Inspection on 31/07/07 for Gorselands

This inspection was carried out on 31st July 2007.

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 01/08/06

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 Mrs Geraldine Allen Unannounced Inspection 31st July 2007 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 Gorselands DS0000037280.V347752.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.V347752.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 RSIVA91@hotmail.com Cieves Limited Sally Ann Parton Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Gorselands DS0000037280.V347752.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st August 2006 Brief Description of the Service: Gorselands is a care home providing personal care and accommodation for up to twenty-one older people. The home is privately owned by Cieves Limited. Gorselands is located in the seaside town of Hunstanton and is adjacent to all facilities. It is a large detached property and provides accommodation on the ground and first floors. There are 17 single rooms and two double rooms. Eight of the bedrooms have en suite toilets. A shaft lift allows easy access to the first floor 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 feature. The garden at the rear of the home is suitable for wheel chair users. Mrs Siva confirmed that the current fees are between £347:00 and £395:00. There are additional charges for items such as hairdressing, private chiropody and personal items. Currently, these charges are advised verbally at the time of the initial enquiry and are not put in writing until the terms of residence is provided. Gorselands DS0000037280.V347752.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place during the day of 31st July 2007. Information was obtained from various sources, including looking at records, speaking with residents, visitors to the home and staff and touring the premises. Time was also spent observing practice. All services are required to complete a document named the Annual Quality Assurance Assessment (AQAA) each year when requested by the Commission. Despite reminders, this had not been received by the time this inspection was carried out. Despite assurances from Mrs Siva – representing the registered company - that the AQAA would be forwarded, this document remains outstanding at the time of this report. Because the AQAA was not returned as required, it was not possible to write to residents, next of kin or health and social care professionals to find out their views of the service. Such views could only be obtained by speaking with people during this inspection and therefore opportunities were limited. Since the last key inspection dated 1st August 2006, two further unannounced inspections have taken place on 5th September 2006 and 5th March 2007. Both inspections were carried out in order to ensure requirements were being met. Overall, people who use this service described good experiences and were positive about life at the home and the care they receive. They expressed confidence in the manager, Mrs Parton and the staff group whom they described as kind and caring. Unfortunately, the standard of some records do not support the good work done by staff. As a result of this inspection, 9 requirements and 8 recommendations have been made. Of these 3 are repeated requirements and have been outstanding for a considerable period of time and must be dealt with without any further delay. What the service does well: People have access to and receive good health care support that is delivered in a timely way. Staff follow the advice and guidance given by health care staff. People say they enjoy a good quality of life at this home. They gave examples of how the service meets their physical and social needs. They spoke warmly about Mrs Parton and the support given by staff. Gorselands DS0000037280.V347752.R01.S.doc Version 5.2 Page 6 People are encouraged to personalise their own rooms and this was seen to good effect for some people. Some people were happy to show their special possessions that were on display in their room. Staff were observed throughout the day, providing care and support to people. Interactions were appropriate and staff respectful when speaking with people. All care was given in private and behind closed doors, ensuring each person’s privacy and dignity was protected. What has improved since the last inspection? What they could do better: More work is required on the Statement of Purpose and Service User Guide so that people receive accurate and up to date information about the home before they move in. Care plans still do not give sufficient information and guidance to staff to help them provide the right care. People need to be involved in their own care planning. Some procedures need to be updated so that they contain up to date information and reflect best practice. These include the complaints procedure and the procedure for safeguarding adults. The Home needs to reconsider the arrangements for preparing and clearing up at tea time. Currently, care staff are undertaking these duties 5 days per week. This means that care staff are not necessarily available to provide personal care when needed, hygiene standards could be compromised and the variety of the teatime menu is limited. The AQAA is a legally required document that must been provided when requested by the Commission. Despite reminders, this document has not been provided. As a result, the Commission cannot make informed judgements about the quality of this service or the appropriateness of any improvement plan set by the service provider. Gorselands DS0000037280.V347752.R01.S.doc Version 5.2 Page 7 Monthly service provider visit reports are required to be made and sent to the Commission. This is not currently taking place. 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. Gorselands DS0000037280.V347752.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 Gorselands DS0000037280.V347752.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): 1, 3 & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service has developed a Statement of Purpose and Service User Guide but both documents need to be updated to ensure information accurately reflects the service. People have a needs assessment before they move into the home but this needs to include social and emotional needs in more detail, as well as physical needs. This home does not provide intermediate care. EVIDENCE: Mrs Siva confirmed that the current fees are between £347:00 and £395:00. There are additional charges for items such as hairdressing, private chiropody and personal items. Currently, these charges are advised verbally at the time of the initial enquiry and are not put in writing until the terms of residence is provided. Mrs Siva said she would arrange for a printed sheet to be included with the home’s brochure, detailing the fees payable. The brochure was not Gorselands DS0000037280.V347752.R01.S.doc Version 5.2 Page 10 available at the time of inspection and Mrs Siva said she needed to print more off her computer. A copy of the Statement of Purpose and Service User Guide was obtained. The Statement of Purpose needs to be updated to ensure the information is accurate and reflects the home at this time. The same issues apply to the Service User Guide. The inspection report included within the Service User Guide is dated 4th June 2003 and needs to be replaced with a more up to date report. Three care plans were looked at in detail. Each contained a fully completed, signed and dated pre-admission assessment. Gorselands DS0000037280.V347752.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): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service have access to health care services both within the home and in the local community. Care plans did not provide sufficient information about the needs of people and how the care should be delivered. Medication systems do not always follow good practice. Staff were aware of the need to treat individuals with respect and to consider their dignity when providing personal care. EVIDENCE: Three care plans were looked at in detail. Each file contained a completed, dated and signed pre-admission assessment. The personal history for each person was either not completed or was very brief. There needed to be more information about the social, emotional and spiritual needs of each person. There was some information about hobbies and interests but not how they could be maintained at the home. The care plan was very brief and gave little guidance for staff. The daily pattern sheet contained very little information Gorselands DS0000037280.V347752.R01.S.doc Version 5.2 Page 12 about social and emotional needs and activity although it did provide good information about physical needs. There was no evidence to show that residents are involved in their own care planning. The care plans were discussed with Mrs Parton and with Mrs Siva. A different format was suggested that will provide more information for staff. Mrs Parton was keen to develop and implement a better care plan process and documentation. Risk assessments also need to be developed and used to inform the care plans. The care plan needs to be reviewed monthly and residents and/or their relatives need to be involved in care planning and review. There need to be care plans for strengths as well as deficits so that people’s skills and abilities can be supported and maintained. Finally, the social and emotional needs of people need to be better understood and recorded. Evidence was seen on the care plans that showed people receive health care in a timely way. These interventions are properly recorded. The administration of medicines was observed at lunchtime. There was some practice that needs to be improved. For example, the medicine administration record was signed before ingestion was observed. The recording of the administration of controlled medicines must be properly signed and not initialled. Mrs Parton conducts a fortnightly medication audit. The monitoring of competence was discussed and Mrs Parton agreed this could be part of the regular supervision process and she will develop a format along those lines. The need for a care plan for PRN medicines was also discussed. During the course of the day, all people received personal care behind closed doors. Evidence was seen that staff protect people’s dignity and privacy. Gorselands DS0000037280.V347752.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have the opportunity to maintain important personal and family relationships. People have access to meaningful daytime activity of their own choice. Meals are balanced and nutritious. Staff are sensitive to the needs of people who find it difficult to eat. EVIDENCE: Four residents were spoken to in private. One resident said she was very pleased to be at the home. She said she was mainly self caring and said staff were kind and give help when she needed it. The resident said she enjoys sitting in the garden, goes to church weekly and attends the church dinner each month. The resident said she enjoys the food and knew what was on the menu for the day. Another 2 people were spoken to in private. They said the home had improved since Mrs Parton took over. They agreed that Mrs Parton was easy to talk to, always listened to their views and was trying to meet their expectations. They said she “couldn’t do better”. They both usually go on arranged outings, have Gorselands DS0000037280.V347752.R01.S.doc Version 5.2 Page 14 lots of visitors who can call whenever they wish and are offered refreshments. They said they will speak to Mrs Parton if they have any worries and she will always deal with. They said the food was good and there was plenty of it. Another resident was spoken to in private. She said she was very happy at the home. She said the food was excellent. Her daughter visits frequently so she goes to the kitchen to make her daughter a drink if she wishes. She said she can talk to Mrs Parton if she is unhappy, but she isn’t. She said there were always plenty of staff about and they answer call bells quickly. She said there was plenty of activity at the home. A visitor to the home was spoken to. She had arrived to take her relative out for the afternoon. She said she was very happy with the care given. She said she feels welcomed at the home and knows the staff very well. She said she is very confident in Mrs Parton’s abilities to manage the home well. She said she has no worries about her relatives care The activities calendar was seen and included activity approximately 4 days per week. These activities include friendly faces, exercise, slide show and PAT dog. The interaction between staff and residents was observed throughout the day and was always good. Residents spoke about being able to joke and laugh with staff and all said staff were easy to talk to. Lunch time was observed. All meals were plated and covered. Some residents ate in the dining room but others were in the lounge or their own rooms as they preferred. One liquidised diet was seen and the components had been mixed together and looked unappetising. One resident was seen being assisted by a member of staff, who sat beside her and talked to her. The dining room had recently been redecorated. The room looked clean and fresh. Gorselands DS0000037280.V347752.R01.S.doc Version 5.2 Page 15 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): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure that is not in line with best practice. The home has a policy about safeguarding adults but this does not accurately reflect the existing adult protection protocol. EVIDENCE: The complaints procedure was seen displayed in the home. This did not reflect the timescales the complainant could expect a response within. The procedure is also included in the Statement of Purpose and Service User Guide. There are inaccuracies within this document and it needs to be reviewed and updated, including the contact details for the Commission. The home’s adult protection policies were looked at. These referred to bullying and aggression and also referred to other policies for example, finance and complaints. The policy continues to refer to the home investigating any allegations before reporting under safeguarding adults procedure and is therefore not in accordance with current practice and needs to be amended. Gorselands DS0000037280.V347752.R01.S.doc Version 5.2 Page 16 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): 19, 24 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides an environment that meets the needs of the people who live there. People said they can personalise their rooms. There is a programme to improve the décor and fixtures. Generally, the home was clean and tidy. There is outstanding work that needs to be completed to ensure that electrical installations and fire safety requirements are complied with. EVIDENCE: A tour of the premises was conducted on arrival at the home. All areas were clean and tidy and there were no unpleasant odours. Two people said they brought their own furniture into the home and many of their pictures and other important possessions. These were seen displayed Gorselands DS0000037280.V347752.R01.S.doc Version 5.2 Page 17 throughout their room. They said they enjoyed spending time in their own room, including mealtimes. The dining room had recently been decorated and looked bright and fresh. It was noted that there was no hand towel in 1 toilet for residents to dry their hands on. All locks were in place to ensure privacy and dignity. There were no window restrictors fitted to the windows on the 1st floor, although Mrs Siva said these windows did not open wide enough for anyone to get through. There were outstanding issues regarding electrical installations and fire safety – see standard 38. Staff need to ensure that all cupboard doors are properly closed to ensure safety of themselves and residents. Gorselands DS0000037280.V347752.R01.S.doc Version 5.2 Page 18 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): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service have confidence in the staff who care for them. There are enough qualified, competent and experienced staff to meet the needs of people using the service. The recruitment process needs to improve so that people are safeguarded by thorough checks. The manager is aware there are some gaps in the provision of statutory training and these are being dealt with. EVIDENCE: The staff rota for the period of inspection was provided. For the day of inspection, there were 3 care staff on duty between 07:30 and 14:00, 2 care staff between 14:00 and 20:00 and 1 waking night staff between 20:00 and 07:30. A member of staff also sleeps in to provide assistance if necessary. Domestic and catering staff are also employed. However, there is only teatime catering assistance available for 2 evenings per week. Mrs Parton works 35 hours per week off the rota as the manager at the home. Two staff files were looked at in detail. The files did not fully comply with requirements. For example, they did not contain a minimum of 2 written references and there were no staff photographs on file. One application did not have a full employment history and there was no evidence that this was Gorselands DS0000037280.V347752.R01.S.doc Version 5.2 Page 19 explored with the applicant. Staff induction records were seen and were in accordance with the common induction standards. However, the induction documents were labelled with the name of another home. It is also recommended that a checklist is developed to ensure staff files contain all the elements required. Additional references need to be requested where only 1 is returned. The training file was seen. This contained certificates for all staff training events and these included fire training (3 only), NVQ2, 1st aid, falls, vulnerable adults at risk, pressure area care, moving & handling, safe handling of medicines, food hygiene, diabetes and blood sugar monitoring. Mrs Parton said that more fire training is being organised. A further member of staff is just starting NVQ2, with a further member of staff wanting to do it. More staff training about safeguarding adults is also organised. Three staff were spoken to in private. The senior staff on duty said she had completed NVQ2. She said she had completed medication training at King’s Lynn college approximately 3 years ago. She said her NVQ assessor checked her competence. Another carer said she had worked at the home for 4 – 5 months. She said she had been told about the fire procedures but had not attended any training. A senior carer was also spoken to in private. She said she completed NVQ2. She said all statutory training and update training is arranged at the home and spoke about 1st aid, fire safety and abuse awareness. She had a good understanding of safeguarding adults and whistle blowing and was able to describe the circumstances where she would blow the whistle. Gorselands DS0000037280.V347752.R01.S.doc Version 5.2 Page 20 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): 31, 33, 35, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager has the necessary experience to run the home. The service provider did not provide the Annual Quality Assurance Assessment (AQAA) as required by the Commission. The service has a quality assurance process but this does not give people sufficient opportunity to fully express their views. The service provider is not conducting monthly visit reports and sending a copy to the Commission as required. Staff are now receiving supervision but this is at an early stage. The service has health and safety arrangements that generally meet requirements although some areas for improvement have been highlighted. Gorselands DS0000037280.V347752.R01.S.doc Version 5.2 Page 21 EVIDENCE: Mrs Parton has recently been registered as manager of the home. Residents spoken to spoke highly of Mrs Parton and the confidence and stability she brings to the home. The quality assurance process was looked at. The home is doing an annual questionnaire for residents and their relatives. The questionnaire was seen and was composed of closed questions. The previous questionnaire did not have a resultant summary or improvement plan. The process needs to be opened up to all stakeholders and all questions need to be re-phrased so they are open. A summary and improvement plan also needs to be developed. Mrs Parton said she does a quality service check each month that involves her sitting and speaking with each person private to obtain their views and opinions about life at the home and how it can be improved for them. The AQAA was not completed and returned. Mrs Siva confirmed that she has not yet worked on the AQAA and she was reminded this was a legal requirement. She was asked to complete and return the AQAA without further delay. Monthly visit reports are not consistently being completed and returned to the Commission as required. Mrs Parton confirmed that the home does not handle any resident’s money. Mrs Parton is doing all staff supervisions but has only achieved 1 session for each member of staff in 7 months. She will not therefore meet the standard. Various health & safety records were looked at. The electrical installation report dated 29/1/07 states that the overall installation is unsatisfactory. There was a significant list of work to be carried out that numbered 34 items. Mrs Siva said the urgent work had been completed but the others were outstanding. Other maintenance certificates seen included gas safety, lift maintenance, hoist servicing, and alarm systems. The fire records were seen. There was a report on file of a fire safety check dated 17/4/07, carried out by the fire service. An action plan was attached but some items had not yet been rectified. These were notated on the action plan as “delayed due to sourcing and arranging” The fire risk assessment was in place, the alarm system last checked 11/5/07, there were weekly alarm tests and monthly emergency lighting tests. Gorselands DS0000037280.V347752.R01.S.doc Version 5.2 Page 22 Accident records were looked at. There was evidence that Mrs Parton investigates these but she needs to record the date her investigation is carried out. An accident report seen on a care plan was cross referred and fully recorded. The certificate of registration was not displayed. Mrs Siva had been advised the week before at the inspection of her other home that this was an offence. Gorselands DS0000037280.V347752.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 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X 3 X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 2 Gorselands DS0000037280.V347752.R01.S.doc Version 5.2 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4&5 Requirement All people considering using the service must receive a copy of the Statement of Purpose and also the Service User Guide that is up to date and accurate. This will ensure that people are confident about the information provided and that it can be used to help them make an informed decision about living at the home. All people must have a care plan that is clear and provides information and guidance to staff about how they wish to receive the care and support they need. The person should be involved in a monthly review of the plan wherever possible. This will mean that people receive the care they need that reflects their preferences. The service needs to ensure that the complaints procedure is correct and up to date. All people must be given a copy of the revised complaints procedure. This will mean that people visiting and using the service have the information DS0000037280.V347752.R01.S.doc Timescale for action 01/10/07 2. OP7 15 01/10/07 3. OP16 22 01/09/07 Gorselands Version 5.2 Page 25 4. OP18 13 (6) 5. OP27 18 6. OP29 19 7. OP33 26 8 OP37 17(2) 9. OP1 7 they need if they wish to make a complaint. The service needs to amend the current procedural guidance about safeguarding adults so that it reflects the agreed Norfolk protocol. This will ensure that best practice is followed at all times. The arrangements for the teatime period must be revised to ensure care staff are available to provide personal care at all times and also that good standards of hygiene are maintained. This requirement has been outstanding since 30/09/06. The information listed in Schedule Two of the Care Homes Regulations must be obtained prior to staff starting work at the home. This will ensure that robust recruitment procedures that safeguard people living at the home are followed. This requirement has been outstanding since 06/03/07. Monthly visit reports are not being completed and sent to the Commission as required. This means that there is no record of monitoring of quality by the service provider being kept. This requirement has been outstanding since 30/09/06 The Annual Quality Assurance Assessment was not completed and returned to the Commission as required. This means that it has not been possible to assess the service’s plans for improvement. The service must display in a prominent place, the registration certificate. This will mean that people can see the home is operating within its registration and that the information is DS0000037280.V347752.R01.S.doc 01/09/07 01/10/07 01/09/07 01/10/07 01/10/07 01/10/07 Gorselands Version 5.2 Page 26 current. 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 OP3 Good Practice Recommendations The assessment of needs completed before a person moves into the home needs to include more information about their social and emotional needs and aspirations. This will ensure that the care and support they receive is more holistic. The inspection report kept with the Service User Guide needs to be updated with the most recent report. This will give people up to date information about the performance of the service. Staff must ensure they follow best practice guidance at all times when administering and recording medicines. This will mean that errors will be reduced and there will be good records providing clear audit trails. Care plans need to be developed for all people who have medicines prescribed on an “as needed” basis. This will give staff clear guidance about when these medicines should be used. People who need their food softened or liquidised should receive their food so that all components remain separate and recognisable. This will increase the enjoyment for people when eating. Staff need to make sure they keep all cupboard doors closed when not in use. This will help to reduce the risk of accidents to people who use, visit and work in the service. The quality assurance questionnaires developed by the service need to be improved so that the questions are not closed. The process also needs to include all people who visit the service. This will ensure that the service receives the views of people that can be used to develop and improve the care given. The requirements and work identified in order to ensure all fire safety and electrical installation safety must be carried out in the timescales identified by each agency. This will ensure that the environment is well maintained and safe. 2. OP3 3. OP9 4. OP9 5. OP15 6. 7. OP19 OP33 8 OP38 Gorselands DS0000037280.V347752.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Gorselands DS0000037280.V347752.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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