Inspection on 01/08/06 for Gorselands

This inspection was carried out on 1st August 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Gorselands 03/07/08

Gorselands 31/07/07

Gorselands 07/02/06

Gorselands 31/10/05

Gorselands 27/01/05

Gorselands 15/04/04

Gorselands 28/10/03

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

CARE HOMES FOR OLDER PEOPLE Gorselands 25 Sandringham Road Hunstanton Norfolk PE36 5DP Lead Inspector Lella Andrews Unannounced Inspection 1st August 2006 08:30 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 Gorselands DS0000037280.V306773.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. Gorselands DS0000037280.V306773.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gorselands Address 25 Sandringham Road Hunstanton Norfolk PE36 5DP 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) 01485 532580 cieves@ntlworld.com Cieves Limited Position Vacant Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Gorselands DS0000037280.V306773.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th February 2006 Brief Description of the Service: Gorselands is a large detached residential home which has 21 beds, and is situated in Hunstanton, which provides care for older people. The accommodation is on the ground and first floors with a shaft lift to access the first floor. There are 17 single rooms and two double rooms. Eight of the bedrooms have en suite toilets. There are assisted bathrooms and toilets. The communal areas consist of a large lounge and dining room, both of which have good natural light. There is a large paved car parking area at the front of the home. The gardens, which are well maintained, have a range of ornamental flowers and a fountain. The garden at the rear of the home is suitable for wheel chair users. The home is adjacent to the facilities and seafront of Hunstanton. Gorselands DS0000037280.V306773.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspection of this service includes information provided to the Commission since the last key inspection, information gathered during the random inspection carried out on the 7th June 2006 and the visit to the Home on the 1st August 2006 between 8.30am and 5.30pm. During the visit discussions were held with residents and staff as well as the manager and proprietor. Records were seen and a tour of the accommodation was carried out. The pre-inspection questionnaire was not returned to the Commission. The comment cards sent to the Home were not distributed to the residents and relatives by the proprietor and so cannot be included in this report. The Home is being managed partly by the acting manager (referred to in this report as the ‘manager’) and partly by the proprietor. The acting manager has not applied to the Commission to be registered despite previous requirements to do so. The proprietor is currently working very hard to try and manage both this Home and the other Home owned by the company. It is not possible for one person to do this as is evidenced by this report. There are currently 20 residents living at the Home. The fees range from £290.00 to £400.00 per week. What the service does well: The residents speak highly of the staff, saying that they are: “A1”, “ very kind”, “couldn’t be more helpful”. The residents enjoy their meals and are offered choices about what they eat and where they have their meals. A range of activities are provided on a weekly basis as well as trips to local places of interest. Gorselands DS0000037280.V306773.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Gorselands DS0000037280.V306773.R01.S.doc Version 5.2 Page 7 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 Gorselands DS0000037280.V306773.R01.S.doc Version 5.2 Page 8 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 and 3. The Home does not provide intermediate care. Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. Some changes need to be made to the Statement of Purpose so that it reflects an accurate view of the services provided. Pre admission assessments need to be carried out for residents coming to the Home for respite care as well as those moving in permanently so that the proprietor is able to assess whether the residents needs can be meet at the Home. EVIDENCE: The Statement of Purpose needs to be reviewed as there are some inaccuracies in it. The Service User Guide provides accurate information about the service provided. The proprietor and manager said that pre admission assessments are carried out for residents and that this information is then written into the care plans. Gorselands DS0000037280.V306773.R01.S.doc Version 5.2 Page 9 The format for the assessment has been recently reviewed and updated, a blank form was seen. Pre admission assessments are not undertaken for residents who come to the Home for respite. It is required that assessments are carried out for all residents who come to the Home whether for respite or on a permanent basis. It is important that the pre admission assessments consider carefully the residents needs at night time as there is only one waking night staff and one sleep in. Gorselands DS0000037280.V306773.R01.S.doc Version 5.2 Page 10 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, 8, 9 and 10 Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. The care plans need to be improved so that they provide good information to staff about how to meet individuals needs. The health care needs of the residents are being met but there is a need to improve the information in the care plans about individuals health needs. Improvements are needed to be made to the medication system to ensure that the residents are protected and that their needs are met with regard to medication. Residents said that the staff are very kind and that they are respectful of their privacy and dignity. EVIDENCE: Four care plans were seen. The manager said that she has started to update the care plans but that only one has been completed as yet. This care plan Gorselands DS0000037280.V306773.R01.S.doc Version 5.2 Page 11 was seen and is much improved on the standard of the others. The new format contains detailed information about how to meet the residents needs, risk assessments, personal history and is written in a style which is personal to the resident. The other care plans were variable in the quality of the information they contain. One of the residents has two pressure areas and the care plan does not even mention these or provide a plan for the care of them. It is required that the care plans are all updated and that they include detailed guidance about how to meet the individuals needs. The care plans also need to include risk assessments. The daily notes were also seen. These are very brief and contain little information about what the resident has been doing during the day. More care needs to be taken over writing the daily notes as the entries for one resident who had only been in the Home for a day read “ usual care given” “usual self”. It is required that the daily notes are more detailed and accurate. The staff also complete a handover book. This contains information about individual residents in one book which is not satisfactory as all information about individual residents should be separate so that they are able to view their own records without compromising confidentiality of other residents. It is required that the handover book does not contain personal details of individual residents. It was also noted that some information recorded in the handover book was not included in the residents daily notes. The proprietor explained the arrangements in place for residents to see the optician, chiropodist, dentist and hearing clinic. These appear to be satisfactory but this information needs to be included in the individual care plans to ensure that residents have regular check ups. Despite the majority of staff having attended moving and handling training the previous week staff pushed residents in wheelchairs without cushions or footplates. It is required that the wheelchairs have cushions and footplates. The medication administration was observed and the storage and records inspected. The administration was carried out appropriately and the records completed accurately. The medication trolley is appropriately stored in locked cupboards and a locked medication trolley. There were medications which were out of date stored in the cupboard as well as dosset boxes with medication in. It is required that out of date medication and medication no longer used is returned to the pharmacy as soon as possible. There were tablets in a foil packet which were not in the original box and therefore no details about whose tablets they are or the correct dosage to give. There were also two bottles full of tablets with no original label on with a Gorselands DS0000037280.V306773.R01.S.doc Version 5.2 Page 12 handwritten label stating “paracetamol” and “co-codamol”. It is required that only medication from the original packaging is administered to the residents. It is required that a record of medication received at the Home is kept as currently this is not happening. The medication procedure was seen and this is satisfactory except for the lack of information about homely remedies. It is required that the medication procedure contains details about homely remedies. Staff said that they only administer medication once they have received training. This training takes the form of distance learning as well as training provided by the pharmacy who provides the monitored dosage system. The residents said that the staff are very kind and that they are respectful of their privacy and dignity. Staff were seen to knock on bedroom doors. Screens are provided in the one room that is currently shared. It is required that the lock on the bathroom door on the first floor is repaired. Gorselands DS0000037280.V306773.R01.S.doc Version 5.2 Page 13 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, 13, 14 and 15 Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. The residents enjoy the range of activities and trips out that are provided. Visitors are made to feel welcome and are able to visit at any time. The residents feel that they are able to make their own decisions about a range of situations. The proprietor needs to review the staffing levels provided during the evening/night to ensure that residents needs/choices can be met. Residents speak highly of the meals offered and are able to choose where they have their meals. Staffing needs to be increased so that the care staff do not have to be involved in kitchen duties during the afternoons. Gorselands DS0000037280.V306773.R01.S.doc Version 5.2 Page 14 EVIDENCE: The residents said that there are plenty of activities during the week for them to take part in if they wish to. The programme of activities was seen and this includes music, exercise, card games and church visits on a regular basis as well as additional activities planned for the summer months such as trip to the theatre, strawberry evening as well as trips to other local places of interest. The new format for the care plans contains information about individuals interests and hobbies. Residents said that their friends and relatives are able to visit when they like. There were several visitors in the Home at the time of the visit. Visitors said that they are always made to feel welcome and that they are offered drinks and meals. The majority of residents who spoke to the Inspector said that they are able to make their own choices about what time they get up and go to bed, where they have their meals and where they spend their time during the day. However, two of the residents made comments about having to go to bed earlier than they would like as the evening staff are so busy. The proprietor said that residents are able to choose what time they would like to go to bed as there are staff on duty all evening. However, there are only two staff on duty until 10pm as there is only one waking night staff and a sleep in after that time. Therefore, if a resident needs two staff to assist them then they will have to go to bed before 10pm. It is required that the proprietor reviews the night time needs of the residents to ensure that two staff on duty during the evening and then only one waking night staff is sufficient. The residents spoke highly of the meals provided by the cook. They said that he knows what they like and dislike and that they are always offered a choice. The cook writes the menus in conjunction with the proprietor. The cook said that there is always flexibility within the menus. The staff tell each of the residents what is on the menu each morning and ask if they would like to have that or whether they would prefer an alternative. The cook is aware of the dietary needs of the residents. The majority of the residents have their breakfast in their rooms. They said that they are able to make the choice about where they would like to have their meals. The dining tables are set nicely with napkins and tablecloths. The layout of the kitchen is not ideal but the proprietor and the cook make the best of the space that they have. However, the kitchen seems to be the centre of the Home and there are constantly staff and visitors in and out of the kitchen. The proprietor/managers office is accessed through the kitchen also. Care staff have to use the kitchen to prepare drinks for the residents throughout the day and to prepare, serve and clear up after tea. This Gorselands DS0000037280.V306773.R01.S.doc Version 5.2 Page 15 situation means that the risk of cross infection is fairly high. It is recommended that this situation is addressed to see if the amount of additional people going in and out of the kitchen can be reduced. There are no kitchen staff on duty after 1pm. The care staff are responsible for clearing up after lunch, preparing, serving and clearing up after tea as well as preparing and serving drinks throughout the day. Dependant on what is on the menu, the cook prepares some teas before he goes off duty. However, this does mean that sandwiches are provided on a regular basis for tea. It is required that additional staff are on duty during the afternoon so that the two care staff on duty are not responsible for preparing or clearing up after tea. It was noted that the tea time sandwiches had been covered with cling film and left out on the side in the kitchen. It is required that food is stored appropriately. The cook has a cleaning schedule and also keeps records of fridge/freezer temperatures. Information provided to residents prior to moving to the Home makes it clear that the Home will not be involved in looking after residents money. Gorselands DS0000037280.V306773.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 and 18 Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. The residents know who to complain to if they wished to. The procedure relating to the protection of vulnerable adults needs updating and there are still a few staff who have not yet received training in this subject. EVIDENCE: The complaints procedure is now displayed in the Home. Residents said that they would feel happy to raise any concerns with the manager or proprietor but that they have not had to do so. The proprietor confirmed that she has not received any complaints in the last year but is aware of the need to keep a record if she did receive any. The staff have all recently attended protection of vulnerable adults training and the manager and proprietor intend to attend this training in October of this year. The proprietor said that she has previously attended this training about three years ago and so this will be an update for her. It is required that the procedure relating to the protection of vulnerable adults is updated and includes information about the procedure to follow after an allegation of abuse is made. Gorselands DS0000037280.V306773.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 and 26 Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. The Home provides adequate accommodation for the residents with some rooms being very attractive and others in need of redecoration. Previous requirements made about the accommodation have not been met. The Home was clean with no unpleasant smells. EVIDENCE: A tour of the building was undertaken with the manager. All of the communal areas, including bathrooms and toilets were seen but only a few of the bedrooms were seen on this visit. The Home provides accommodation which is furnished in a homely manner. The bedrooms show evidence of the residents having been encouraged to bring in personal possessions to personalise their rooms. Some of the bedrooms are ensuite and the rest have Gorselands DS0000037280.V306773.R01.S.doc Version 5.2 Page 18 hand basins in them. The bedroom doors now have name plates on them, following a previous recommendation. The bedrooms and bathrooms have call bells. It is required that the vanity unit around the sink in room 12 is replaced as it is broken in places. There are areas around the Home which would benefit from redecoration and the proprietor said that these are part of the ongoing plan of upgrading that is taking place. New carpet has been laid for the majority of the first floor and stairs. The area of carpet that had not been previously replaced on the first floor corridor and the steps to the upper first floor had a requirement made to be replaced by 31st July 2006 (made during random inspection on 7th June 2006). However, this has not been carried out. Neither has the rubber been replaced on the footplate of the chairlift, the floorboards mended, nor were the lights in the corridor on. These were all requirements made during random inspection. The proprietor said that the carpet is going to be laid this week. These requirements are repeated. The Home has a passenger lift which some of the residents use alone. The lift has easy to use buttons and provides a smooth ride. There is also a chairlift from the first floor to the upper first floor. Residents were seen to use the chair lift alone also. The lighting in this area was poor which was why the requirement had previously been made to ensure that the lights were all kept on in this area. The Home only has one communal lounge. Although the chairs are arranged in two groups it is still difficult for small groups of residents to sit together and chat. If the television or music are on in this room a resident would have to go to their own room if they did not wish to watch/listen to it. The lounge has lots of natural light due to the amount of windows. There is a nice view into the small garden area. Residents said that they enjoy sitting in the garden. There are no call bells in the lounge or dining room, despite notices in the lounge stating to press the call bell if help is needed. The manager said that the call bell from the lounge had been removed to put in one of the bedrooms. The residents said that they have to call for help if they need it. This situation is not satisfactory. It is required that call bells are put into the lounge and dining room. Due to its size, the communal lounge will need more than one call bell. The laundry room is situated on the ground floor. There are three domestic style washing machines and one domestic tumble dryer. Laundry is carried out by the care staff. The Home has domestic staff who work Monday to Friday. It is recommended that domestic staff are provided every day. Gorselands DS0000037280.V306773.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, 28, 29 and 30 Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. The provision of training has improved over the last year. Some of the necessary recruitment records are not available, therefore, lacking evidence that appropriate checks have been done on staff. EVIDENCE: The rotas confirmed the information provided by staff which is that the usual care staffing arrangements are as follows: three care staff from 8am to 2pm, two care staff from 2pm to 10pm, then one waking night staff and one sleep in staff. In addition to this the manager works part time, although she has been spending almost full time hours in the Home recently. The Home has a clear structure for each shift with the staff knowing clearly what they are each responsible for. Staff said that they like to have this structure. Residents spoke very highly of the staff, saying that they are “A1”, “ very kind”, “couldn’t be more helpful”. They also made comments about how busy they are and how hard they work. Gorselands DS0000037280.V306773.R01.S.doc Version 5.2 Page 20 Examples of shortfalls caused by the staffing levels have already been highlighted. There is a need to provide kitchen staff for teatime duties and a requirement is made about this. There is also a need for the staffing needs during the evening/night time to be closely reviewed as comments were made by some residents that would indicate that there are not enough staff at these times. The proprietor disputes this and the assessments/care plans are not good enough to provide clear evidence either way. Separate accommodation is not provided for the sleep in member of staff. They either sleep in the lounge or in a bedroom if there is one empty. There is currently one member of staff who is under the age of 18 and is providing personal care – the NMS state that staff under 18 years old should not do so. The Home will shortly meet the standard of 50 of its staff having completed NVQ Level 2. Agency staff are not used in the Home. Four of the recruitment files were seen. These did not all contain the necessary records. It is required that the information in Schedule Two of the Care Homes Regulations is kept for all members of staff. Following a recommendation, the manager has put together an overall training record/plan for the staff team. This should make it easier to ensure that all staff receive updates of necessary training. Staff have recently attended training in moving and handling, protection of vulnerable adults and diabetes. The cook has appropriate food hygiene training and it is required that all staff involved in the preparation of food have appropriate training. Induction is provided in house by the proprietor and then staff attend college to undertake formal induction training to Skills for Care standard. It is recommended that the in house induction is better organised to ensure that new members of staff receive training in a timely manner. Gorselands DS0000037280.V306773.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): 31, 33, 35, 36 and 38 Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. The management of the service will be improved by the employment of a suitable manager who is registered with the Commission. Improvements have been made with the introduction of formal supervision for the staff. The proprietor has started to implement a formal quality assurance process, which needs further development to ensure that the views of the people who use the service are taken into account. The health and safety needs of residents and staff are considered but improvements are needed to improve this area. Gorselands DS0000037280.V306773.R01.S.doc Version 5.2 Page 22 EVIDENCE: The Home is currently being partly managed by the proprietor and partly by the part time manager. There is no registered manager. The two previous dates of May 06 and July 06 for the Commission to receive an application to register the manager have not been met and the requirement is repeated. There are some differences between the standards required by the proprietor and the manager. As both are partly managing the Home this can be confusing for the staff and also means that there are no clear lines of responsibility and accountability. However, the staff do say that the proprietor is contactable if there are any problems when she is not there. The proprietor is working very hard to manage both this Home and the other Home that the company own but this is not possible for one person to do, as is evidenced in this report. The proprietor has started to implement a plan for a formal quality assurance process. The manager and proprietor have drawn up a development plan for the Home, which is mainly based on environment and administrative tasks. There is a need to develop the process and seek the views of the residents, relatives, staff and other stakeholders, which will then form the basis of the improvements made in the Home. Team meetings take place, as do meetings between the manager and the proprietor. The proprietor and manager have recently started to implement a formal supervision system which includes appraisal, supervision and observed practice. Records show that this has taken place for some staff. A timetable of sessions for the coming year is in place. This is an improvement and enables staff and manager/proprietor to discuss individual strengths and weaknesses and to draw up a development plan for each member of staff. However, the supervisions should include feedback about actual working practices and therefore should have picked up the issue about poor moving and handling practice. As the Home is owned by a company it is required that monthly visits are carried out as per Regulation 26 and that a copy of the report is sent to the Commission. A sample report format was given to the proprietor. The proprietor said that she does not look after money for any of the residents. The service user guide makes this clear. This is good practice. The Home has health and safety policies but these were not inspected on this visit. The proprietors husband, a director of the company, is responsible for overall health and safety matters and a member of staff is employed part time to carry out general maintenance. A health and safety audit of the environment was carried out in October 2005. Gorselands DS0000037280.V306773.R01.S.doc Version 5.2 Page 23 Records show that the fire safety equipment is regularly serviced. The fire alarm went off during the visit and staff reacted appropriately. It is required that a fire risk assessment is carried out. It is recommended that regular fire drills are carried out. Records show that the hoist, chairlift and passenger lift receive regular servicing. The gas safety certificate was not seen during this visit but the proprietor said that this is carried out regularly. The accident book was seen and shows that several falls have taken place. The proprietor said that Falls Awareness Training is being provided in September. It is expected that, following the training, falls audits will take place on a regular basis. A random inspection was carried out in June 2006 following contact from the Environmental Health Department to the Commission about an accident that had happened at the Home in May 2006. The Commission had not been notified, as they should have been. An unannounced visit was carried out by the Inspector and the Environmental Health Officer. Whilst it was not possible to state what actually caused the resident to fall at that time, several requirements were made to improve the condition of the flooring and lighting around the chair lift on the first floor. These requirements have not been met and so the requirements are repeated in this report. Gorselands DS0000037280.V306773.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 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 1 X 2 X 3 2 X 2 Gorselands DS0000037280.V306773.R01.S.doc Version 5.2 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 OP31 Regulation 8 (1) Requirement It is required that Commission receives an application for registration from the manager The previous dates or 1st May 2006 and 31st July 2006 have not been met. It is required that pre admission assessments are carried out for ALL prospective residents. It is required that the care plans contain detailed information about the needs of the service users and that they are regularly reviewed. The previous date of 31st July 2006 was not met. It is required that risk assessments are carried out for all residents. It is required that the daily notes are more detailed and are accurate. It is required that the wheelchairs have cushions and footrests. It is required that medication which is out of date or is no longer used is returned to the pharmacy. DS0000037280.V306773.R01.S.doc Timescale for action 31/10/06 2 3 OP3 OP7 14 15 02/08/06 30/09/06 4 5 6 7 OP7 OP7 OP8 OP9 15 15 13 (5) 13 (2) 30/09/06 02/08/06 31/08/06 04/08/06 Gorselands Version 5.2 Page 26 8 OP9 13 (2) 9 10 11 OP9 OP10 OP14 OP27 13 (2) 12 (4) 12 (2) 18 18 12 OP15 OP27 13 14 15 16 OP15 OP18 OP19 OP19 16 13 (6) 23 (2b) 23 (2b) 17 OP19 23 (2b) 18 OP19 23 (2b) 19 OP19 23 (2p) 20 OP19 23 (2n) It is required that medication is only administered from the original packaging or from a monitored dosage system supplied from the pharmacy. It is required that a record is kept of medication received at the Home. It is required that the broken lock on the bathroom door is mended. It is required that a review of the residents needs during the evening and night is carried out in relation to the staffing levels. It is required that additional staff are employed to undertake kitchen duties at teatime every day. It is required that food is stored appropriately. It is required that the protection of vulnerable adults procedure is updated. It is required that the vanity unit in room 12 is replaced. It is required that the floorboards at the top of the chair lift are repaired. The previous date of 31/07/06 was not met. It is required that the carpet on the first floor corridor and the steps is replaced. The previous date of 31/07/06 was not met. It is required that the rubber matting is replaced on the footrest of the chair lift. The previous date of 31/07/06 was not met. It is required that suitable lighting is provided in the area of the chair lift at all times. The previous date of 30/06/06 was not met. It is required that a suitable DS0000037280.V306773.R01.S.doc 02/08/06 02/08/06 08/08/06 30/09/06 30/09/06 02/08/06 31/08/06 30/09/06 31/08/06 31/08/06 31/08/06 02/08/06 30/09/06 Page 27 Gorselands Version 5.2 21 22 OP30 OP33 18 24 23 OP38 23 (4) number of call bells are provided in the dining room and the lounge. It is required that all staff who work in the kitchen receive appropriate training. It is required that monthly visits are carried out to the Home and that copies of the report are sent to the Commission. It is required that a fire risk assessment is carried out. 31/10/06 30/09/06 31/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP15 OP26 OP30 OP38 Good Practice Recommendations It is recommended that the number of people using the kitchen is reduced to prevent infection and reduce the risk of an accident. It is recommended that domestic staff are employed every day of the week. It is recommended that the induction programme is better organised to ensure that new members of staff receive training at appropriate times. It is recommended that regular fire drills are carried out. Gorselands DS0000037280.V306773.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Gorselands DS0000037280.V306773.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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