Inspection on 24/02/06 for Gorsey Clough Nursing Home Limited

This inspection was carried out on 24th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

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... 18/05/06

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 Harwood Road Tottington Bury Lancashire BL8 3PT Lead Inspector Grace Tarney Unannounced Inspection 24th February 2006 10:00 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 Gorsey Clough Nursing Home DS0000017324.V263929.R01.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 DS0000017324.V263929.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Gorsey Clough Nursing Home 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) Mr Eric Goldsmith 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 (1), Old age, not falling within any other category (35), Physical disability (3) Gorsey Clough Nursing Home DS0000017324.V263929.R01.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 35 service users in the category of (OP) Older People, up to 24 service users in the catrgory 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), One named individual in the category of (MD) Mental Disorder (under 65 years of age) may be accommodated within the overall number of registered places. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 12th July 2005 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. Gorsey Clough Nursing Home DS0000017324.V263929.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was not made aware that this inspection was to take place. This was an unannounced inspection. The inspector spent 7 hours at the home over 2 days. . During this time she looked at care and medicine records to check that the health and care needs of the residents were being met. To make sure that the home and the equipment in it was safe, the Inspector looked at the maintenance and service records. She also looked at how the management recruit their staff and how they handle the residents’ spending money. The Inspector then looked around the building at the bedrooms, bathrooms toilets and sitting areas to check if they were clean and well decorated. She then visited residents in their own bedrooms to check out the care that was being provided for them. In order to obtain information about the home, the inspector also spent time speaking to 3 residents, 2 visitors, 3 nurses, the registered manager, the administrator and one of the directors. Not all the National Minimum Standards were looked at on this visit. The Inspector looked at the Standards that had not been looked at during the last inspection. The Standards that are looked at during inspections are those that are considered to be important for the residents’ safety and well-being What the service does well: What has improved since the last inspection? The way that the medicines were stored was much safer. Many of the bedrooms had been re-decorated, re-carpeted and new furniture provided. Also a new shower room had been installed. Gorsey Clough Nursing Home DS0000017324.V263929.R01.S.doc Version 5.1 Page 6 A new computer system has been installed. This enabled management to streamline the ordering system. 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. Gorsey Clough Nursing Home DS0000017324.V263929.R01.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 DS0000017324.V263929.R01.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 & 6. Although the assessment document needs further amendment, the system for ensuring that all prospective residents had a detailed assessment undertaken before their admission to the home, gave an assurance both to residents, relatives and staff, that a resident was only admitted if the home could meet their needs. EVIDENCE: Before any resident was admitted to the home an assessment of their needs was undertaken, either by a senior member of staff from the home or from the professional i.e. care manager, requesting their admission. Whilst the Inspector was that the home one of the registered nurses left to undertake an assessment of a prospective resident. The preadmission assessment document had been amended so that a clearer, more detailed assessment of a residents’ needs could be undertaken and recorded. The amended document however needs to be further amended to include information about the residents’ oral health, foot care and social interests. Standard 6 does not apply. The home does not provide Intermediate Care. Gorsey Clough Nursing Home DS0000017324.V263929.R01.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. The care plans reflected the support needs of the residents. Care practices ensured that the health care needs of residents were met, they were treated with respect and their right to privacy and dignity was upheld. The medication system ensured that the residents received their medicines safely and correctly. EVIDENCE: Individual care plans were in place for each resident. The care plans of two residents were examined. The care plans gave clear instruction and guidance on how the care needs of the residents were to be met when problems had been identified. Risk assessments were in place and covered such areas as moving and handling, nutrition, pressure sores, the use of bed rails and falls. The residents were weighed at least on a monthly basis and the weight recorded the in their care plan. Equipment necessary for the prevention and treatment of pressure sores was available within the home. Continence aids were in use and the staff were aware of how to contact the continence nurse advisor for advice, if deemed necessary Gorsey Clough Nursing Home DS0000017324.V263929.R01.S.doc Version 5.1 Page 10 Inspection of the care files identified that the residents had access to health care professionals, such as dentists, opticians, chiropodists and district nurses. The Inspector did not look at the medication system in detail during this visit. She checked compliance with the previous requirements. These had been met, apart from the fact that Temazepam was not being stored as a controlled drug. Staff rectified this in the presence of the Inspector. A discussion with the residents and relatives identified that they feel they are treated with respect and their right to privacy is upheld. One resident told the Inspector “ I can wander around wherever I want to, they don’t mind and don’t tell me what to do, they are lovely”. Gorsey Clough Nursing Home DS0000017324.V263929.R01.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. The home enables residents to exercise as much personal freedom and choice as possible EVIDENCE: A discussion with residents indicated that they were satisfied with the personal choices and freedom they were able to exercise. Although there was no activities person employed by the home they were satisfied with the range of activities provided by the care staff. Any activities undertaken are recorded in a designated activities book. The manager told the Inspector that most afternoons the residents enjoy karaoke sessions, board games, arts and crafts, videos or reminiscence sessions. Outside entertainers are also brought into the home. The manager and staff also put on various shows /pantomimes for the residents from time to time. Residents are encouraged to bring personal possessions into the home. Many of their bedrooms were highly personalised with small pieces of their own furniture, pictures, photographs and ornaments etc. Gorsey Clough Nursing Home DS0000017324.V263929.R01.S.doc Version 5.1 Page 12 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): EVIDENCE: Not looked at during this inspection. These Standards were examined during the inspection of the 12/07/2005. There were no requirements. Gorsey Clough Nursing Home DS0000017324.V263929.R01.S.doc Version 5.1 Page 13 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 24 25 &26. The residents live in clean, comfortable and safe accommodation. EVIDENCE: 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. . It was evident that there has been a continuing programme of redecoration and refurbishment throughout the home. The lounge areas were clean, well furnished and nicely decorated. The dining room in Kendal is in need of refurbishment however. The décor looked very jaded and there were several odd tables and chairs. One of the directors informed the Inspector that refurbishment of the dining area is to be undertaken fairly soon. Gorsey Clough Nursing Home DS0000017324.V263929.R01.S.doc Version 5.1 Page 14 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 had no disability adaptation. To promote independence and dignity this should be provided. There are several assisted bathing facilities however 2 of the bathrooms are not being used, as they do not allow disabled access. A new assisted shower has been installed in room 58. This offers a good facility. Room 36,the shower room, is in need of redecoration. The toilet in room 18 had no disability adaptation. The floor covering in this room was damaged and is not non-slip. It is in need of replacement. Many are of the bedrooms have been redecorated re carpeted and new furniture provided. The bedrooms that are in urgent need of redecoration and refurbishment are bedrooms: 6a, 9a, 27d, 30 &49. A lockable facility was provided in the bedrooms and the doors had a Yale lock. The locks had been disabled to prevent residents locking themselves in. Staff had a master key. The heating within the home was adequate. All the rooms were centrally heated with radiators that were suitably protected. 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. Hand washing facilities were in place in each resident’s room, in bathrooms, and toilets. Gorsey Clough Nursing Home DS0000017324.V263929.R01.S.doc Version 5.1 Page 15 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 . The residents were cared for by a sufficient number of staff that were suitably qualified and trained and therefore had the knowledge and skills to meet the residents needs EVIDENCE: Examination of the duty rotas and a discussion with staff, residents and relatives showed that there was enough staff on duty to meet the needs of the 51 residents. 24-hour nursing care continues to be provided by qualified nurses who are supported by suitably trained care assistants. The home continues to provide training in NVQ Care and further training continues to be provided in moving and handling, fire safety, dementia care and challenging behaviour. Gorsey Clough Nursing Home DS0000017324.V263929.R01.S.doc Version 5.1 Page 16 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 The experience and qualifications of the manager ensures there is effective leadership and guidance to the staff thereby ensuring that the residents receive consistent quality care. A satisfactory accounting system was in place that ensured the residents’ interests were protected. Current practices within the home in relation to the maintenance of a safe environment, promoted and safeguarded the health, safety and welfare of the people using the service. EVIDENCE: The manager is a Registered Mental Nurse (RMN) with extensive nursing experience in the NHS and the private sector. She has been employed at Gorsey Clough for 11 years. She has attained the registered managers award. An inspection of the managers personnel file showed that she regularly undertakes training to update her clinical skills. She has recently undertaken basic computer skills training. Gorsey Clough Nursing Home DS0000017324.V263929.R01.S.doc Version 5.1 Page 17 The home has the Investors in People award. There were however, no formalised effective quality assurance and monitoring systems in place. The systems in place for the management of residents’ money were good. The home had a satisfactory accounting system in place. The administrator could determine exactly how much money the home was holding for each person and how the money was being spent. Receipts were retained for all financial transactions. It was noted that when any money is deposited in the bank it goes into the “Resident” bank account. The Inspector was told that this is not an interest accruing account and that only small amounts of money are deposited. The bank does not levy any bank charges because of this. The equipment and services within the home were serviced on a regular basis in accordance with the individual requirements. The home had a detailed Health & Safety Policy. The inspector was present when a Fire risk assessment had recently been undertaken. The assessors report was made available to the Inspector. The administrator stated that the Directors were in the process of formulating an action plan to do with the requirements and recommendations made by the assessor. The fire logbook was up-to-date. All staff received Induction Training with regard to food hygiene, fire safety, moving and handling and infection control. Fire training was undertaken on an annual basis. Gorsey Clough Nursing Home DS0000017324.V263929.R01.S.doc Version 5.1 Page 18 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 2 x X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 2 2 2 x x 2 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 3 Gorsey Clough Nursing Home DS0000017324.V263929.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP9 OP20 Regulation 13 23 Requirement Temazepam must always be stored in the controlled drug cupboard. The dining room must be redecorated. An action plan to be forwarded to the CSCI by the timescale date. New dining room furniture must be provided. An action plan to be forwarded to the CSCI by the timescale date. To aid independence adaptations must be provided to the toilets in rooms 18 and 20. New non slip flooring must be fitted in bathroom 18 An action plan to be forwarded to the CSCI by the timescale date. Shower room 36 must be redecorated. An action plan to be forwarded to the CSCI by the timescale date. The bedrooms identified in this report must be redecorated and refurbished. DS0000017324.V263929.R01.S.doc Timescale for action 24/02/06 30/04/06 3. OP20 16 30/04/06 4. 5 OP21 OP21 23 13 30/04/06 30/04/06 6 OP21 23 30/04/06 7 OP24 23 30/04/06 Gorsey Clough Nursing Home Version 5.1 Page 20 8 OP33 24 9 OP38 23 An action plan to be forwarded to the CSCI by the timescale date. 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 at the home An action plan in relation to the fire risk assessment must be forwarded to the CSCI. 30/06/06 30/04/06 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. Refer to Standard OP3 Good Practice Recommendations The preadmission assessment document should be amended to include information about the residents oral health, foot care and social interests. Gorsey Clough Nursing Home DS0000017324.V263929.R01.S.doc Version 5.1 Page 21 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. Extracts may not be used or reproduced without the express permission of CSCI Gorsey Clough Nursing Home DS0000017324.V263929.R01.S.doc Version 5.1 Page 22 - 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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