Inspection on 26/04/07 for Gorstyfield Nursing Home

This inspection was carried out on 26th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Gorstyfield Nursing Home 07/02/06

Gorstyfield Nursing Home 24/03/05

Gorstyfield Nursing Home 14/09/04

Gorstyfield Nursing Home 02/03/04

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

CARE HOME ADULTS 18-65 Gorstyfield Nursing Home Ridge Hill Brierley Hill Stourbridge West Midlands DY8 5ST Lead Inspector Mrs Mandy Beck Key Unannounced Inspection 26th April 2007 10:00 Gorstyfield Nursing Home DS0000004876.V329986.R01.S.doc Version 5.2 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 Gorstyfield Nursing Home DS0000004876.V329986.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 Adults 18-65. 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. Gorstyfield Nursing Home DS0000004876.V329986.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gorstyfield Nursing Home Address Ridge Hill Brierley Hill Stourbridge West Midlands DY8 5ST 01384 401018 01384 404617 gorstyfield@shaw-homes.co.uk 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) Shaw healthcare Limited Alison Hodgkins Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places Gorstyfield Nursing Home DS0000004876.V329986.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. MHD - Mental Health Establishment taking people liable to be detained. Date of last inspection 7 February 2006 Brief Description of the Service: Gorstyfield Nursing Home is privately owned by Shaw Homes. The home provides accommodation for up to 16 service users who have a mental illness and require nursing care. The aim of the home is for service users to be as independent as possible whilst living in a supported environment, which enables them to develop life and social skills. The home was previously a three-storey block of flats, each flat consisting of four single bedrooms, a kitchen and a bathroom. The communal rooms are situated on the ground floor and consist of two lounges, a dining room and a smoking breakfast kitchen. Laundry and catering facilities are available on site. The home currently charges £451 per week for residency; this fee does not include toiletries, newspapers, hairdressing or spending money for day trips and holidays. Gorstyfield Nursing Home DS0000004876.V329986.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took 7 hours to complete. We used a variety of methods to help us make the judgements in this report. Time was spent talking to staff and some of the residents. We looked in depth at some of the resident’s files as part of the case tracking process, this helps us make decisions about the quality of care planning and care delivery in the home. We also looked at staff files to see if the home continues to recruit people in a manner that safeguards the people who live at the home, and to see if the staff are receiving all of the training and support they need to carry out their roles. The inspector would like to thank all of the staff and residents at Gorstyfields for their hospitality throughout the inspection. What the service does well: All of the residents said that they liked living at the home and that the staff were very kind and helpful. Residents also stated that they spend time away from the home doing activities or visiting day centres. Some of the residents go home at the weekend to visit their families. The manager and staff are very welcoming and friendly, all of the staff spoken to had a clear understanding about their roles in the home and of their residents needs. One resident commented “if I’m not happy I can talk to all of the staff, they help me”. There is a newsletter produced by the residents for the residents and this keeps them informed of any changes in the home, of outings or other planned activities. Residents produce this on the computer that has recently been purchased by the home for their use. Residents have the choice to lead an active social life, the home provides many trips to local theatres, pubs and woodland walks. In addition to this the home provides two holidays a year, one usually to Minehead Butlins, which is a resident favourite. There are regular residents meetings during which time everyone is encouraged to talk about life at the home and offer their suggestions for improving the service. Gorstyfield Nursing Home DS0000004876.V329986.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Gorstyfield Nursing Home DS0000004876.V329986.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Gorstyfield Nursing Home DS0000004876.V329986.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4 Quality in this outcome area is good People who may use this service will have the information needed to choose a home which will meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home provides good sources of information to prospective new residents. This information will help them make a decision about wanting to live in the home. The manager is currently updating the service users guide to make it more “user friendly” and relevant to residents needs. Once completed it will give a clear guide of the type of service new residents can expect to receive when they move in. All of the residents have an in depth assessment of their needs before they move into the home. the home also obtains a copy of the care management assessment that is integrated with the Care Programme Approach (CPA). Residents are involved in thin process and the home uses the assessment to plan individual care plans with the residents. Before new residents are offered a permanent place at Gorstyfields they are given the opportunity to “test drive” the service. This may mean that new residents can visit on a daily basis and spend time with other residents or they may have the opportunity to live at the home for a trial period. This helps Gorstyfield Nursing Home DS0000004876.V329986.R01.S.doc Version 5.2 Page 9 both the residents and staff know whether or not the new residents needs can be met by the home. Gorstyfield Nursing Home DS0000004876.V329986.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. Residents are involved in making decisions about their lives and they play an active role in planning their care and the support they receive. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Every resident has their own individual plan that details all of their care needs. The plan is drawn up with their involvement and is agreed by them. It was pleasing to see that there have been improvements to this process. The home is now working toward a more person centred approach to planning care. This was seen when we looked at resident’s files. Each plan has a description of needs as seen by the nursing staff and a description of needs from the resident’s point of view. Both of these are then used to plan care in a way that residents want. There are good systems in place for dealing with limitations on freedom, in accordance with the CPA and Mental Health Act 1983. This means that both Gorstyfield Nursing Home DS0000004876.V329986.R01.S.doc Version 5.2 Page 11 staff and residents are aware of the restrictions placed upon them and they are managed sensitively. Staff encourage all of the residents to make decisions about their lives, they do this by offering them choice and giving them information needed to make decisions. Some residents manage their own finances and the home supports them in doing so, other residents have chosen to let the home staff deal with their money. All decisions made by residents are kept under review and are documented. The home has very good systems in place to make sure that all monies are kept safe and secure. Residents have their own individual risk assessment that enables him or her to live as independently as possible. The manager has recently introduced a new system of risk assessment and has linked it to the evaluation of residents care. Each risk assessment has a scoring system so that it is easy to see the progress that residents are making. Where no progress has been made this gives both the staff and residents the opportunity to sit down and discuss how to change the care plan so that progress can be made. Gorstyfield Nursing Home DS0000004876.V329986.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome area is excellent Residents are able to make choices about their life style and are supported to develop their life skills. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All of the residents are encouraged to take part in activities both at the home and in the community. It is the aim of the home to support residents to take part in activity because they feel it encourages identity, independence, choice and control over their lives. There are good opportunities for all residents to be part of the local community. Several of the residents attend day centres during the week, this gives them the opportunity to meet with friends and spend time away from the home. Other residents spend their time visiting their families and in some cases stay with them for weekend leave. Gorstyfield Nursing Home DS0000004876.V329986.R01.S.doc Version 5.2 Page 13 During residents meetings there is an opportunity to put suggestions forward for trips, holidays and other outings residents are interested in. All of the residents are invited to go on holiday twice a year, the home will pay for this but residents will have to provide their own spending money. A popular choice is Butlins Minehead, it is anticipated that this will be one of the holiday destinations this year. There are opportunities for residents to visit the theatre and the pub if they wish to do so. The home has an activity coordinator whose role it is to encourage each resident to reach his or her highest level of independence whilst living in a care environment. There are plenty of activities available to do in the home as well. A computer has recently been purchased and residents make full use of it. They produce a newsletter that is displayed in the entrance of the home; the newsletter keeps everyone informed of forthcoming events and other interesting information such as birthdays and the agenda for the next residents meeting. There are plenty of art and craft materials for residents to use, along with games and books. The home has communal areas and all of the residents live in flats. Each flat has four bedrooms and communal kitchen and bathrooms. As part of each residents plan some domestic activity is encouraged. Most residents do their own laundry and are able to cook their own meals. The home does employ a cook to supply meals to residents. The home does offer a menu for guidance but if residents don’t like what is on offer they are offered an alternative choice. Meals are provided three times a day but residents do have the choice to use the kitchen in their own flat if they want to make something extra. Most of the residents will take part in meal planning and preparation, including doing their own shopping. It was pleasing to see that the home routinely completes risk assessments for each resident that looks specifically at their nutritional intake. Residents are supported to make choices about their diet and it was good to see that the dietician had been asked to come and advise some residents on their dietary intake. This gives residents the opportunity to discuss their diets and gives them the information they need to make choices about healthy eating and dietary recommendations. Gorstyfield Nursing Home DS0000004876.V329986.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. Residents are given personal support in the way they prefer. The staff do support residents to make sure that their physical and emotional need are met. Medication practices are safe but residents could be more involved in the process. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff have been working hard to further improve upon the standard of their care plans. it was very pleasing to see that new plans of care have been agreed with the residents about how they want to receive their care. Some of the plans sampled were good examples of person centred care, they contained the nurses view of the residents current health issues, the residents current view of their own health issues and a plan of care that is negotiated and agreed by the resident and staff. These plans included things such as they way residents wanted to be assisted with their personal care, their preferences for a female or male carer and what time they prefer to go to bed at night. It is also evident that residents are supported by a network of community workers such as doctors, psychiatrists, mental health nurses and dieticians. All Gorstyfield Nursing Home DS0000004876.V329986.R01.S.doc Version 5.2 Page 15 of the residents have their health monitored and the home has a number of risk assessments in place to help them do this. Each resident is risk assessed for falls, nutrition, moving and handling and pressure sore risk development. Any risks arising are managed with a written plan that shows both the resident and staff how the potential risk to their health will be dealt with. The manager has also begun health promotion campaigns in the home in an attempt to educate residents. There is a wealth of information for residents about the benefits of giving up smoking. The home has been supported by the Smoking cessation worker from the local PCT. Some of the residents have chosen to give up smoking as a result of these visits and have been supported by the home in doing so. One service user said “I’m doing well I used to smoke 80 a day and I haven’t had any”. The manager stated that families had also commented that some residents were smoking less at home as a result of an increased knowledge about the dangers of smoking. The home has good systems in place for dealing with the administration, ordering and safe storage of medication. There are some areas for improvement, it was noted that there is a system of secondary dispensing. This means that staff are dispensing medication from the blister packs received from the pharmacy and putting it into medicine bottle to give to the resident to take at home whilst on leave. This must not happen; if the resident leaves the home on a regular basis and requires their medication to take out with them then the home should ask the pharmacy to provide medication in a labelled container or dossette box. If the manager feels that it is absolutely necessary to carry on with secondary dispensing there must be written protocol available and staff will need to be trained to undertake this. It is recommended that the manager obtain a copy of the CSCI document “the administration of medicines in care homes” for further professional guidance. At present none of the residents administer their own medication, it is recommended that the manager consider ways for this to happen as part of the recovery and rehabilitation of residents within a risk management framework. Gorstyfield Nursing Home DS0000004876.V329986.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is excellent. Residents who use this service are able to express heir concerns and have access to an effective complaints procedure. They are protected from abuse and have their rights protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has received no complaints at all since the last inspection. All of the residents who completed the surveys for the CSCI indicated that were aware of who to talk to if they were unhappy about anything. The home has a clear policy and procedure to follow in the event of any concerns being raised. All residents are encouraged to raise concerns during residents meetings and privately with their key worker if they choose to do so. All of the staff have had training in adult protection, this included recognising the signs of abuse, the different forms of abuse and where to go to get help when alleged abuse has taken place. In addition to this staff have also had training in challenging behaviour and “low arousal” techniques designed to reduce the amount of restraint needed if residents should become physically aggressive. The home has very good systems in place to ensure that all of the resident’s monies are handled safely and kept securely. Both the home manager and the organisations accountant regularly audit records to make sure that this good practice is maintained. Residents are encouraged to manage their own money but staff are available to assist them if needed. Gorstyfield Nursing Home DS0000004876.V329986.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. The home is clean and welcoming, residents live in comfortable environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been some improvements to the environment since the last inspection. The manager told us that they have had new carpets in the corridors and on the stairs, in addition pictures and photographs from resident’s outings have been framed and put up, this makes the corridors and stairways feel more inviting and homely. As a result of recent resident meetings, some of the residents have chosen to redecorate their bedrooms. In some cases they have bought new furniture and have been able to choose new carpets and wallpaper for their own bedrooms. We looked at a couple of rooms that had been recently decorated and it was pleasing to see that they were cosy and had been personalised by the residents making them individual to them. Gorstyfield Nursing Home DS0000004876.V329986.R01.S.doc Version 5.2 Page 18 Generally the home is well maintained, there are areas for improvement that the manager is aware of and she is trying to fit these improvements into her budget for the home. For example some of the bathrooms in the individual flats are in need of repair and redecoration. Each of the flats has its own washing machine and residents are encouraged to do their own washing as part of their ongoing recovery and rehabilitation. There is also a communal laundry situated outside for those residents who wish to use it. Gorstyfield Nursing Home DS0000004876.V329986.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 Quality in this outcome area is excellent. The home has experienced and well-trained staff. Staff are recruited in a manner that will safeguard residents. All of the staff are well supported and benefit from regular supervision. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are enough members of staff on duty to meet resident’s needs but in addition to this the home also allows staff to have “Resident Activity Days”. These days are extra to the hours staff work in the home and gives them an opportunity for one to one work with the residents. There is always a trained nurse on duty and support workers to assist them. Most of the staff have now completed their NVQ level 2 in healthcare and in some cases have completed the NVQ level 3. The manager also told us that they provide a “training placement” for student nurses. We read some of the evaluation sheets from these placements and it was pleasing to see the comments were all positive. One person had commented “I had a fear of working with people with mental health problems but they really changed my outlook regarding mental health issues”, “brilliant, my mentor was brilliant, included me and supported me ….. boosted by confidence”. Gorstyfield Nursing Home DS0000004876.V329986.R01.S.doc Version 5.2 Page 20 Residents also commented about the staff saying “they are great”, “staff are very helpful, that makes me happy”, “they help me to see my family”. Some staff files were examined to make sure that the home has all of the required documentation. It was pleasing to see that all records were up to date, that staff had had the required safety checks before being employed and that they had received an induction when they began working in the home. It is recommended that each staff file has a current photograph of the worker attached to it, as outlined in the Care Home Regulations 2001. Each member of staff has their own individual training plan and the organisation has good systems in place to identify when staff are due for updates in training. This ensures that all staff has the required knowledge and skills to care for the residents. The manager also told us that she is planning training in specific mental health subjects that will give staff a clearer understanding of the residents needs. All staff receive regular supervision, this gives them the opportunity to discuss their progress and to identify any specific training needs they may have. The manager also completes an annual appraisal for each member of staff. New workers are appointed a mentor who supports them through their induction period. Gorstyfield Nursing Home DS0000004876.V329986.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is excellent. There is a confident manager who runs the home in the best interests of the residents. There a good systems in place to make sure that residents needs are met and that quality is maintained. Resident’s welfare and safety are promoted and protected by the organisation. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has worked for over 9 years in the home, she has the skills and knowledge to run the home and is very enthusiastic about the standards of care that residents receive. The home has very good systems in place for making sure that quality is maintained. They conduct audits every 3 months, this includes the environment, individual kitchen audits, accidents and incidents and medication. Gorstyfield Nursing Home DS0000004876.V329986.R01.S.doc Version 5.2 Page 22 The manager will usually make an action plan based upon the results of each audit. In addition to this residents and relatives are also asked to complete a questionnaire about the home and the care and support they receive. Any comments from these questionnaires are then collated and made into an action plan. The manager stated that any issues arising as a result of these questionnaires are usually addressed very quickly. Some of the comments on the questionnaires included “happy with the management”, “satisfied with the staff”, “would like new flat furniture”. More recently there have been positive comments from relatives about the health promotion work that the home has been encouraging residents to take part in. Safe working practices within the home are a priority and all staff have annual updates or statutory training. This helps to keep their knowledge and skills updated. The manager has a training matrix that identifies when staff training is due so that all staff are assured of a place and do not miss out. Safety certificates for the building are all up to date; the manager indicated this in the pre inspection questionnaire she completed prior to our visit. Gorstyfield Nursing Home DS0000004876.V329986.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 Adults 18-65 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 3 2 3 3 x 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 x 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 4 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 4 x LIFESTYLES Standard No Score 11 X 12 3 13 4 14 4 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 2 x 4 X 3 X X 3 x Gorstyfield Nursing Home DS0000004876.V329986.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard YA20 YA20 YA20 YA20 YA20 Good Practice Recommendations The home must not “secondary dispense” medication and must arrange for TTO’s to be provided in suitable containers for residents to take with them. It is recommended that the temperature of the room where the medicines are stored is recorded daily to ensure that it stays below 25oC. It is recommended that resident’s capabilities be risk assessed to enable them to administer their own medication. Where a variable dose is recorded then staff must show which dose of medication they have administered. When residents administer their own creams staff must make sure that a risk assessment has been completed and is recorded in the individual residents plan. This must also be completed when “PRN” medication is prescribed. Gorstyfield Nursing Home DS0000004876.V329986.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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. 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