Inspection on 03/10/07 for Gorton Parks Nursing Home

This inspection was carried out on 3rd October 2007.

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 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 20/06/06

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 Unannounced Inspection 09:30 3 October 2007 rd 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.V342461.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.V342461.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 (CFHCare) 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.V342461.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.V342461.R01.S.doc Version 5.2 Page 5 Date of last inspection 20th February 2007 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 residents assessed as requiring intermediate, nursing and Dementia 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 £639.73 per week. Gorton Parks Nursing Home DS0000021678.V342461.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 the Commission for Social Care Inspection (CSCI) since the last inspection on 20 February 2007 and supporting information received in the Annual Quality Assurance Assessment (AQAA) submitted by the manager prior to this visit. Residents and General Practitioners (GP’s) were sent comment cards. Two GP comment cards were received although no resident comment cards were received by CSCI. This unannounced visit forms part of the overall inspection process and took place on Wednesday 3 October 2007. The opportunity was taken to look at all the core standards of the National Minimum Standards (NMS). This inspection was also used to decide how often the home needs to be visited to make sure that it meets the required standards. As part of the visit time was spent examining relevant documents and files, talking with the home’s manager, 2 unit managers, several people living at the home, a visitor, some members of staff. A tour Sunny Brow and Delamere units was undertaken. What the service does well: A pre admission assessment of needs is carried out before a resident is admitted to the home to make sure that the home can meet their needs. The visitor spoken to said that she had been and had a look around the unit before her relative was admitted and staff were very friendly and helpful. Staff were seen to be kind and patient with residents when carrying out their duties. The atmosphere on Sunny Brow felt relaxed and staff and residents were seen to have good relationships. On Delamere, the Dementia care unit, residents were seen freely walking around the home and again staff were seen to have good relationships with the residents. There is a choice of meals at each mealtime and staff spoken to confirmed that the chef would make any reasonable alternative to the menu and snacks and drinks are provided on request. There is an open visiting policy, which was confirmed by the staff and the visitor spoken to. The visitor said that she visited every day at different times and staff were always welcoming and cheerful. There are 2 activity co-ordinators employed by Gorton Parks and evidence was seen of forthcoming entertainment, for example a trip to Blackpool lights, a potato and pie evening to celebrate Halloween and a coffee and bingo morning. Gorton Parks Nursing Home DS0000021678.V342461.R01.S.doc Version 5.2 Page 7 The activity co-ordinator was seen sat playing dominos with a group of ladies who appeared to be enjoying it very much. The décor and furnishings on Sunny Brow was of a high standard and the unit was clean and tidy. The visitor spoken to said that whenever she visited the home was always “this clean”. The visitor spoken to said that she couldn’t fault the staff or the care given to her relative on Sunny Brow she said that she was “more than happy with everything”. One of the returned GP comment cards state that there is a “good standard of caring and nursing care offered”. What has improved since the last inspection? What they could do better: The bedroom furniture and the furnishings in general on Delamere were not of the same high standard as Sunny Brow and the lounge and corridor carpets were dirty and ‘sticky’. The unit had a stale unpleasant smell and one bedroom door was missing a door handle. It was of concern that on Delamere the dignity of residents was not always respected. This was discussed with the registered manager during the visit. Appropriate activities were being provided and a record was kept of the activities attended by residents. However it is recommended that the activity co-ordinator records any discussions or consultations she has with residents or relatives regarding activities. It order to ensure that all staff have received appropriate induction training before they start work and that staff have received training appropriate to the job they are doing and have been assessed as competent following that training, it is recommended that the training records are kept up to date and accurate. Gorton Parks Nursing Home DS0000021678.V342461.R01.S.doc Version 5.2 Page 8 To ensure the safety of residents living at Gorton Parks it is important that any potential or suspected abuse of a resident is referred through the proper channels and not investigated by staff at the home. To ensure the safety of residents living at the home a robust recruitment procedure must be adhered to at all times and there must be evidence that all safety checks have been undertaken before anybody is offered work. To try and reduce the risk of cross infection it is recommended that hoist slings are not shared and each resident needing the use of the hoist have their own sling. 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. Gorton Parks Nursing Home DS0000021678.V342461.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.V342461.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents needs are assessed prior to them being admitted to the home to ensure that their needs can be met. EVIDENCE: A pre admission assessment is in use to ensure that prospective residents are only admitted on the basis of a full assessment and for those residents who are referred through Care Management arrangements a copy of the Care Management Assessment is obtained before admission is arranged. Where possible, prospective residents and their family/representative are encouraged to view the home prior to making a decision about admission. The relative spoken to confirmed this. There are 12 intermediate care beds on Debdale House. The beds are used for people 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 Gorton Parks Nursing Home DS0000021678.V342461.R01.S.doc Version 5.2 Page 11 accommodation is available, which includes the appropriate equipment and therapy staff. Policies relating specifically to this provision and admission/discharge policies have been implemented. A revised Statement of Purpose and Service User’s Guide has also been implemented. Gorton Parks Nursing Home DS0000021678.V342461.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service Some shortfalls were identified in ensuring that the health care needs of residents were being met. EVIDENCE: As already stated in this report since the last inspection new care plan documentation had been implemented. The system is called ‘Quest’. Staff had received training and had been assessed and signed as competent following the training. Staff spoken to said they liked the new system, that it was much better than the old care plans and that it was used as a working document. The staff spoken to said that they liked them because they made you think about the individual needs, likes and dislikes of the resident. Care files were examined on Sunny Brow and Delamere. The files looked at on Sunny Brow were person centred and contained sufficient information for staff to deliver individualised care to residents. They contained appropriate risk assessments, including the use of bed rails, which if Gorton Parks Nursing Home DS0000021678.V342461.R01.S.doc Version 5.2 Page 13 needed generated a care plan. Care plans had been reviewed and updated on a monthly basis to reflect any changes in care needs. Evidence was seen that where possible residents and/or their representatives are consulted and included in the care planning process. The files were found to be user friendly and easy to use. There was an index at the front of the file and the files examined were filed in the order of the index. There was a ‘Daily life’ entry. This is a daily recording of the care given over a 24 hour period. These entries were seen to be of varying standards. Some entries were detailed and informative, however some entries were vague and lacked detail. In order to ensure that all assessed needs are being met it is recommended that an accurate record of care provided should be kept. One of the care files on Delamere contained conflicting and inaccurate information. One entry stated the resident was a single lady and another entry stated that her husband had passed away. Also it was noted that the care plan stated that the resident should wear her glasses at all times. She was not wearing her glasses and the unit manager said that she does not wear them she just holds them in her hand. To ensure that the care needs of residents are properly met it is important the care plans have accurate and consistent information. It is recommended that the care files are reviewed and updated to ensure they contain accurate and consistent information. Residents were seen to be registered with a General Practitioner (GP) and evidence was seen of referral to other specialised services according to individual assessed needs. Medication Administration Record Sheets (MAR) were examined on Sunny Brow. It was only day 3 of week 1 of the cycle and therefore the records available were minimal. From the evidence available medication carried over from the previous month had been recorded and deliveries and returns of prescribed medications had been recorded and accounted for, so providing a full audit trial. Two staff witness and sign for the disposal of waste medication. This is seen as good practice. There is a copy of the GP’s original prescription so that staff can cross reference the medication received from the dispensing pharmacy with the medication prescribed and recorded on the Medication Administration Record (MAR) sheets. From a visual check of the blister packs all medication appeared to have been given appropriately. Several residents had been prescribed a drink thickener. The administration of the drink thickener had not been signed for on the MAR and the MAR did not cross reference to where the drinks had been signed for, as recommended in Gorton Parks Nursing Home DS0000021678.V342461.R01.S.doc Version 5.2 Page 14 the last report. There was a fluid balance record, however it did not evidence that each drink given had been thickened. To ensure that residents needs are appropriately met it is recommended that the MAR should clearly cross reference to where there is a signed, accurate recording of all the thickened fluids given to residents. The staff member who gives the resident the drink should sign for it. From a visual check of the blister packs all medication appeared to have been given appropriately. 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 should be clearly documented. This issue has been raised previously. It was of concern that the dignity of some residents on Delamere did not appear to be protected. For example several residents had food stained clothes and 2 ladies asleep in the chair were exposing their legs. Staff walked past these residents and made no attempt to pull their skirts down or cover their legs. One resident required help to have their drink. The member of staff was seen stood up in front of the resident giving assistance. Residents dignity must be maintained at all times. Gorton Parks Nursing Home DS0000021678.V342461.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. 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. EVIDENCE: Two activity co-ordinators are employed at Gorton Parks and forthcoming activities were on display. The co-ordinator said that residents can attend any of the activities in the other houses if they wish. It was encouraging to note that the new care plan documentation had a ‘map of life’, which in all the files examined had been competed. The co-ordinator records in the ‘daily life’ when a resident attends an activity or if a resident declines the offer to attend an activity. As well as the organised activities many 1:1 activities or small group activities take place. The co-ordinator said that one family requested that she spends time with doing a jigsaw with a particular resident, which she does. It is recommended that such discussions/consultants with residents or relatives are recorded. It was nice that photographs were on display of some activities that have taken place. However it was noted that on Delamere the photo display of the Christmas party was dated 1999. It is recommended that the displayed photographs are updated to more recent activities. Gorton Parks Nursing Home DS0000021678.V342461.R01.S.doc Version 5.2 Page 16 Staff and visitors spoken to confirmed that the home facilitated open visiting and visitors could be received in the resident’s own room or any of the communal areas of the home. The visitor spoken to said that the staff have always made her feel very welcome and staff regularly keep her informed of any changes or incidents that may have occurred. From speaking to the visitor and staff it appeared that residents are encouraged to exercise choice and control over their lives and that residents are encouraged to bring personal possessions into the home. The menu on display on the units demonstrated that a varied and nutritionally balanced diet was available. The staff spoken to confirmed that alternatives to the menu were available and snacks and drinks were available on request. It was recommended that on the Dementia care units the menu on display had photographs of the meal instead of the written version. As already stated in this report a staff member was seen stood up in front of a resident offering assistance to have a drink. It is recommended that staff sit next to residents when offering assistance. Gorton Parks Nursing Home DS0000021678.V342461.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. 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. Systems and procedures are in place that allow people to express their complaints/concerns. However, all suspected abusive situations must be referred appropriately under the Safeguarding procedures. EVIDENCE: There was a complaint procedure in place, which was included in the Service User’s Guide, and every resident had been given a copy. The manager was asked about the homes Safeguarding procedures and stated that the local adult safeguarding policies and procedures had been adopted. A copy of the Safeguarding policy and procedures dated 5/12/06 was examined and found to appropriately refer staff to the “No Secrets” guidance. The manager said they do obtain copies of other authorities policy and procedures if residents are funded out of area. Notes of a supervision meeting arranged by the unit manager clearly identified a possible abusive situation. It is of concern that the unit manager and the registered manager had not referred the incident to Adult Safeguarding. When the registered manager was asked why it was not referred as a safeguarding issue he said that it had been dealt with by training. To ensure the safety of residents all suspected abusive situations must be referred to Adult Safeguarding. Gorton Parks Nursing Home DS0000021678.V342461.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all the units offered the same high standard of furnishings and cleanliness. EVIDENCE: Sunny Brow was comfortable and homely. All areas of that unit were tastefully decorated and bedroom furniture and furnishings were of a high standard and colour coordinated. The visitor spoken to confirmed that she was happy with her relative’s room and when she visited the unit was always clean and tidy. Delamere, the Dementia care unit, did not have the same standard of furnishings and cleanliness. The unit had a stale unpleasant odour and the carpets were dirty and sticky. The bedroom furniture and old lino flooring looked to be institutionalised in comparison to Sunny Brow and the door handle to bedroom 19 was missing. There was an updated infection control policy since the last visit and the policy referred to monitoring and reporting of incidents, facilities for isolation and the Gorton Parks Nursing Home DS0000021678.V342461.R01.S.doc Version 5.2 Page 19 control of infectious outbreaks and education. It identified the ways in which infection can spread and detailed hand washing procedures, standard infection control procedures, the removal of clinical waste and oral hygiene in residents care. However it was noted on Sunny Brow that the hoist slings were being stored on top of each other. This is a risk of cross infection and it is recommended, inline with the Department of Health Infection Control Guidance for Care Homes, that each resident has their own sling. Gorton Parks Nursing Home DS0000021678.V342461.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service The number and deployment of staff appeared sufficient to meet the residents’ assessed needs. However, evidence was not available to demonstrate that staff had completed the required training to meet residents’ needs. 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 employed 85 care staff, 25 of whom had achieved NVQ level 2 or above and 30 members of care staff were currently undertaking the training. A random sample of staff files were inspected and some shortfalls were seen. One file inspected did not have a reference from their last employer and there was a copy of a visa with limited leave to remain in the UK. There were no copies of any letters from the Home Office on file and therefore it could not be determined if there were restrictions on where this person was employed. This person no longer works at Gorton Parks, however the manager was advised to contact the Home Office and check with them. If there is a letter and it states a specific employer they must inform the Immigration Intelligence Unit that this person has left their employment and moved on. Gorton Parks Nursing Home DS0000021678.V342461.R01.S.doc Version 5.2 Page 21 Another file did not have any evidence of a CRB or POVA check. The manager said that this person had been transferred from another BUPA home where the check had taken place. The day after the visit the manager confirmed that CRB had given confirmation that a CRB and POVA check had been undertaken and are in the process of sending a copy. However the manager should have received this confirmation prior to any work being undertaken to ensure that the person was safe to work with vulnerable people. The manager said that they were in the process of undertaking a full audit of staff files looking in particular at CRB’s/POVA and references. A checklist was seen to confirm this. The manager said that staff do sometimes commence work on a POVA 1st but confirmed that staff working with only a POVA 1st are supervised at all times. Staff spoken to confirmed that training was provided but staff files inspected and a computerised print out provided by the manager did not provide up to date evidence that staff had received or were receiving, on an ongoing basis, appropriate training to enable them to undertake the work they are performing. It is recommended that staff training records are kept up to date to evidence that all staff have received training appropriate to the job they are doing and have been assessed as competent following the training. The staff files inspected did not evidence that a structured induction had been undertaken. However the manager confirmed that all new employees must undertake a one-week classroom based induction. A timetable covering the week was given to the inspectors. The completed AQAA evidenced that both parts of Skills for Care national minimum dataset for social care had been completed. Gorton Parks Nursing Home DS0000021678.V342461.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 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 appeared to safeguard and protect residents’ financial interests and the home was seen to promote the health, safety and welfare of the residents and staff. EVIDENCE: The manager is registered with CSCI and has successfully completed the Registered Managers Award. Policies and procedures had been reviewed since the last inspection and the policy file was made available for inspection these were dated December 2006. Gorton Parks Nursing Home DS0000021678.V342461.R01.S.doc Version 5.2 Page 23 The financial system is computerised and there are clear records of resident’s personal monies and receipts kept for all transactions. There was one query regarding cigarettes bought on behalf of a resident, which was discussed with the manager. All cigarettes bought were of the same brand with the exception of one packet. No explanation could be offered for the one packet of a different brand. It is recommended that when staff purchase items on behalf of a resident they sign the back of the receipt so if there are any queries an explanation can be sought. The manager said that there has been a recent in-house audit of resident’s finances. The AQAA completed by the manager stated that Gorton Parks have successfully achieved the Investor in People accreditation and that they carry out regular surveys across a random number of clients and their families. The results are collated independently and then returned. The results of these surveys were not seen on this visit. The information provided in the AQAA demonstrated that the home’s maintenance certificates and records were up to date. Gorton Parks Nursing Home DS0000021678.V342461.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 x x x x x x 2 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 x x 3 Gorton Parks Nursing Home DS0000021678.V342461.R01.S.doc Version 5.2 Page 25 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. 2. Standard OP10 OP18 Regulation 12 (4) (a) 13 (6) Requirement Residents’ dignity must be maintained at all times. To ensure the safety of residents all suspected abusive situations must be referred to Adult Safeguarding. To ensure the safety of residents living at the home a robust recruitment procedure must be adhered to at all times and all safety checks must be undertaken prior to any work being undertaken. Timescale for action 04/10/07 04/10/07 3. OP29 19 (1) (a) (b) (i) (c) (4) (a) (b) (i) 31/10/07 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 OP7 Good Practice Recommendations 1. It is recommended that the ‘Daily life’ recordings include sufficient information to evidence the care DS0000021678.V342461.R01.S.doc Version 5.2 Page 26 Gorton Parks Nursing Home delivered over a 24-hour period. 2. It is recommended that the care files on Delamere are reviewed and updated to contain accurate and consistent information. It is strongly recommended that medication with a limited life should clearly document the date of opening to ensure out of date medications are not given to residents. 1. It is recommended that individual staff members sign for all thickened drinks/soups given to a resident. 2. It is recommended that the MAR should clearly cross reference to where there is a signed accurate recording of thickened fluids. 1. It is recommended that a record is kept of consultations/discussion with residents and relatives regarding the programme of activities. 2. It is recommended that the photographs on display on Delamere are updated as some date back to 1999. 1. It is recommended that the menu on the Dementia care units have photographs of the meals rather than the written version. 2. It is recommended that staff sit next to residents when offering assistance to eat or drink. 6. 7. 8. OP19 OP26 OP30 It is recommended that all the units offer the same standard of cleanliness and furnishings. To reduce the risk of cross infection it is recommended that each resident has their own hoist sling. It is recommended that staff training records are kept up to date to evidence that all staff have received training appropriate to the job they are doing and have been assessed as competent following the training. 2. OP9 3. OP9 4. OP12 5. OP15 Gorton Parks Nursing Home DS0000021678.V342461.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Gorton Parks Nursing Home DS0000021678.V342461.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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