Inspection on 09/09/08 for Gorsefield Residential Home

This inspection was carried out on 9th September 2008.

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

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 10/09/07

Gorsefield Residential Home 29/09/06

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 19/12/2008.

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 9th September 2008 09:30 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.V371663.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.V371663.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 Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (17), of places Physical disability over 65 years of age (5) Gorsefield Residential Home DS0000008233.V371663.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th September 2007 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 has registration to provide accommodation for up to 17 older people 5 of whom may have a physical disability and 8 may have dementia care needs. There is presently no registration for people with mental health needs. Current weekly fees can be obtained by contacting the service direct. Gorsefield Residential Home DS0000008233.V371663.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced Key Inspection was carried out on one day by one inspector from 08:30 - 16:30. The inspector was assisted by an Expert by Experience. This is someone with personal experience of using a similar service and trained to take part in the inspection of a service. This Expert by Experience talked with residents, staff and visitors to Gorsefield and was asked to focus on the quality of life for residents with particular reference to activities, occupation and external visits. A report was provided on her findings and incorporated into this report. The Registered Manager was on holiday at the time of the inspection but the Senior Carer on duty assisted in a competent and professional way with the inspection process establishing an open and positive dialogue about the operation of the home. There was an inspection of the environment including communal areas and a sample of bedrooms. Records relating to the inspection process were examined including - care plans, risk assessments, medication and staffing records, staff rosters and other documents. There were 15 people in residence at the time of this inspection. There were 2 vacancies. Most residents were seen and spoken with together and separately during the inspection day. Written feedback was received directly (confidentially) by us from 7 residents/relatives. Many positive comments were made including: “I felt very welcome when I arrived, I love it here” “Could not wish for better care and support – with a smile at all times” “Team very helpful, very understanding”. Four people commented about the lack of activities and stimulation in the home. An immediate requirement notice was left in the home in relation to security of the building and the provision of suitable mattresses. What the service does well: Gorsefield Residential Home DS0000008233.V371663.R01.S.doc Version 5.2 Page 6 A small home where individual, close relationships are established with residents, staff and visitors. Staff have high awareness of healthcare needs and swiftly refer to healthcare professionals if there are concerns about healthcare matters. Good working relationships exist between the homes staff, GP and District Nurses. A committed staff group with low turnover provides necessary continuity of care. A well presented environment with good standards of hygiene and infection control. A high level of resident satisfaction with food provision. Good, varied menus with choice at all mealtimes. Residents have input into menu choice. Food is well presented in a pleasant dining setting. What has improved since the last inspection? What they could do better: Urgent replacement of mattresses is needed. Residents have complained about their discomfort many are not suitable for purpose. An urgent audit of all mattresses in the home is needed. All external doors should be alarmed to ensure the safety of vulnerable residents who may wish to leave the home. This will alert staff in the event of anyone leaving the building and reduce risks to residents. Gorsefield Residential Home DS0000008233.V371663.R01.S.doc Version 5.2 Page 7 Training is needed for all staff in the Safeguarding of Vulnerable Adults. There has not been staff training in this important area of care. An assessment is needed to establish the appropriate use of a wheelchair for a resident and a moving & handling risk assessment must be provided. A risk assessment is also needed in relation to leaving the building and behaviours which may affect other residents. Additional staffing hours would address issues of dependency, peak time care and provision of activities. This would improve quality of life. A walk-in shower would provide an alternative bathing option and meet the needs of those residents who prefer a shower. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Gorsefield Residential Home DS0000008233.V371663.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.V371663.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 – 5 were inspected on this visit Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good pre-admission procedures and assessments ensure the home is suitable and can meet the needs of the person. EVIDENCE: There is a statement of purpose/service users guide available in the home for visitors and a copy is given to all residents/relatives. The information is readily available to prospective residents and their carers. Gorsefield Residential Home DS0000008233.V371663.R01.S.doc Version 5.2 Page 10 Contracts are provided by the local authority for funded residents and there is a private contract provided by the home for self-funding residents. Evidence seen of the latter on files in previous inspections. Pre admission assessment are carried out by the Manager in the persons current location. All prospective residents are invited to the home prior to admission to assess the suitability of the home to meet their needs. This is the preferred option and had happened in two instances where records of recently admitted residents were seen. They had stayed at Gorsefield for tea allowing them the opportunity to observe the routines and suitability of the home for them. Additionally this allows a more pertinent assessment by the home to ensure that needs can be fully met. Relatives are always involved in the pre admission processes. Gorsefield Residential Home DS0000008233.V371663.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7 – 10 were inspected on this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service meets the health and personal care needs of the residents. Some risk assessments are needed to ensure the safety of residents. EVIDENCE: A sample of care plans evidenced good recording of health and personal care needs. The social needs of residents were not recorded. Care plans are in two parts – one is a summary of the actions required to meet needs and readily available for staff, the other provides additional detailed information and is available in the office on the first floor for reference. Information was found to be up to date, relevant and provided a good working document for staff reference. Care plans are reviewed on a monthly basis in the home. Gorsefield Residential Home DS0000008233.V371663.R01.S.doc Version 5.2 Page 12 The home have a good record of early referral to healthcare professionals if there are any concerns or changes in the health of residents. During the night prior to this inspection there were concerns about a resident having breathing difficulties, the paramedics were called but the resident refused to go to hospital. Close monitoring continued throughout the night and the GP visited during the inspection and arranged for a nebuliser to be provided and gave further advice to staff. A resident who has been cared for in bed for 3 years and is totally dependent is receiving a high level of care from staff to maintain nutritional status and equipment and actions to ensure good tissue viability. The nursing service have ceased their regular visits but available immediately if there is any deterioration. Three requirements of the last inspection report have been actioned Food/fluid charts are established where nutrition is poor. Evidence showed that residents are weighed at least monthly or weekly if there are concerns about weight loss and review of medication is carried out by the GP when there are signs of possible over-sedation. Risk assessments were in place relating to moving & handling and other areas of risk but there were shortfalls in two areas: A risk assessment should be provided for a resident who does not wish to stay at Gorsefield, has tried to leave previously and stated her intention of doing so at the earliest opportunity. Another male resident who has displayed aspects of behaviour towards other residents has been correctly referred via the GP to the local hospital. A CPN (Community Psychiatric Nurse) has become involved and a chart to monitor ongoing behaviours established. It is important also to provide a risk assessment. A resident admitted some months ago is now using a wheelchair at all times. This has been provided by the family who are encouraging him to use it. Unfortunately his mobility is deteriorating, he needs 2 staff to assist with personal care. A hoist is available but not in operation/being used. The resident is having difficulty using the wheelchair in the lift to his first floor bedroom, there is limited space for manoeuvre. This person should be reassessed for wheelchair use by referral through GP to Occupational Therapist/Physiotherapist. Guidance is required to maximise his independence and ensure the correct moving and handling procedures for his wellbeing. If wheelchair use continues the home should consider the use of ground floor bedrooms for wheelchair users. There are good relationships established between the home and healthcare professionals. This was confirmed in discussions with a GP and visiting District Nurse on the last inspection. The medication system was inspected and found to be accurately recorded with no omissions or shortfalls. It was noted that medication no longer prescribed Gorsefield Residential Home DS0000008233.V371663.R01.S.doc Version 5.2 Page 13 was still appearing on MAR (Medication Administration Records) sheets, although none further supplied. To avoid any confusion these entries should be removed from MAR sheets and the pharmacist will be asked to do this. Gorsefield Residential Home DS0000008233.V371663.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12 – 15 were inspected on this visit. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. A limited range of activities within the home mean that residents are not occupied and are unable to participate in stimulating and motivating activities that would improve their quality of life. EVIDENCE: The Expert by Experience was asked to focus upon the quality of life for residents with particular reference to activities, occupation and external visits. After discussions with residents and staff and from observations, she made the following comments: Over-use of TV in two lounges, one is a “quiet” lounge and there is constant TV, some residents were asleep and others not watching. Gorsefield Residential Home DS0000008233.V371663.R01.S.doc Version 5.2 Page 15 There were no activities during the morning of the inspection. In the afternoon mild exercise to music took place for about an hour, attended by about 6/7 residents. This is a fortnightly event. There is a visiting organist once a month. A church group provide a short service fortnightly. Outings were previously arranged but there have not been any this year. A successful visit last year to the social club next door to the home has not been repeated. There is no structured activity programme and staff admitted that activities were not provided. Specific staff time for activities is not allocated and as there are only two care staff on duty to provide care for 15 current residents, there is no time for them to provide any kind of structured activity. The Expert commented that “staff in the home are dedicated, caring, flexible and committed, but that they are hard-pressed and working to the limit, with very little extra time to spend with residents on an individual basis”. The lack of activity and stimulation has been highlighted in previous reports. Residents have confirmed that they are “bored” and that their time is not occupied. In written feedback received by us from residents/relative prior to this inspection, comments made included: “Not enough staff on duty to be able to arrange activities” “Maybe some mental stimulation and activities would be good” Activities take place “sometimes”. Residents making these comments also commented favourably about other aspects of care but clearly wanted improvements in these quality of life issues. Food provision is good. Residents spoken with confirmed again on this inspection that the quality and quantity of food was good and that they had choices. The Expert by Experience was impressed with the evidence of choice and nutrition, commenting that food was home-cooked on the premises and care being taken to provide good quality meals and choice. Gorsefield Residential Home DS0000008233.V371663.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 – 18 were inspected on this visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents complaints are listened to and acted upon. Staff training in Safeguarding will further ensure protection of residents. EVIDENCE: There is a satisfactory complaint procedure available in the home for both residents and visitors. No complaints have been received directly by the home or by us since the last key inspection. A resident in written feedback in relation to complaints said the home were “Quick to act upon every need and concern” At the time of the last report there was concern that Safeguarding (Vulnerable Adults) procedures had not been followed in relation to an incident of abuse and a requirement was made. It is important that all staff have training in Safeguarding of Vulnerable Adults and this should be arranged as soon as possible. There has been no training for staff in this important area of care. Gorsefield Residential Home DS0000008233.V371663.R01.S.doc Version 5.2 Page 17 Gorsefield Residential Home DS0000008233.V371663.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 – 26 were inspected on this visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complete security of the building is needed to ensure the safety of vulnerable residents and replacement of mattresses is immediately required to ensure the comfort and wellbeing of residents. EVIDENCE: There is a generally good standard environment. Since the last inspection further improvements have been made: Many bedrooms have been redecorated, re-carpeted and some new furniture provided. The dining room Gorsefield Residential Home DS0000008233.V371663.R01.S.doc Version 5.2 Page 19 furniture and flooring has been replaced. New chairs have been purchased for the main lounge areas, with redecoration and new soft furnishings. It was identified during this inspection that mattresses in the home require replacement. New beds and mattresses were purchased 2-3 years ago with funds raised by staff. A recently admitted resident had stated (and it had been recorded 10 days previously) that she needed a new mattress and was unable to sleep as she was uncomfortable. She also raised this during the inspection with the Expert by Experience. When examined, her mattress had springs that were sticking up beyond the surface of the covering and was uncomfortable and unacceptable. This resident is slight and frail, her care notes state she has brittle bones. Two other mattresses (of the same age) were inspected and found to be the same. An immediate requirement was left to provide new mattresses to replace those seen and to urgently carry out an audit of all the mattresses in the home. A resident who does not wish to remain at Gorsefield and has stated her intention of leaving the home. She has made an attempt to leave through a door which is alarmed. She has also written in the complaints book that she does not wish to stay and will leave. Care notes record that “she will get out of here – please observe” - There are 2 doors leading to the rear garden area which are not alarmed. Alarms must be fitted immediately to ensure the safety of this resident (and others). Staff need to be alerted if anyone leaves the building. A risk assessment must also be provided in relation to this person and this potential risk. An immediate requirement notice was also left in relation to fitting the alarms to external doors. There are 3 bathrooms in this home. There is one assisted bath on the ground floor and one on the first floor. A third bathroom is unassisted. The number of bathrooms is satisfactory for the numbers of residents but there is no shower facility/choice for residents. A recently admitted resident said that he would prefer a shower – he had a shower at home and that is his preferred option. The home should consider the possibility of providing a walk-in shower as a bathing option for residents. There are showers in some en-suite rooms but theses are unsuitable and unused being the usual domestic type shower cubicles and not accessible. All areas of the home were bright, clean, well-presented and hygienic. There were no mal-odours. These are the usual standards for this home. There is a pleasant garden area but residents confirmed it had not been used much during the summer months. Although the weather has been poor there was no evidence of residents using the garden area. The external furniture for sitting in this area is in poor condition and needs replacement. A provider indicated to the Expert by Experience during the inspection that replacements were planned. Gorsefield Residential Home DS0000008233.V371663.R01.S.doc Version 5.2 Page 20 A self-closing device has been provided to a bedroom door following a requirement of the last report. Gorsefield Residential Home DS0000008233.V371663.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27 – 30 were inspected on this visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Additional staffing at peak times would ensure that the needs of residents can always be met and would improve quality of life. EVIDENCE: This home is staffed to the minimum level with 2 Carers on duty throughout the day and one waking night carer and someone sleeping-in in the building an on-call. Additional staffing hours are required at peak times of care. During this inspection the 2 staff on duty were consistently busy meeting the personal care needs of residents, there was no time to engage individually or generally with residents or provide activities. During this inspection the Senior Carer and Care Assistant on duty had to meet the needs of all residents and additionally be involved in the inspection, received visitors (including GP) and answer telephone calls. Fortunately the catering and domestic staff are also employed as carers and were therefore able to assist. This is how needs are met but when these staff switch to care their other duties are neglected, there are no Gorsefield Residential Home DS0000008233.V371663.R01.S.doc Version 5.2 Page 22 additional hours. Two residents currently need 2 carers for personal care. The home have added people with dementia care needs to their categories of admission. The above indicate the reasons to consider the provision of additional care hours at peak times of need during the day. There is low staff turnover and a high degree of commitment to residents in this home. The Expert by Experience commented independently “It was obvious to me that the staff in this home are dedicated, caring, flexible and committed, but also that they are also hard-pressed and working to the limit with very little extra time to spend with individual residents”. There has been an improvement in training for staff to NVQ standards. The number of staff trained to NVQ 2 or above now meets the required 50 minimum. Several staff have completed NVQ 3 training. As mentioned previously in this report all staff require training in Safeguarding (Protection of Vulnerable Adults) and this should be provided as soon as possible. Staff records were sampled and showed that all checks had been carried out prior to employment and documents required under Regulation 19 were present in those records seen. Gorsefield Residential Home DS0000008233.V371663.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31 – 33 and 37 – 38 were inspected on this visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Actions in relation to security and risk assessments and immediate requirements will improve the safety and wellbeing of residents. EVIDENCE: The Manager is competent and takes a positive hands-on approach to care in the home. She has considerable experience in providing care for older people. Gorsefield Residential Home DS0000008233.V371663.R01.S.doc Version 5.2 Page 24 She works 1 day per week off the rota to allow her time to carry out the numerous management duties. There are no residents meetings or quality assurance processes in place, although the Manager speaks individually to all residents and relatives on a regular basis as a means of assessing their satisfaction with the service. Visitors were not spoken with during this inspection, although some had completed written feedback forms returned directly to us. Residents and visitors were satisfied with most areas of care, with the exception of activities. Many positive comments were made. Risk assessments are required in relation to a resident wishing to leave the building and a person whose behaviour may affect other residents. There is a list of the potential responses of residents in the event of a fire completed as part of the fire risk assessment. An immediate requirement notice was left in the home on the day of inspection and followed by a letter to the providers. These relate to security of the building and replacement of mattresses. These requirements will be closely monitored. Gorsefield Residential Home DS0000008233.V371663.R01.S.doc Version 5.2 Page 25 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 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 2 3 3 3 2 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 X X x 3 2 Gorsefield Residential Home DS0000008233.V371663.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP19 Regulation 13(4) Requirement All external doors must be alarmed to alert staff in the event of residents wishing to leave. This will ensure safety of vulnerable residents who would be at risk if they left the building Mattresses identified must be replaced immediately. An audit of all mattresses in the home must be carried out. Timescale for action 09/09/08 2 OP24 16(2) (c ) 09/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP8 Good Practice Recommendations Seek review with Occupational Therapist/Physiotherapist for use of wheelchair for resident identified. Gorsefield Residential Home DS0000008233.V371663.R01.S.doc Version 5.2 Page 27 2 3 4 OP18 OP21 OP27 Provide training for all staff in Safeguarding (Protection of Vulnerable Adults). Consider provision of shower facility to meet the needs of all residents. Additional staffing hours at peak time should be considered to meet the needs of the people using the service and improve the provision of meaningfull activities and as a consequence their quality of life. Gorsefield Residential Home DS0000008233.V371663.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Gorsefield Residential Home DS0000008233.V371663.R01.S.doc Version 5.2 Page 29 - 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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