Inspection on 18/05/06 for Gorsey Clough Nursing Home Limited

This inspection was carried out on 18th May 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

Gorsey Clough Nursing Home... 26/08/09

Gorsey Clough Nursing Home... 22/05/09

Gorsey Clough Nursing Home... 30/08/07

Gorsey Clough Nursing Home... 24/02/06

Gorsey Clough Nursing Home... 12/07/05

Gorsey Clough Nursing Home... 18/03/05

Gorsey Clough Nursing Home... 30/06/04

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

CARE HOMES FOR OLDER PEOPLE Gorsey Clough Nursing Home Limited Harwood Road Tottington Bury Lancashire BL8 3PT Lead Inspector Mike Murphy Key Unannounced Inspection 18th May 2006 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 Gorsey Clough Nursing Home Limited DS0000017324.V288803.R02.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Gorsey Clough Nursing Home Limited DS0000017324.V288803.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Gorsey Clough Nursing Home Limited Address Harwood Road Tottington Bury Lancashire BL8 3PT 01204 882976 01204 886824 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) Gorsey Clough Nursing Home Limited Mrs Collette Conway Care Home 61 Category(ies) of Dementia - over 65 years of age (24), Mental registration, with number disorder, excluding learning disability or of places dementia (5), Old age, not falling within any other category (31), Physical disability (3) Gorsey Clough Nursing Home Limited DS0000017324.V288803.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 61 service users, to include: up to 31 service users in the category of (OP) Older People, up to 24 service users in the category of DE(E) Dementia (over 65 years of age), up to 3 service users in the category of PD Physical Disabilities (under 65 years of age), up to 5 service users (one of whom is named) in the category of (MD) Mental Disorder (under 65 years of age). The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 26th February 2006 2. Date of last inspection Brief Description of the Service: Gorsey Clough is a large detached extended property situated in a very pleasant rural area of Tottington Bury. The house is set in its own very large beautifully kept gardens. There is a very large terrace to the rear of the house that has plenty of garden furniture for residents use. There is plenty of parking within the grounds of the home. Gorsey Clough is not easily accessible by public transport but it is approximately 2 miles from the centre of Tottington Village. The doors at the front and back of the home allow a level access for wheelchair users and people who have problems climbing steps. The home provides accommodation in single and double bedrooms on the ground and first floor. The bedrooms on the first floor are reached either by stairs or a passenger lift. The home is divided into 2 areas, Windermere and Kendal. The Windermere Unit is a designated supervised combined lounge/dining area. The Kendal unit has a combined lounge and dining area plus 2 other lounges. Some of the toilets and bathrooms have aids to assist any resident with a disability or mobility problem. The home is registered to provide general nursing, dementia or social care for up to 61 residents. 24-hour nursing care is provided by suitably qualified nurses supported by care assistants. The current fees for residential care is £341.00 (with nursing fees being structured in accordance with PCT assessment) – information supplied by the provider. Gorsey Clough Nursing Home Limited DS0000017324.V288803.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection visit took place over a period of six hours. The inspection included discussion with some residents, relatives, and visiting healthcare professionals, a tour of the premises, inspection of care and other records maintained at the home, and discussion with the manager and staff. Consideration was also given to the completed pre inspection questionnaires returned by residents/relatives, visiting GP’s, social workers The home was being appropriately managed and provided residents with a clean and comfortable environment in which to live. Residents were supported and cared for appropriately and encouraged to make personal choices and retain as much personal independence as possible. What the service does well: What has improved since the last inspection? What they could do better: Whilst there have been significant environmental improvements in the home a small number of bedrooms still require redecoration/refurbishment. The Gorsey Clough Nursing Home Limited DS0000017324.V288803.R02.S.doc Version 5.1 Page 6 communal dining area is also in need of redecoration/refurbishment. Requirements made at the last inspection in respect of WC/bathroom areas remain outstanding. There is also a need to update electrical safety and gas safety certification (the inspector was informed this had been mobilised by the provider) and to develop a formal system of quality assurance in respect of the services provided by the home. These issues were discussed with the manager and the provider’s representative, at the end of this inspection, and are detailed in the requirements section of this report. 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. Gorsey Clough Nursing Home Limited DS0000017324.V288803.R02.S.doc Version 5.1 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 Gorsey Clough Nursing Home Limited DS0000017324.V288803.R02.S.doc Version 5.1 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): 3. Standard 6 does not apply to this service. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. No prospective resident is admitted to the home without their needs being assessed appropriately. EVIDENCE: Prior to residents being admitted to the home the manager or a senior member of the nursing staff carry out an assessment of the prospective resident’s needs in consultation with the resident, their relatives and relevant health (for example doctors) and social care professionals (for example social workers). The purpose of such an assessment is to assist the prospective resident (and their relatives) in their considerations of how appropriate a placement at the home would be and enable the nurse conducting the assessment if the home will be able to meet the prospective resident’s needs appropriately. The care records for the last six residents admitted to the home all contained a record of such assessment. Gorsey Clough Nursing Home Limited DS0000017324.V288803.R02.S.doc Version 5.1 Page 9 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): 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The health and personal care residents at the home receive is appropriate and is meeting the expectations of residents and their relatives. EVIDENCE: The care records of six residents were inspected. These contained care plans that were initially based on the pre-admission assessment that is referred to earlier in this report. Detailed care plans addressed the health, personal and social care needs of residents appropriately and were evaluated at least monthly. Risk assessments, that seek to protect resident’s health and safety were also recorded in respect of residents skin integrity (assessing the risk of pressure sores), mobility (including the risk of potential falls and fractures, and nutrition (including weight monitoring) and other relevant areas and were also evaluated at least monthly. All residents are registered with a local GP and it was evident that all were enabled to access opticians, chiropodists, dentists, district nurses and other Gorsey Clough Nursing Home Limited DS0000017324.V288803.R02.S.doc Version 5.1 Page 10 specialist services as individual resident’s require. Relatives spoken to and in pre inspection questionnaire responses were of the view that they were kept informed of all significant changes in their relation’s health. The procedures for the receipt, recording, storage, handling, administration and disposal of resident’s medicines were appropriate and safe. The qualified nursing staff, are responsible for all aspects of managing medication in the home. Medication administration records had been completed appropriately. No residents were able to manage their own medication at the time of this inspection. Discussion with residents, relatives and staff revealed that residents were treated with respect and that their right to privacy was upheld. Comments made included; ‘the girls always speak about my mum with respect’, ‘I was asked what my dad’s preferences were when he came in’, ‘the staff make sure you feel you are an individual person and speak to you nicely’, ‘the doctors see all residents in their own room when they come to examine residents’. Certainly on the day of inspection staff were observed to treat residents with respect, sought to protect their dignity and assist them appropriately. Gorsey Clough Nursing Home Limited DS0000017324.V288803.R02.S.doc Version 5.1 Page 11 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): 12,13,14,15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents appeared to be supported by staff to participate in social activities and are able to retain the ability to make personal choices. There was a general satisfaction with meals provision at the home. EVIDENCE: A record of leisure activities provided and participated in by residents is maintained. This record reflected that activities are varied and include occasional entertainers coming to the home. Discussion with residents and staff identified the things residents enjoyed and they also felt they were enabled to participate or not as they chose to do. Residents and relatives were also of the view that the routines of daily life were as reasonable as possible and it was evident on the day of inspection a significant number of service users had either chosen to get up later in the morning, spend time in their rooms or use the communal lounges as they wanted to. Residents and their relatives report no unreasonable restrictions to visiting at the home which take place in communal areas or resident’s bedrooms. Gorsey Clough Nursing Home Limited DS0000017324.V288803.R02.S.doc Version 5.1 Page 12 residents are encouraged to maintain contact with local community if they wish. Resident’s and relatives indicated that residents are actively encouraged/enabled to retain as much personal autonomy and make personal choices in their daily lives as they can and many have brought a number of personalise items to individualise and personalise their rooms. Meals are cooked on site in the home’s kitchen. Menus are varied and balanced and provide choice. Meals are served in an appropriate dining area although it is noted that this area is in need of redecoration and refurbishment. Residents meal times are as reasonable and as flexible as they can be in such a setting. Lunch was observed on the day of inspection. This was a hot and substantial meal and staff assisted and served residents their meals appropriately. Residents appeared to be happy with their food provision. Comments made by residents included ‘ you get plenty to eat and its good’, ‘I do enjoy the food here – its good plain food’. Gorsey Clough Nursing Home Limited DS0000017324.V288803.R02.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents (who were able to express a view) and relatives spoken to felt comfortable enough to and knew how to make a complaint if they felt it necessary. Written guidance and training arrangements ensure that staff members have a good knowledge of abuse and protection arrangements and safeguards were in place to protect the welfare of residents. EVIDENCE: The complaints procedure was prominently displayed and also is available in the ‘Service users guide’ that is provided for resident’s information. Residents spoken to stated that any concerns or worries brought to the manager’s attention are responded to quickly and rarely become formal complaints. A complaints log/incident log is maintained. There were no complaints logged since the last inspection (January 2006). Gorsey Clough operates ‘abuse and whistle blowing’ policies that seek to protect elderly persons. In addition, a copy of Bury’s Inter agency protection procedure is held on site. Staff spoken to confirmed that they had received training and were aware of the whistleblowing policy. Gorsey Clough Nursing Home Limited DS0000017324.V288803.R02.S.doc Version 5.1 Page 14 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): 19,20,21,22,24,25,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Whilst the home appeared to be structurally well maintained and significant progress has been made in respect of many environmental decorating and refurbishment issues a number remain outstanding. EVIDENCE: Significant progress has been made in the decorating and refurbishment of resident’s bedrooms. These rooms were clean, adequately heated, appropriately furnished, suitably decorated and in some cases very personalised. The inspector was informed that this programme is to continue until all bedrooms have been completed. Communal lounge areas were clean, warm and appropriately ventilated and in the main adequately furnished. The inspector was informed that some new lounge seating was in the process of being purchased for the lounge area to the rear of the home. Gorsey Clough Nursing Home Limited DS0000017324.V288803.R02.S.doc Version 5.1 Page 15 The dining room was clean and warm and in itself provides a suitable area for residents to dine. However this area (as identified at the last inspection) is still in need of redecoration and refurbishment of dining furniture. Toilets are within close proximity of communal spaces. Each toilet and bathroom has a lock on the door to ensure privacy and the facilities were all clearly marked. The toilet in room 20 still requires to be supplied with a disability adaptation to further promote resident’s independence and dignity. There are adequate assisted bathing and showering facilities. The toilet in bathroom room 18 still had no disability adaptation (this was identified at the last inspection). The inspector was informed by one of the directors that disability adaptation aids have been purchased and would be fitted within a week of this inspection. The floor covering in this room was damaged and is not non-slip. It is in need of replacement. (Again this was identified at the last inspection). The heating provision in the home was adequate. All rooms were centrally heated with radiators that were suitably covered to provide protection. Thermostatic control valves were in place on immersion baths and showers. Ventilation was either natural or mechanical. The home was clean and mainly free from odours. Suitable hand washing facilities were in place in each resident’s room, in bathrooms, and toilets. Gorsey Clough Nursing Home Limited DS0000017324.V288803.R02.S.doc Version 5.1 Page 16 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): 27,28,29,30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Staff were meeting resident’s needs appropriately and staff are subject to an appropriate recruitment procedure that is consolidated by appropriate training when appointed. EVIDENCE: Inspection of staffing rotas provided by the home indicated that staffing provision at the home complied with the current minimum requirements that apply to care homes for older people. Discussion with management at the home indicated that they were of the view that staffing levels were appropriate to meet the dependency levels of resident’s. Inspection of 3 staff personnel files revealed that these contained an application form (including health declaration), 2 written references, details of work permits (where applicable), a Criminal Records Bureau check (including a ‘POVA first’ check), proof of identity and evidence of induction training. At the time of this inspection 40 of the care staff had achieved an NVQ2 qualification or above. The remainder are either undergoing induction training or are seeking to achieve and NVQ2 qualification. The inspector was informed Gorsey Clough Nursing Home Limited DS0000017324.V288803.R02.S.doc Version 5.1 Page 17 that the home has recently secured appropriate NVQ 2 training that will enable night staff to be supported in achieving such qualifications. A record of staff training is maintained for each member of staff that reflects that a range of appropriate training has been provided that supports them in caring for residents appropriately. Gorsey Clough Nursing Home Limited DS0000017324.V288803.R02.S.doc Version 5.1 Page 18 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): 31,33,35,38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Gorsey Clough is well managed by a manger who is a registered nurse of many years experience in psychiatric nursing and care of the elderly. EVIDENCE: Residents, relatives, staff and visiting professionals commented positively about the manager being accessible, approachable and very supportive. They said their concerns or worries were addressed speedily and appropriately and in a way that made them feel happy to express their views. The arrangements for the management of residents personal allowance monies (where these are managed by the home) were secure and appropriately documented. Records in respect of fire safety equipment, fire drills and fire Gorsey Clough Nursing Home Limited DS0000017324.V288803.R02.S.doc Version 5.1 Page 19 safety training for staff, the passenger lift, lifting equipment, clinical waste removal and the regulation of water temperatures were inspected. These were found to be satisfactory. However an action plan in respect of the home’s fire safety risk assessment still needs to be completed as required in the last report. It was noted that the certificates for gas soundness and the 5 yearly inspection of the electrical installation are due for renewal – the inspector was informed that these issues were to be addressed shortly. Accidents at the home were appropriately documented and appear to have been appropriately managed. The home has the Investors in People award. There were however still no formalised effective quality assurance and monitoring systems in place although it was evident that these were being developed. . Gorsey Clough Nursing Home Limited DS0000017324.V288803.R02.S.doc Version 5.1 Page 20 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 X X 3 X X 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 2 X X 2 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 x 3 X X 2 Gorsey Clough Nursing Home Limited DS0000017324.V288803.R02.S.doc Version 5.1 Page 21 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 OP20 Regulation 23 Requirement An updated action plan is to be provided to the CSCI detailing; a) When the dining room redecoration/refurbishment (including provision of new dining furniture) is to be completed. b) When the redecoration/refurbishment of the remaining residents bedrooms are to be completed Timescale for action 31/07/06 2 OP21 23 To aid independence adaptations 31/07/06 must be provided to the toilets in rooms 18 and 20. Outstanding requirement New non slip flooring must be fitted in bathroom 18 An action plan to be forwarded to the CSCI by the timescale date. Outstanding requirement A quality assurance system must be in place. The registered person must establish and maintain a system for reviewing and improving the quality of care DS0000017324.V288803.R02.S.doc 3 OP21 13 31/07/06 4. OP33 24 31/07/06 Gorsey Clough Nursing Home Limited Version 5.1 Page 22 at the home. The outcomes of quality assurance measuring are to be communicated to the CSCI 5. OP38 23 An action plan in relation to the fire risk assessment must be forwarded to the CSCI. Outstanding requirement 31/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Gorsey Clough Nursing Home Limited DS0000017324.V288803.R02.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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. 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