R01.S.doc Version 5.2 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 – 11 The quality of this outcome is good. This judgement is made using the available information and a visit to the service. Care plans have split information but are satisfactory and being reviewed. Health care is promoted very positively, early referrals to health professionals and advice strictly followed. The medication system is safe. Arrangements for privacy and dignity are good. Standards relating to dying & death are positively evidenced. EVIDENCE: Care planning information is provided based upon assessed need. Plans are in 2 parts – one in file for all residents in readily available daily reference form and giving basic information, the other in more detailed form held in the office area. The Manager was given additional time off the rota to allow her time to update and re-write plans and this continues. Care planning information was inspected relating to a recently admitted resident and contained all relevant information relating to health and social Gorsefield Residential Home DS0000008233.V310924.R01.S.doc Version 5.2 Page 12 care which was based upon pre-admission assessments including a specialist social work assessment and other information available. Risk assessments were in place and relevant (the person is registered blind). The care plan and nursing notes relating to a resident who is bedfast was reviewed. She has been bedfast for sometime and receiving treatment from the nursing service for 4 pressure areas. She is provided with an airwave mattress and pressure relieving cushion when out of bed for very short periods. She is turned 2 hourly throughout the 24 hour period. Her food is liquidised and she has prescribed vitamin enhanced food also. She is seen 2-3 times weekly by the nursing service and staff are clearly working closely with the nurses. Her tissue viability status has improved recently. There are pressure sores to heel, hip and sacrum. The GP saw her the previous week. Daily notes record her care in the home including food/fluid inputs and turning. It was recommended that a separate daily chart to accurately quantify fluid and food input would allow easier monitoring (rather than “a cup of tea”). Turns could be incorporated into the same simple chart. A sample chart was explained to the Manager who will implement this. Bed-guards with protectors are in place and positioning pillows also for pressure relief. The home are providing a good level of care to this resident working directly with the Nursing Service and GP. A visiting GP was spoken to during the inspection. He had been called to see 2 residents, a diabetic resident with high blood-sugar levels and another with a suspicious lump seen whilst bathing. Relatives had been informed and one present in the home to meet the doctor. The GP left and discussed with staff an action plan for both residents. Dialogue between them was open, relaxed and professional. The GP reported that there was a pro-active approach to health care issues by staff and that they followed any advice/instructions given. A resident in written feedback said “I see my GP when I need to”. The home is known to have worked closely recently with Speech & Language nurse, Continence Advisor and Physiotherapist – all seen in the home recently during inspections. A person admitted prior to the last inspection with dementia care needs has been transferred to another home. The home does not have category to admit people in DE (dementia) or MD (mental disorder) categories and the proprietors have made a decision not to make application for additional categories for admission. - People in these categories must not, therefore be admitted to this home. Medication is supplied in MDS (blister pack) form by Boots Chemists. Some MAR sheets were seen but a check of the system not made on this visit due to time limitation. A previous recommendation to provide a means of safely and Gorsefield Residential Home DS0000008233.V310924.R01.S.doc Version 5.2 Page 13 securely transporting medication within the home has been done. A medication trolley has been supplied by Boots Chemists allowing easier and safer transport. In relation to dying & death - the home provided excellent care for a resident who died recently. The previous report had reflected the high standards of care for this person. This was confirmed in writing from the relative following the persons death who complimented the home for their care and has purchased a special food trolley for use in his memory. A person very ill at present has no relatives, is receiving a high level of care under the direction of the nursing service and from the homes staff she has known for a long period. Social workers have been alerted about her condition and her wishes upon death sought and now recorded. Gorsefield Residential Home DS0000008233.V310924.R01.S.doc Version 5.2 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 The quality of this outcome is adequate, This judgement is made using the available information and a visit to the service. Given minimum staffing levels the preferred routines of residents are generally met. Leisure, social activities and interests are poor. Contact with the community dependent only upon relatives involvement. Food provision has previously been good. Alternatives choices to main menus could be more clearly explained to residents. EVIDENCE: There is poor provision of activities in this home. There is no activities programme and apart from daily dialogue with staff and together residents have only arranged entertainment/leisure comprising: 2 weekly music/movement, hairdresser, singer 6 weekly and organist/entertainer 6 weekly. There is the minimum staffing level of 2 staff on duty throughout the waking day and staff feel they do not have time to engage in activities. In written feedback residents said that “activities were occasional” One relative said “as far as I am aware there are no activities apart from Xmas”. Gorsefield Residential Home DS0000008233.V310924.R01.S.doc Version 5.2 Page 15 The former comment appears accurate. Some relatives have regular visitors and also go out with visitors on a weekly basis. Some have irregular visitors and do not go out. The garden area of the home has been improved since the last inspection. The pool has been filled in for safety, a patio area created and there is good seating and now easy and safe access to the excellent garden area which is private and pleasant. The work has been carried out by the Princes Trust and residents said that they had spent and enjoyed time in the garden area during the summer months. Routines in the home are flexible. Residents seen rising late for breakfast. A recently admitted resident asked for a bath spontaneously and was assisted by one of the two staff on duty. She confirmed she enjoyed bathing, liked to choose her time at short notice and this was always accommodated. Records and discussion with resident confirmed that retiring times were flexible and some retiring to bed at 10 – 10.30 p.m. Food provision has been generally good in the home. Feedback from residents on this visit gave different views: “meals lack variety” and “the food is very good”. Menus are reported to be discussed with residents and whilst there is no specific alternative to the daily main meal there is an “additional menu” in the home but an expectation that people will ask for an alternative. It was suggested that the additional menu could be more readily available (on tables) or explained/read to residents. Gorsefield Residential Home DS0000008233.V310924.R01.S.doc Version 5.2 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 The quality of this outcome is good. This judgement is made using the available evidence and a visit to the service. Standards relating to complaints and protection are 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 requirement of Regulation 22. No complaints have been received by the home or the Commission since the last inspection report. In fact no complaints have been received overe the past 4 years. A resident in written feedback to the question “Do you know who to speak to if you are not happy?” answered “Yes, Shirley” (Manager). 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. Some staff have commenced NVQ training and the subject has been covered for them in more detail. A whistle-blowing policy is on the notice board. Gorsefield Residential Home DS0000008233.V310924.R01.S.doc Version 5.2 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 The quality of this outcome is adequate This judgement is made using the available information and a visit to the service. There is basically a good standard environment and the home presents well but maintenance is delayed and poor with some non-compliance. This needs to be addressed urgently and has been discussed with the proprietor. EVIDENCE: Gorsefield provides generally a good standard environment. There has been redecoration and refurbishment of some of the communal areas, providing good and pleasing lounges and dining area which are comfortable and attractive with good natural light from large windows. The home preserves much of its original character. Ongoing maintenance/replacements however are sometimes delayed. This applies currently in the following instances: Gorsefield Residential Home DS0000008233.V310924.R01.S.doc Version 5.2 Page 18 A requirement to provide immediate means of communication between waking and night staff has not been satisfactorily addressed and is a further requirement of this report. A immediate requirement for the repair of the call alert in the ground floor toilet area has not been actioned. The alert remains inoperative and therefore presents some risk to residents. Compliance in the above matters is now required urgently/immediately. Additionally a relative has reported issues relating to a (shared) bedroom that require urgent attention: Damage to the ceiling due to burst water pipe requires action, the ceiling paper peeling and hanging from the ceiling. In the same bedroom the carpet requires urgent cleaning/replacement. These are matters of requirement arising from this report and must be rectified. Compliance on all the above issues will be monitored. The garden area is private, secluded and pleasant. Improvements have been made since the last inspection. The small pool defined as hazardous by the Health & Safety Officer has been filled in. The garden has been improved with patio seating area and now presents well. The work has been carried out by the Princes Trust. Residents have spent time in the garden area during the recent hot weather. Standards of hygiene in the home are good with cleaning routines in place. Gorsefield Residential Home DS0000008233.V310924.R01.S.doc Version 5.2 Page 19 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 quality of this outcome is poor. This judgement is made using available information and a visit to the service. The home operates on minimum staffing levels. High dependency of bedfast resident requires increase in night staffing. Staff have been consistently recruited without POVA/CRB checks this practice must cease. NVQ training is poor and must be increased. EVIDENCE: The minimum staffing numbers for this home continue, with two care staff on duty throughout the day and one waking night care assistant and one person sleeping-in and on call. Dependency levels are generally low to medium but a resident is currently bedfast and requires considerable care including 2 hourly turning as part of pressure area management. Turns during the night are carried out by the waking night care assistant alone. This is not acceptable, does not comply with moving & handling safety and presents some risk to the resident. The home must review the night staffing arrangements to ensure adequate staff to meet the needs of residents. There are presently only 11 people in residence (15 on the last inspection). The daytime staffing levels at this time are therefore adequate for the current Gorsefield Residential Home DS0000008233.V310924.R01.S.doc Version 5.2 Page 20 numbers, but as they increase again consideration should be given to additional staffing at peak times of need or higher dependency needs. Staffing records showed that a new member of staff had commenced duties without a POVA/CRB check being carried out prior to employment. Three previous requirements have been made in relation to this matter and a further made in this report. This is another area of non-compliance. NVQ training commenced in this home in 2005. The home did not meet the target of 50 of staff NVQ trained by 2005 as stated in the standards. Since the last inspection one member of staff who completed NVQ training has left the home further reducing the numbers of trained staff. A recommendation of the last report to step-up NVQ training is further made in this report. Three recommendations have been made in previous reports to provide staff with employment contracts. Staff confirm that this has now been done. Gorsefield Residential Home DS0000008233.V310924.R01.S.doc Version 5.2 Page 21 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): EVIDENCE: The Manager is competent to manage the home although she has not obtained the Registered Managers Award. She has recently been able to work 1 day per week supernumerary (not on rota) allowing her time to spend on management duties. This is an improvement. The Manager has clear responsibility for all aspects of care in the home but does not have any control over financial matters. That rests with the proprietors. The majority of requirements in this report have financial implications. Gorsefield Residential Home DS0000008233.V310924.R01.S.doc Version 5.2 Page 22 There is a relaxed atmosphere in the home between staff and between staff, residents and visitors. Visitors which include relatives and professionals are received warmly and there is good dialogue with staff. There are no residents meetings or quality assurance process, but the manager has regular individual discussions with all residents as a means of assessing resident satisfaction. Moving & Handling training was provided for staff on 15.07.06. Food Hygiene and Health & Safety training was carried out in 2005. Three requirements have been made to provide annual fire training for staff. This was finally provided on 28/07/06. A letter/report from the Fire Officer dated 13th April 2006 containing certain recommendations must be addressed by the providers. Notification of completion of work can be reported to the Fire Officer and copied to the Commission. At night time there is a waking night care assistant and one person sleeping-in on call. Thee is no means of the waking night care worker contacting the person sleeping-in without having to visit the sleeping-in room. Two requirements have been made to provide a system for immediate contact between the 2 night staff. Walkie-talkie type solutions have been provided but not reliable. A discussion with the proprietor during this inspection agreed that a simple low-cost installation of portable phones would easily resolve this problem and also improve daytime telephone answering as there is only one fixed phone on each floor (one in locked office). The importance of night-time contact between staff is highlighted elsewhere in this report in relation to a very dependent resident and a further requirement made to provide this vital contact. Gorsefield Residential Home DS0000008233.V310924.R01.S.doc Version 5.2 Page 23 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 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 2 3 2 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 2 3 2 x x x 3 2 Gorsefield Residential Home DS0000008233.V310924.R01.S.doc Version 5.2 Page 24 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 OP29 Regulation 19 Requirement CRB checks must be completed for all staff. – (This was a requirement of the last three reports- timescale not met) Provide immediate means of communication between waking and non-waking night staff. (requirement of the two reports timescales not met). Call alert in ground floor toilet area must be operational at all times (previous timescale not met) Copy contracts for self-funding residents identified to be forwarded to the Commission. Carpet in bedroom identified must be cleaned/replaced Repair/redecoration of ceiling in bedroom identified requires immediate remedial action. Arrange additional night cover to ensure 2 staff available to assist with 2 hourly turning of resident Recommendations of the Fire Officer in report dated 13/09/06 DS0000008233.V310924.R01.S.doc Timescale for action 30/09/06 2. OP38 12(1) 30/09/06 3 OP22 23(2)(c) 30/09/06 4 5 6 7 8 OP2 OP24 OP19 OP27 OP38 5(1)(c ) 16(2)(c) 23(2)(d) 18(1)(a) 23(4) 14/10/06 31/10/06 30/09/06 30/09/06 30/11/06 Gorsefield Residential Home Version 5.2 Page 25 must be addressed. 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 OP8 OP28 Good Practice Recommendations Provide fluid/food intake chart to monitor daily intake for resident identified Increase NVQ training to meet target of 50 of NVQ trained staff Gorsefield Residential Home DS0000008233.V310924.R01.S.doc Version 5.2 Page 26 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.V310924.R01.S.doc Version 5.2 Page 27 - 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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