Inspection on 20/06/06 for Gorton Parks Nursing Home

This inspection was carried out on 20th June 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

Gorton Parks Nursing Home 21/04/08

Gorton Parks Nursing Home 18/12/07

Gorton Parks Nursing Home 03/10/07

Gorton Parks Nursing Home 02/03/06

Gorton Parks Nursing Home 07/06/05

Gorton Parks Nursing Home 11/11/04

Gorton Parks Nursing Home 01/06/04

Gorton Parks Nursing Home 23/02/04

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

CARE HOMES FOR OLDER PEOPLE Gorton Parks Nursing Home 121 Taylor Street Gorton Manchester M18 8DF Lead Inspector Geraldine Blow Key Unannounced Inspection 20th June 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 Gorton Parks Nursing Home DS0000021678.V298870.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. Gorton Parks Nursing Home DS0000021678.V298870.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gorton Parks Nursing Home Address 121 Taylor Street Gorton Manchester M18 8DF 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) 0161 220 9243 0161 230 7439 www.bupa.com BUPA Care Homes (CFH Care) Limited Jason Paul Axford Care Home 148 Category(ies) of Dementia - over 65 years of age (90), Old age, registration, with number not falling within any other category (43), of places Physical disability (15) Gorton Parks Nursing Home DS0000021678.V298870.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of older people requiring nursing care at any one time shall not exceed 43 patients of either sex aged 60 years or over. There are three named service users requiring care by reason of physical disability. Should these service users no longer require the accommodation offered the places will revert to the category of old age (OP). This accommodation is in Sunny Brow and Debdale Houses. In addition a maximum of 12 places are designated for use as intermediate care beds for service users aged 55 and over requiring intensive rehabilitation by reason of physical disability following discharge from hospital care. The rooms are located in Debdale House and equipped with appropriate specialist facilities, equipment and staffing. The length of stay should not normally exceed 6 weeks. A maximum of 60 places in Delamere House and Melland House are registered for older people with dementia who require personal care only. A maximum number of 30 places in Abbey Hey House are registered for either sex aged 60 years or over for people with dementia assessed as requiring nursing care. Minimum nursing staffing levels as specified in the Staffing Notice issued under Section 13 of the Care Standards Act 2000 on 15 February 2006, will be maintained for Sunny Brow and Debdale Houses. The service provider will keep the needs of all service users living in Debdale House under continuing review and ensure that the numbers and skills of staff deployed in that unit are adequate to meet their differing assessed needs. All staff employed in Debdale House will be trained in techniques for rehabilitation as detailed in National Minimum Standard 6.3 (National Minimum Standards, Care Homes for Older People) and this training will be maintained on an ongoing basis. Minimum nursing staffing levels as specified in the Staffing Notice issued under Section 13 of The Care Standards Act 2000 on 15 February 2006, will be maintained in Abbey Hey House. All staff employed in Abbey Hey House must receive accredited training in dementia care by 31st March 2006 and this level of training will be maintained on an ongoing basis. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 2. 3. 4. 5. 6. 7. 8. 9. 10. Gorton Parks Nursing Home DS0000021678.V298870.R01.S.doc Version 5.2 Page 5 Date of last inspection 2nd March 2006 Brief Description of the Service: Gorton Parks Nursing Home is owned by BUPA Care Homes. The home is a purpose built building and consists of 5, 30 bedded units. The home can provide accommodation for 36 residents assessed as requiring nursing care, 60 residents with Dementia assessed as requiring personal care only, 30 residents with Dementia assessed as requiring nursing care and 12 residents 55 years of age and over who require intermediate care. Each unit is a single storey building with a lounge, dining area, a conservatory, a smoke room and a kitchenette. All bedrooms are single and all rooms provide a wash hand basin and a mirror. There are no en-suite facilities available. Accessible toilets and bathrooms, with aids and adaptations for those residents who are wheelchair users or with poor mobility are located near to bedrooms and living rooms. The home is located in the residential area of West Gorton in the North of Manchester. Local amenities, including a market, banks and shops are all within easy walking distance. Public transport is accessible. There are ample parking facilities at the front of the building. An administration building houses the main kitchen, hairdressers, laundry and offices. The charges for fees range from £373.54 to £602.08 per week. Information about the home can be gained through contacting the registered provider (BUPA). The Commission for Social Care Inpsection (CSCI) inspection report is available at the home and through the CSCI Internet site. Gorton Parks Nursing Home DS0000021678.V298870.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on information gathered by Commission for Social Care Inspection (CSCI) since the last inspection on 2 March 2006 and some supporting information received in the pre-inspection questionnaire that was submitted to CSCI by the home and the requirements made at the last inspection. This visit was unannounced, conducted by 2 inspectors and forms part of the overall inspection process and it took place on Tuesday 20 June 2006. The opportunity was taken to look at all the core standards of the National Minimum Standards (NMS) and the requirements made at the inspection on 2 March 2006. This inspection was also used to decide how often the home is to be visited to make sure that it meets the required standards. As part of the visit time was spent with the residents who live at the home, a visitor to the home, observing how staff work with residents, discussions with the deputy manager (head of care), several members of staff, a visiting Tissue Viability Nurse, assessing relevant documents and files and a tour of the premises was undertaken. The CSCI had not received any complaints since the last inspection. Since the last inspection some concerns had been raised regarding some possible inappropriate admissions to Abbey Hey House, the Dementia Nursing Care Unit. Following a visit to the home and discussions with the Responsible Individual and the manager of the home the concerns have been addressed. What the service does well: The home carries out a pre admission assessments before a resident is admitted to the home to make sure that the home can meet the person’s needs. The Tissue Viability Nurse who was visiting a resident at the home, at the time of this inspection, said that the staff were very good and always followed her advise on wound care and regularly rang her for advise if they needed it. The relationships between residents and staff appeared to be very good. Staff were seen to be sensitive to individual resident needs and were seen sat chatting to residents. One resident said, “the staff are always kind and help you when you needed it”. Another resident said that she had lived at the home for 14 years and after a recent admission to hospital was very glad to get back to the home. Gorton Parks Nursing Home DS0000021678.V298870.R01.S.doc Version 5.2 Page 7 The garden areas of the home are attractive and well maintained. The houses visited, Debdale and Abbey Hey, were clean and nicely decorated. One visitor spoken to said that the home was always clean and didn’t have any unpleasant smells. The residents spoken to were nicely dressed, chatty and appeared happy. From observations made from talking to staff and residents at the home, it appeared that the privacy and dignity of residents was protected and that residents were able to have choice with regard to their every day life. The home offered a choice of meals at each mealtime and the majority residents spoken to said that they were happy with the choice and quality of food. One resident said that the quality of food had recently improved, however another resident said that she had to complain because she had been given a “burnt chop” but since she complained she thought it had improved. The lunch served on the day of this visit offered soup, a Varity of sandwiches, cheese on toast, salads and a Varity of puddings, all which looked and smelt good. The home had an open visiting policy, staff, residents and a visitor to the home confirmed that visitors could be seen in any of the communal areas of the home or in the privacy of residents’ own rooms. One resident spoken to said the staff always made her visitors feel very welcome. The home employed 2 activity co-ordinators who were very keen and enthusiastic about their jobs. A programme of activities had been organised as well as one to one activities, which sometimes would be just sitting and chatting. Activities such as the summer fete and a 100th birthday party were in the planning stages. On the day of inspection some residents were doing flower arranging and a resident was playing the piano while the activity coordinator was dancing with a resident. The home looked after residents’ monies safely. What has improved since the last inspection? Since the last inspection the home’s manager has successfully completed the registration process with CSCI. The previous inspection report identified some areas of work within the home that needed improving. The home has taken the steps to look at these areas and have undertaken the work needed to make the improvements necessary. Gorton Parks Nursing Home DS0000021678.V298870.R01.S.doc Version 5.2 Page 8 These included improving the residents care plans and improving the systems for dealing with medicines. Since the last inspection the home has employed some new staff and due to this over the past few weeks the home have not had to use agency staff to make up the staff numbers. Also the numbers of staff have been reviewed and more staff have been employed for some of the houses. Due to this the staff said they feel the quality of care has improved. Two unit managers have recently completed a training course in the Protection of Vulnerable Adults and are now able to train the rest of the staff. In order to protect the residents the requirement made at the last inspection that fire doors must not be wedged open and the fire alarm on the units must not be silenced as it disables the display that shows where the source of the fire might be has been met. 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. Gorton Parks Nursing Home DS0000021678.V298870.R01.S.doc Version 5.2 Page 9 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 Gorton Parks Nursing Home DS0000021678.V298870.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service The home undertakes an assessment of prospective residents’ care needs prior to their admission. Designated intermediate care facilities are available. EVIDENCE: The home had a documented pre admission assessment form to ensure that prospective residents are only admitted on the basis of a full assessment. The deputy manager and both unit managers confirmed that all residents have the pre admission assessment prior to admission and for residents who are referred through Care Management arrangements the home obtains a summary of the Care Management Assessment prior to admission. Following the pre-admission assessment the registered person is required to confirm in writing to the prospective resident that the home is able/not able to meet their assessed needs. Gorton Parks Nursing Home DS0000021678.V298870.R01.S.doc Version 5.2 Page 11 In one care file inspected it was noted that a resident had recently been admitted to hospital and returned to the home with very different care needs. It is recommended that if a resident is re-admitted to the home from hospital with different care or dependency needs that the home undertake a further assessment to ensure that they can continue to meet the needs of the resident. The home has 12 intermediate care beds on Debdale House. The beds are only to be used for people over the age of 55 being discharged from Central Manchester PCT Acute Trust. These beds are specifically funded by the PCT for intensive, specialised rehabilitation direct from hospital prior to discharge into the community. Designated accommodation is available, which includes the appropriate equipment and therapy staff. Policies relating to the new provision and admission/discharge policies have been implemented and a revised Statement of Purpose and Service User’s Guide has also been implemented. The nurses and care staff are continuing to receive training in the techniques for rehabilitation. Since the last inspection the home has increased the staff numbers for the residents receiving intermediate care and the overall dependency level of the residents have reduced. Staff and residents appear much happier than at the last inspection. Gorton Parks Nursing Home DS0000021678.V298870.R01.S.doc Version 5.2 Page 12 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 this service Each resident had an individual plan of care, which promoted privacy and dignity. The systems and procedures for dealing with medicines protected residents. EVIDENCE: A random sample of care plans were examined on Debdale House. Evidence was seen of ongoing work to improve the documentation of the care planning system since the last inspection. In an attempt to improve and then maintain good standards the deputy manager said that the unit managers as part of their weekly ‘manager’s report’ undertake weekly audits of 6 care plans and document the results in the manager report. This is then forwarded to the deputy manager who reviews the information and she then audits 6 care plans over the 5 houses. Based on the results of her audit training is provided in the required areas, either in group sessions or on an individual basis depending on the need. This is seen as good practise. Gorton Parks Nursing Home DS0000021678.V298870.R01.S.doc Version 5.2 Page 13 As recommended at the last inspection each individual file was found to contain an up to date photograph of the residents for easy identification. The plans of care were found to be detailed, informative and clearly set out the action that needed to be taken by care staff to ensure that all aspects of health, personal and social care needs of the residents were met. It was encouraging to note that privacy and dignity was promoted within the care plans. The plans of care had been reviewed on a monthly bases and updated accordingly. All sections of the care plans had been appropriately signed and dated with the exception of the food intake record, none of the entries had a signature. All entries should be signed by the person making that entry. As required at the last inspection, the files inspected evidenced that the plan of care had been drawn up with the involvement of the residents or their representative and signed for where possible. In addition the daily record of the nursing care provided was much improved. Residents were registered with local General Practitioners and had access to visiting healthcare professionals e.g., Dietician, Chiropody, Dentistry and Ophthalmology. This ensured residents were in receipt of appropriate health services necessary to support their health care needs. Evidence was seen that the Medication Administration Recording (MAR) sheets were recorded accurately with the exception of “Thick and Easy” which is a thickening agent added to drinks. This was discussed with the unit manager and it is recommended that the MAR sheet cross reference to where the recordings of drinks are made, making sure that the staff sign when the thick and easy is given. An audit trail must be available for all prescribed medication. All deliveries and disposal of waste medication had been signed so providing a full audit trial and therefore meeting the requirements made at the last inspection. As required at the last inspection ,daily temperature recordings were being maintained fort the drug fridge and the large stocks of medication had been disposed of. In line with the Royal Pharmaceutical Guidelines the home received the prescritions and took a copy before they were sent to the pharmacy for dispensing so that the home had an accurate reocrd of what the GP had prescribed. It was noted that medication with a limited life had not had the date of opening documented. To ensure out of date medication is not given to residents the date of opening must clearly documented. From observations made during the inspection and discussions with members of staff, residents and a visitor to the home it appeared that the nurses and care staff treated the residents with respect and dignity. However, one visitor Gorton Parks Nursing Home DS0000021678.V298870.R01.S.doc Version 5.2 Page 14 to the home said that sometimes staff, especially when the home employed agency staff sometimes did not pay attention to detail. For example, they often rolled her mothers skirt up around her waist when she was sat in a chair and she did not feel this respected her dignity. Although she did say that in the past couple of weeks the unit had not been using agency staff. Gorton Parks Nursing Home DS0000021678.V298870.R01.S.doc Version 5.2 Page 15 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 good. This judgement has been made using available evidence including a visit to this service Activities were provided and residents were able to maintain contact with family and friends. Residents were able to exercise choice and control over their lives and the residents enjoyed the meals that they choose. EVIDENCE: The home employed 2 activity co-ordinators. Evidence was seen that a ‘map of life’ was completed which included interests and hobbies. The activity coordinator said that she would document in the daily progress notes of the residents when they had attended any activities or if they had not wanted to attend. A programme of activities had been drawn up and as already stated in this report in addition to these group activities 1:1 sessions were also undertaken with residents. The home had a visiting policy and visitors could be received in the residents’ own room or any of the communal areas of the home. Residents, staff and a visitor to the home confirmed this. Gorton Parks Nursing Home DS0000021678.V298870.R01.S.doc Version 5.2 Page 16 From speaking to residents and staff it appeared that residents are able to exercise choice and control over their lives and that residents are able to bring personal possessions into the home. One resident was having a bath after lunch, at her request and the care assistant spent some time letting the resident choose which towel she wanted to use and which clothes she wished to wear. The home had an advocacy policy and details were available on request. The menu examined demonstrated that the home provided a varied diet, which was nutritionally balanced. An alternative to the main meal was available and residents and staff confirmed this. At the time of this visit the home were providing an African Caribbean diet for 2 of the residents. One resident had some specific food allergies and this was found to be clearly documented in her care file. One visitor to the home said that she had complained to the home’s manager that the vegetables were not cooked enough and that her mother and other residents could not chew them. She said that things had improved after she had complained. Staff were seen given support to residents who required help with eating. Gorton Parks Nursing Home DS0000021678.V298870.R01.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service The home has the systems and procedures in place that allow people to express their complaints/concerns. However, people are not fully protected as all staff had not undertaken the relevant training. EVIDENCE: The home had a complaint procedure, which was included in the Service User’s Guide, and every resident had been given a copy. Residents spoken to appeared to know how to make a complaint and one resident said that she had made some complaints over the 14 years she had lived at the home and spoke to the unit manager to make a complaint. A visitor to the home said that she had made some complaints to the home manager regarding clothes being lost or shrunk. The home’s manager maintained a file containing details of the complaints received. However, on examination of the file, it did not contain evidence of a detailed investigation or a cross reference to where this information could be found. One complaint did not have a conclusion letter although the deputy manager said one had been sent. In addition one complaint record had a conclusion letter from a different complaint. The registered person must ensure that any complaint made under the complaint’s procedure is fully investigated. Gorton Parks Nursing Home DS0000021678.V298870.R01.S.doc Version 5.2 Page 18 The home’s corporate policy, dated September 2003, relevant to vulnerable adult protection was made available at the inspection. This policy did not accurately reflect the Department of Health ‘No Secrets’ guidance as it stated that the manager would investigate the allegation and the resident would be interviewed. The homes’ own policies must be in line with the multi-agency policy and the Department of Health (DOH) guidance, “No Secrets.” This was a requirement made at the last inspection and has been reiterated in this report. The deputy manager had a copy of the Manchester Multi-Agency Adult Protection Procedures and said that all units had been given a copy. However on inspection, one of the units had the guidance and the staff on another unit said that they did not have a copy. The Whistle Blowing Policy was available on the units. As already mentioned in this report, 2 of the unit mangers have recently done a training course in the Protection of Vulnerable Adults and are now able to do training for the rest of the staff, although at the time of this visit the training had not yet commenced. The staff spoken to confirmed that they had not received any training relating to the Protection of Vulnerable Adults. In order to protect the residents living at the home all staff must receive Protection of Vulnerable Adults Training, which includes the actions to be taken in the event of an allegation of abuse. Gorton Parks Nursing Home DS0000021678.V298870.R01.S.doc Version 5.2 Page 19 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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service The premises generally were clean and comfortable for the residents living there. EVIDENCE: The home provides large grounds with a variety of garden areas, which are accessible to those residents who are wheelchair bound. The garden areas were attractive and well maintained. Gorton Parks Nursing Home DS0000021678.V298870.R01.S.doc Version 5.2 Page 20 The home felt comfortable and homely. All areas of the home were tastefully decorated and furniture was of a domestic nature and of a high standard. The home was divided into 5 separate houses, each house accommodated 30 residents, with the exception of Debdale House, which accommodated 28 residents, and the home had an administration building. Each unit consisted of a lounge, dining area, a conservatory, a smoking area and a kitchenette. One resident spoken to said that she had reported to the staff that her call bell was not working properly and sometimes when she buzzed it did not work. In addition a visitor told the inspector that her mother’s buzzer had also not been working properly. The deputy manager said that they had experienced some difficulties with the buzzer system. In order to prevent any unnecessary risk to residents the buzzers must be in good working order. The home had policies relating to infection control and the latest Infection Control Guidelines. However the infection control policy was dated 1999. It is recommended that this be reviewed and updated accordingly. The home was clean, tidy and no offensive odours were detected. Residents and a visitor spoken to confirmed that the home always clean and tidy. Gorton Parks Nursing Home DS0000021678.V298870.R01.S.doc Version 5.2 Page 21 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 this service The number and deployment of staff appeared sufficient to meet the residents’ assessed needs. However, the home was unable to demonstrate that its staff had completed the required training to meet resident’s needs and the procedures for recruiting staff were not robust and must provide adequate safeguards to protect residents. EVIDENCE: On the day of the inspection the staffing numbers and skill mix appeared appropriate to meet the needs of the residents accommodated. The home employs 79 carers, 21 members of staff have successfully achieved NVQ Level 2 and 1 had achieved NVQ Level 3. In addition, 4 members of care staff were working towards achieving NVQ Level 2. A random sample of staff files were inspected. The files were found to be confusing and difficult to locate information due to poor filing, the deputy manager agreed with this. It is recommended that the staff files are audited and filed in an orderly fashion. It was seen that CRB and POVA checks had Gorton Parks Nursing Home DS0000021678.V298870.R01.S.doc Version 5.2 Page 22 been undertaken. However one file had 2 references from a “friend” and one from a “colleague and friend”. To ensure the safety of the residents 2 written references must b obtained and one must be from the previous employer or the reasons why documented. A training matrix was available for inspection. Looking at the matrix, evidence could not be provided that staff had undertaken the necessary mandatory (including refresher) training. In order to protect the residents living at the home the provider must ensure that appropriate training is made available for all staff. This requirement is unmet from the last inspection and has been reiterated in this report. In addition it is recommended that staff have an individual staff training and development plan. From September 2006 a new Induction Module programme is being introduced by Skills for Care (formerly TOPSS). BUPA have produced a Staff Induction programme that, it says, incorporates Skills for Care Induction Standards. It was found that the induction modules are in fact the old TOPSS modules. It is recommended that the home take account of the new requirements and include them in their induction programme. Gorton Parks Nursing Home DS0000021678.V298870.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 28 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems and procedures were in place, which safeguards and protects residents’ financial interests and systems were in place to monitor the service based on peoples’ views. However all appropriate procedures were in place to protect the health and safety of people living at the home. EVIDENCE: Since the last inspection the manager has successfully completed the registration process with CSCI. The home has a policy file, which is kept in the main administration building. The deputy manager said that policies are updated by BUPA’s Quality Gorton Parks Nursing Home DS0000021678.V298870.R01.S.doc Version 5.2 Page 24 Department and updated policies are sent by e-mail to the homes. Some of the policies were dated back to 1999. It is recommended that evidence is provided that policies and procedures are regularly reviewed and updated in light of changing legislation and good practise advise. The home has a quality monitoring system in place, which includes obtaining views of residents and their relatives. The Care Home Resident’s Satisfaction survey was sent out in the autumn of 2005. The results of the surveys have been collated and the results were published in February 2006. The home is currently appointee for one resident and are not taking on appointeeship for any new residents. The home has a clear and transparent system for managing and recording the residents’ personal finances. Evidence was provided that the home’s maintenance certificates and records were up to date in order to protect the residents and staff employed. However as already mentioned in this report it was of concern that the fire risk assessments for the home had not been updated since 6/11/98. In order to sort out the problem the maintenance person rang the local fire service to get some advise during the inspection. The last fire drill on Debdale was dated 9/1/06. It was noted that the record did not include a response time and contained no other details than the names of the staff who attended. Gaps were also found in the recording of the weekly fire safety checks. For example there were gaps in the fire alarm testing on Debdale and Sunny Brow between 2/6/06 and 16/6/06 and the last recorded fire test of the administration building was dated 19/5/06. In order to protect the residents and staff these safety checks must be maintained on a consistent basis. As referenced at the last inspection, all staff were still not receiving supervision. To ensure that residents in the home are being appropriately cared for all persons working in the home must be appropriately supervised. It is recommended that staff receive formal supervision 6 times a year. Gorton Parks Nursing Home DS0000021678.V298870.R01.S.doc Version 5.2 Page 25 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 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 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 x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 2 x 2 Gorton Parks Nursing Home DS0000021678.V298870.R01.S.doc Version 5.2 Page 26 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 OP3 Regulation 14 Requirement Following the pre admission assessment the home must confirm in writing, to the prospective resident, that the home is able/not able to meet their assessed needs. The responsible individual must make arrangements for the recording, handling and safe administration of medicines which are detailed below: Medication with a limited life must clearly document the date of opening to ensure out of date medications are not given to residents. 3. OP16 22 The registered provider must provide evidence that any complaints made under the homes complaints procedure is fully investigated. 1. The adult protection procedure must be easily accessible at all times and contain the information relevant for making referrals to the appropriate local authority. DS0000021678.V298870.R01.S.doc Timescale for action 18/07/06 2. OP9 13 30/07/06 30/07/06 4. OP18 13 30/07/06 Gorton Parks Nursing Home Version 5.2 Page 27 2. The homes Adult Protection policy and procedure must accurately reflect the Departments of Health ‘No Secrets’ guidance. 3. Evidence must be provided that all staff have received Protection of Vulnerable Adult Training, which includes the actions to be taken in the event of an allegation of abuse. (Previous timescale of 1/4/06 had not been met) 5. OP19 13 The registered provider must 17/07/06 ensure that all the call bells are in good working order so as to avoid any unnecessary risk to the health or safety of residents. Two written references must be 18/07/06 obtained for each employee and one reference must be from their last employer. 1. All staff must undertake the 01/09/06 necessary mandatory (including refresher) training and have an individual staff training and development plan. (Previous timescale of 1/8/05 and 7/5/06 had not been met) The responsible individual must ensure that all staff are appropriately supervised. (Previous timescale of 1/4/06 had not been met) To ensure the health and safety of residents and staff are protected at al times the responsible individual must ensure: 1. The fire risk assessments are updated. Gorton Parks Nursing Home DS0000021678.V298870.R01.S.doc Version 5.2 Page 28 6. OP29 17 Schedule 2 18 7. OP30 8. OP36 18 30/07/06 9. OP38 12 & 13 30/07/06 2. The registered provider must ensure that the home consistently carries out and records fire safety checks 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 It is recommended that if a resident is re-admitted to the home from hospital with different care or dependency needs that the home undertake a further assessment to ensure that they can continue to meet the needs of the resident. It is recommended that all documented entries in the care file be signed by the person making that entry. It is recommended that the MAR sheet cross reference to where the addition of “Thick and Easy” is added to residents’ drinks. It is recommended that the complaint file contain details of any investigation undertaken which includes details of any staff statements or interviews. It is recommended that evidence be provided that the infection control policy dated 1999 has been reviewed and updated accordingly. It is recommended that staff files are audited and filed in an orderly fashion Skills for Care have introduced new requirements for staff induction and training. It is recommended that the home take account of the new requirements and include them in their induction programme. It is recommended that evidence is provided that policies and procedures are regularly reviewed and updated in light of changing legislation and good practise advise. 2. 3. 4. OP7 OP9 OP16 5. 6. 7. OP26 OP29 OP30 8. OP33 Gorton Parks Nursing Home DS0000021678.V298870.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 Gorton Parks Nursing Home DS0000021678.V298870.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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