Inspection on 02/11/06 for Gorway House

This inspection was carried out on 2nd November 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

Gorway House 09/12/09

Gorway House 01/04/09

Gorway House 06/10/08

Gorway House 14/08/07

Gorway House 21/05/07

Gorway House 31/05/06

Gorway House 20/10/05

Gorway House 24/05/05

Gorway House 26/11/04

Gorway House 27/09/04

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

CARE HOMES FOR OLDER PEOPLE Gorway House 40 Gorway Road Highgate Walsall West Midlands WS1 3BG Lead Inspector Ms Maggie Bennett Key Unannounced Inspection 2nd November 2006 08:55 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 Gorway House DS0000020811.V317154.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. Gorway House DS0000020811.V317154.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gorway House Address 40 Gorway Road Highgate Walsall West Midlands WS1 3BG 01922 615515 01922 725059 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) Mrs Pamela Brown Mrs Jennifer Beale Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Gorway House DS0000020811.V317154.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user to be admitted in the category of DE(E). Date of last inspection 31st May 2006 Brief Description of the Service: Gorway house is a two storey detached property situated on a quiet residential area of Walsall. There are 24 single rooms and two doubles, the majority having en suite facilities. There are two large lounges and a separate dining room. To the rear is a very pleasant garden. The fees range from £350.00 to £450.00 per week. Gorway House DS0000020811.V317154.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 which took place on a weekday between 8.55 a.m. and 7.20 p.m. All the key standards of the National Minimum Standards were inspected on this occasion. 41 statutory requirements were made at the last inspection in May 2006. 11 of those requirements have been met or are in the process of being met. A further 8 statutory requirements were made following this visit. There were 20 service users living at Gorway at the time of the inspection. During the course of the day a number of service users were spoken to and asked for their views of the home. Some were seen in private. The assessment information and care plans of 7 service users were seen in order to inspect the home’s assessment and care planning systems and practices. The medication administration was assessed. Various documents were seen in order to assess Complaints and Adult Protection policies and procedures and health and safety within the home. A number of staff files were seen so that recruitment practices could be inspected. A tour took place of the building. Staff were observed during their duties and discussion took place with 3 members of staff. Discussion was also held with the Registered Manager and Manager throughout the day. What the service does well: Gorway House is an attractive property, generally well-maintained and is set in very pleasant gardens in a quiet residential area of Walsall. Service users spoken to said that the staff looked after them well. They said the staff were “fine”, “very good”. They also said that they liked living at Gorway. One person said “it’s lovely here.” Service users felt that their privacy was respected and several said that they were able to choose when they got up and went to bed. Service users benefit from the fact that Gorway is a family run home, with the Registered Provider and Managers being close by and spending a good deal of time on the premises. Staff spoken to were committed to the care of the service users and 2 in particular were enjoying the opportunities for training. Although choice of food appears to be limited, the quality of the home cooked food is good and several service users commented on how much they enjoyed their meals. Gorway House DS0000020811.V317154.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Although the home have developed an assessment tool, they are failing to use this in all cases, with the result that they may still be admitting service users without full knowledge of their needs. The Registered Manager must consult with the Commission and apply for a Variation to their category of registration if they wish to admit anyone outside of their current category. They have recently admitted a service user with a diagnosed dementia. Care plans have improved and the Registered Manager states that she is in the process of obtaining advice on this subject and will be producing a suitable system. At present plans do not provide staff with the information they need to ensure that all aspects of the health, personal and social care needs of the service users are met. There is no evidence that service users are involved in the development and review of their care plans. Risk assessment is poor and could mean that risks to service users are not properly managed. Although service users are now regularly weighed, the home are not using a nutritional screening tool at assessment or keeping a record of nutrition. The actual administration of medication has improved (see above), but further improvements are still needed with regard to policies and procedures and the home must obtain proper storage and recording facilities for controlled drugs. Service users’ interests and aspirations are not recorded in their care plans and there is no evidence that they have been consulted about their wishes in this area. Although the quality of the food is good and the home cooking much appreciated, there is very little choice offered. None of the service users Gorway House DS0000020811.V317154.R01.S.doc Version 5.2 Page 7 thought that a choice was provided and one even said that they “always” had fish on a Thursday. There are a number of issues with regard to the physical environment of the home which need attention (for details see the section on Environment). At the inspection staffing was judged to be “adequate”, but this was because there are a number of service users who at present appear to have low levels of dependency. The home must assess the numbers of care staff needed by determining the assessed needs of the service users, in accordance with guidance recommended by the Department of Health. Although recruitment checks are being carried out, staff files must contain the evidence to verify this. A training plan for the whole staff group must be produced and all newly staff must receive induction training within the first six weeks of their appointment. The home has not yet produced a quality assurance and quality monitoring system and to date there is no written evidence that service users’ views of the home are sought and acted upon. The Registered Manager has been requested to undertake the Residential Managers’ Training in Fire Safety and to consult with the Fire Service about fire drills and the home’s fire risk assessment. Evidence of the regular servicing of the hoists must be available, as must written evidence that the temperature of the water at outlets accessible to service users is regularly tested. The home must also supply written evidence stating how it intends to ensure that the water system is free of risks of legionella. A written statement of the policy, organisation and arrangements for maintaining safe working practices and risk assessments for all safe working practice topics must be carried out. The Registered Manager must inform the Commission without delay of the occurrence of any serious injury to a service user. 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. Gorway House DS0000020811.V317154.R01.S.doc Version 5.2 Page 8 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 Gorway House DS0000020811.V317154.R01.S.doc Version 5.2 Page 9 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): Standards 3 and 4. Standard 6 is not applicable, as the home does not offer Intermediate Care. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the home have now developed an assessment tool, this has not been used in all cases, with the result that not all service users have their needs fully assessed before they move to the home. This may result in the home admitting people whose needs they cannot fully meet. Staff are taking part in dementia care training, which will enable them to have a greater understanding of the needs of their service users who have dementia. Gorway House DS0000020811.V317154.R01.S.doc Version 5.2 Page 10 EVIDENCE: The assessment information of 4 recently admitted service users was seen in order to check the home’s assessment procedures. In the first of the files seen the service user was privately funded. There was evidence that the Registered Manager had visited the prospective service user and had obtained some initial details. The home’s assessment form, however, was dated on the same day that the service user was admitted to Gorway. Unless it is an emergency admission, assessment information must always be obtained in advance so that the home and the service user can be assured that the service user’s needs can be met. Following assessment, the Registered Manager must write to the service user confirming that the home will be able to meet the person’s needs. Where service users were being funded by the Local Authority, a copy of the Social Work assessment was available on file. In these cases there was no copy of the home’s assessment, or (as above) a letter confirming that the home could meet the person’s needs. This Standard was not met at the last inspection in May 2006 and although there is evidence that the home have now developed a satisfactory assessment tool, this has not always been used and, where it has been used, it has been used on, or following admission, rather than prior to the admission. There is evidence (see Standard 4 below) that the home have admitted a person outside their category of registration. This was an issue at the last inspection and highlights the importance of a proper and thorough assessment. Where assessment information had been obtained, this had been used to develop a service user plan of care (see Standard 7). From information in care plans it could be seen that the home had admitted one person with a diagnosed dementia and another person who had a past history of a depressive illness. In the case of the person with dementia the home must apply to the Commission for a Variation in their Registration Category. In the case of the person with the past depressive illness, a review meeting must be held with the social worker to determine whether this person’s needs can be met at Gorway and a copy of the notes of the review meeting must be forwarded to the Commission. Eleven members of staff plus the home’s 2 Managers are currently taking part in training in dementia care. This is a distance learning course organised by Wolverhampton University. Gorway House DS0000020811.V317154.R01.S.doc Version 5.2 Page 11 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): Standards 7, 8, 9 and 10. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Despite a slight improvement in the care planning systems, care plans are poorly developed and some are out of date. There is no evidence that service users are involved in their care planning. Risk assessment is poor and could mean that risks are not properly managed. The improvement in the administration of medication has been maintained, but there remain some shortfalls, which must be addressed to ensure that service users are protected. Service users feel that they are treated with respect and that their right to privacy is upheld. The home must be able to verify that new staff receive appropriate induction training on how to treat service users with respect at all times. Gorway House DS0000020811.V317154.R01.S.doc Version 5.2 Page 12 EVIDENCE: The care plans of 7 service users were seen at the inspection to assess the home’s social, personal and healthcare practices. There has been some improvement in care planning since the last inspection, with some information now provided on file about the person’s needs. This information is, however, minimal and does not clearly set out in detail the actions needed by staff to ensure that all aspects of the health, personal and social care needs of the service user are met. Of the plans seen, some did contain risk assessments, but these gave minimal information and did not cover some of the risks identified at assessment. One service user was still using their car, but there was no risk assessment. Another service user had a Hospital discharge letter, which stated that they had “paranoid thoughts” and had in the past threatened to kill a relative. This person’s risk assessment said “no risk”. Another person had a history of falls and she mentioned this during the inspection, but her risk assessment did not refer to this. On the risk assessment of a person who had recently fallen, the assessment stated: “risks are minimal now that .. cannot get up unaided.” When this person was discussed with staff there was a discrepancy between them as to how many people this service user needed when being assisted. There was no evidence of risk assessments being reviewed. There is no separate falls risk assessment. Risk assessments must be undertaken when service users are to be taken on activities outside the home, such as local walks. This is particularly important if the service users are accompanied by volunteers. Although there is evidence of some social work review meetings, care plans are not being reviewed by the care staff at the home on a monthly basis. There is no evidence that service users are involved in the development and review of their care plans. It is strongly recommended that daily records be written each day for each service user. Currently staff are only recording what they consider to be “significant events”. Service users’ healthcare needs are documented in a separate file. Their needs with regard to oral hygiene are noted at assessment. There are no pressure sore risk assessments in place. A requirement that this should be done was made at the last inspection and has still not been actioned. Advice is available locally from the Continence Promotion Nurse. Community Psychiatric Nurses currently visit 2 of the service users. Light exercise classes are provided for the service users on a regular basis. Some service users had a nutritional screening tool on file. The home were advised that nutritional screening must take place for all service users on admission and subsequently Gorway House DS0000020811.V317154.R01.S.doc Version 5.2 Page 13 on a periodic basis. Service users are able to register with a local G.P. of their choice. Various other healthcare professionals visit the home, including dentist, chiropodist and optician. As noted earlier, there are some service users with specific mental healthcare needs. There is nothing in the care plan to indicate how these needs are to be met and evaluated. Another service user was noted to have a specific problem with their legs, which was being treated by the G.P., but there was nothing in the care plan to indicate to staff how this problem was being addressed. The home now have a policy and procedures document for the handling of medicines. There was no written evidence that staff who administer medication had read and understood the document. None of the current service users take charge of their own medicine and currently not all have a lockable facility in which to keep their medicines, if they wished to do so. Medicines delivered to the home are checked on arrival, but the member of staff checking the medicines must confirm this receipt on the medication administration record sheet. The home must have a copy of the specimen signatures of all the staff who administer medication. Controlled drugs must be stored in cupboards meeting the requirements of the Misuse of Drugs (Safe Custody) Regulation 1973 as amended. The administration of controlled drugs must be witnessed by an appropriately trained member of staff and a separate record must be kept of the receipt, administration and disposal of controlled drugs. These records must be kept in a bound book or register with numbered pages. The bound book will include the balance remaining for each product with a separate record page being maintained for each service user. The home must produce a policy and procedure for the administration of “homely” remedies. A photograph of each service user must be attached to their individual medication administration record sheet. It was noted that one service user had requested that their prescribed fluvastatin be given to them at night rather than the prescribed time and staff had accordingly changed the time on the medication administration sheet. The home must not alter medication times without the agreement of the G.P. If an alteration is to be made, the G.P. must be requested to confirm this on the medication administration sheet and then to provide an updated prescription. A number of staff have taken part in the accredited medication training. The Registered Manager states that a senior member of staff has introduced a competencymonitoring programme to ensure that staff handle and administer medication safely and accurately. A copy of this programme must be forwarded to the Commission. The majority of service users have their own rooms at Gorway and for these people all personal care giving takes place in private. One shared room is currently occupied by 2 people who wish to share. Service users spoken to said that their privacy was respected at Gorway. During the inspection staff were observed to treat service users with respect, always knocking on doors before entering private bedrooms. The home has introduced a system for recording induction training, but on the staff files seen this form was blank. It Gorway House DS0000020811.V317154.R01.S.doc Version 5.2 Page 14 is not, therefore, possible to verify that new workers are trained in how to treat service users with respect (see Standard 30). Gorway House DS0000020811.V317154.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): Standards 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There has been some improvement in the provision of social care activities, but more is needed so that service users can be offered stimulation through leisure and recreational activities of their choice. This is particularly true of the daily in house activities. There are no restrictions on visits and service users spoken to feel that their rights to autonomy and to make choices are upheld. The quality of the food provided at Gorway is good, but the home must provide more choice, particularly for the main meal of the day. EVIDENCE: Some of the service users spoken to confirmed that they were free to choose whether or not to join in any activities provided at Gorway. There was no record in care plans of service users’ interests and hobbies or any record of activities they had taken part in at the home. There was a list of planned activities on the wall in the office, but these were not advertised to the service users. No activities took place during the inspection. Service users had, however, been assisting staff to make a Guy and a Fireworks and Bonfire Night Gorway House DS0000020811.V317154.R01.S.doc Version 5.2 Page 16 Party was planned for the 3rd November. The Registered Manager stated that staff had started to take individual service users out for walks and on shopping trips. Religious services are held in the home on a regular basis. In addition there is a “Keep Fit” class and a dance class. The mobile Library visits regularly. Several service users have recently been to the Arboretum Lights and events have been arranged for the Christmas season, including 2 Rotary Club events, “Bill’s Band”, a Christmas Fayre and bellringers. Although there is clearly an improvement in this area, the home must record service users’ interests in their care plans and also keep an up to date record of activities that have taken place and are planned. The home need to be able to demonstrate that they have consulted with service users about their social interests and that they have made provision for specific individual needs in this area. During the course of the inspection one service user said: “They are nice people, but I have to stay in every day.” Another was overheard to say: “There’s nothing to do here, I just sit mythering.” There are no restrictions on visits at Gorway, although visitors are requested to avoid the main meal time. There is a visiting policy and all prospective service users and their relatives are given a copy of this. Several examples were seen of service users being able to exercise personal autonomy and choice. Two service users regularly go out alone to visit friends and relatives. Those service users who are able to take charge of their own financial affairs. Service users are encouraged to bring personal possessions with them when they move to Gorway and there was a good example of this in one room, where a service user had brought many small items from home and made the room very much his own. There is information available in the home on the local Age Concern Advocacy Service. Service users spoken to during the inspection spoke highly of the quality of the food at Gorway and the lunchtime meal was very much enjoyed. The planned menu was changed as the cook was being observed as part of her NVQ training and was requested to prepare a beef stew, which was followed by a sponge pudding and custard. Menus seen were planned for one week only and not on a 4 week rotating basis. In fact one service user was surprised by the fact that it was a beef stew, as she said they “always” had fish on a Thursday (the menu stated salmon on Thursdays). The menu did not state an alternative. The cook said that there was always something in the freezer if service users preferred to have something different. The home must provide a more varied menu over a 4 week period and offer a distinct alternative for the main meal of the day. Very few service users were aware of what they were to have for lunch that day, although one stated that it was usually printed on a notice board in the hall. Service users’ nutritional needs and likes and dislikes with regard to food must be recorded on their care plans (see also Standard 8). Gorway House DS0000020811.V317154.R01.S.doc Version 5.2 Page 17 The Registered Manager stated that a cooked breakfast was available 3 or 4 times a week and more cooked suppers had been introduced at the request of service users. There are no service users at the home at present who require any special diets. Staff were attentive during the mealtime and offered discreet assistance to those who needed it. Although this standard was not fully met mainly because there is insufficient choice available, the cook is to be congratulated on the quality of the cooking and the fact that the majority of puddings and cakes served are made on the premises. Gorway House DS0000020811.V317154.R01.S.doc Version 5.2 Page 18 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): Standards 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home have a complaints procedure in place and service users feel that any complaints they may have would be listened to and acted upon. The procedure needs to include timescales. There is an Adult Protection Policy and Procedure available, but this needs to be reviewed to ensure it is in line with the Walsall Social Services Procedure. EVIDENCE: The home has a complaints procedure in place and service users are given a copy of this. It was noted that the procedure does not include details of timescales with regard to responding to complaints. The home were requested to rectify this. One complaint has been received by the home since the last inspection. This is currently being dealt with by the Registered Person and a written response has been requested by the Commission. Service users spoken to said that they would know who to speak to if they wished to make a complaint and they felt that they would be listened to. The home do have an Adult Protection Policy in place but this is unchanged from the last inspection and is not in line with the Walsall Social Services Adult Protection Policy. The Registered Manager stated that she was aware that this needed to be done and was obtaining a copy of the revised Social Services Procedure. A number of staff have taken part in Adult Protection Training and Gorway House DS0000020811.V317154.R01.S.doc Version 5.2 Page 19 more are scheduled to do so in the future. Staff spoken to during the course of the inspection were clear of their responsibilities with regard to the Protection of Vulnerable Adults. Gorway House DS0000020811.V317154.R01.S.doc Version 5.2 Page 20 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): Standards 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Gorway is an attractive and generally well-maintained home, with pleasant gardens to the front and rear of the property. Service users feel that they live in a comfortable and clean home. Further improvements to the environment have taken place since the last inspection, but there are still some areas, which need attention before this outcome area can be judged as good or excellent. EVIDENCE: A number of improvements to the physical environment of the home have taken place since the last inspection. This has included painting the exterior of the home and several individual bedrooms have been refurbished. There is still no copy of a programme of routine maintenance and renewal of the fabric and decoration of the premises available on site. One must be produced and a Gorway House DS0000020811.V317154.R01.S.doc Version 5.2 Page 21 copy forwarded to the Commission. There is a safe and attractive garden to the rear of the property. Several of the requirements of the Fire Officer have been met. All ground floor fire resisting doors have been upgraded and fitted with smoke seals and intumescent strips. Work has now commenced on the doors on the first floor. It was noted during the inspection that several fire doors were wedged upon. If, for the convenience of the service user, it is desirable that the door should be open, an automatic closure device must be fitted. The majority of the areas highlighted as needing attention in individual rooms at the last inspection have now been dealt with. Suitable locks with keys have been provided to rooms and risk assessments have been carried out. Several service users are using their keys. Not all rooms have lockable facilities in which service users can keep valuables, or medication if they wish. An audit must be carried out and lockable facilities provided where needed. Several individual rooms were seen during the inspection and all were decorated and furnished to a good standard. Service users had been able to personalise their rooms. There are still some bedrooms where radiators are not covered. These must be covered as a matter of urgency. In Room 24 a bed was placed against a very hot radiator, which had no cover. Until this radiator is covered, daily checks must be carried out on the temperature of the radiator to ensure the safety of the service user. During the tour of the building it was noted that in one bathroom several toiletries (including steradent) and creams had been left there. All service users’ individual toiletries and creams must be stored in their rooms. The home was clean and free of any offensive odours at the time of the visit. The laundry was in good order, with liquid soap and paper towels being provided. The washing machine has a sluice facility. Gorway House DS0000020811.V317154.R01.S.doc Version 5.2 Page 22 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): Standards 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are adequate on morning shifts for the current group of service users. The home must be able to demonstrate through its assessments that there are sufficient staff on duty from 4.00 p.m. to ensure that service users’ needs are fully met. There have been improvements in staff training, but records must be available to verify this. Similarly up to date records must be kept to verify proper induction training for new staff. Recruitment practices are still not meeting the required standard and may place service users at risk. Service users felt that the staff looked after them well. EVIDENCE: At the time of the inspection there were 20 service users living at Gorway. On the morning shift, between 8.00 a.m. and 4.00 p.m., there were 3 care staff on duty in addition to the cook and cleaner. Between 4.00 p.m. and 6.00 p.m. there are 3 care staff on duty, one of whom prepares the tea-time meal. From 6.00 p.m. to 8.00 p.m. there are 2 on duty and at 8.00 p.m. the 2 waking night staff come on duty and they work through the night until 8.00 a.m. The Registered Manager states that a high number of service users currently living at Gorway have low dependency needs and that the current staffing levels meet the needs of the service users. Staff spoken to during the day confirmed this, although there was some discrepancy between staff as to whether one of Gorway House DS0000020811.V317154.R01.S.doc Version 5.2 Page 23 the service users needed 2 carers to assist them. It was observed during the inspection that several of the service users are able to take charge of their own personal care, apart from supervision with bathing. As stated in Standard 7 (above) and at the last inspection, the dependency levels of each service user must be assessed and these must be recorded in individual care plans. The Registered Manager and Assistant Manager’s hours are supernumerary, but they are available in the home during the week during normal working hours and are also available On Call in the event of any emergency. The staffing levels during the afternoon, particularly from 6.00 p.m. to the night time shift, are at the minimum acceptable level, particularly as the home now have 2 service users with specialist needs because of dementia. The home must ensure that staffing ratios are regularly reviewed and increased when necessary to reflect the needs of the service users. The Registered Manager states that at least 50 of staff are now trained to NVQ level 2, the Senior Carer has commenced NVQ level 3. The cook and cleaner are currently undertaking the NVQ level 1 qualification. The files of 3 newly recruited members of staff were seen. All contained an application form, but in one case the employment history had not been completed. In 2 cases there were no written references. 1 of the files did not contain a start date for the individual and it was not, therefore, possible to verify that a satisfactory Criminal Records Bureau check and POVA check had been received prior to the person starting. In another file there was a start date and it appeared that the person had commenced prior to the satisfactory Criminal Records Bureau check being received. There was no record of a satisfactory POVA first check or of a risk assessment being carried out. 2 of the files did not contain a copy of the statement of terms and conditions. None of the staff files seen contained all of the documents required by legislation. The home have produced a check list to ensure that they have all the required staff documentation, but they do not appear to be using it at present. Staff training continues to improve, but the home still need to improve their planning and records in this area. The home must produce a staff training and development programme, which meets the Skills for Care training targets. A number of staff files were inspected and training certificates seen. The files seen had been provided with a format on which to record individual training and development assessments and profiles, but unfortunately all the forms were blank. The Manager has decided to use the services of a Training Coordinator who is to assist with the development of a Training Plan. Evidence of staff training in the mandatory health and safety areas is referred to in Standard 38 (below). There was no evidence of new staff taking part in induction training to Skills for Care specifications. There were formats on Gorway House DS0000020811.V317154.R01.S.doc Version 5.2 Page 24 individual files, but as with the individual training assessments, these had not been completed. Gorway House DS0000020811.V317154.R01.S.doc Version 5.2 Page 25 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): Standards 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The 2 Managers at Gorway are undertaking the Registered Managers’ Award and hope to complete this in the near future. This will be of benefit to service users and staff in ensuring the smooth running of the home. There has been no progress on the development of a quality assurance and quality monitoring system. Service users and other interested parties’ views are not regularly sought and acted upon. There are a number of steps the home needs to take in order to ensure that the health and safety of service users and staff are fully protected. Gorway House DS0000020811.V317154.R01.S.doc Version 5.2 Page 26 EVIDENCE: The Registered Manager and Assistant Manager are currently undertaking the Registered Managers’ Award. There have been some delays to this training, but both Managers feel confident that they will achieve the Award in the near future. Both managers update their skills by taking part in other appropriate training. There has been no progress on the development of a quality assurance and quality monitoring system at Gorway. A form was forwarded to relatives, but very few responded. The Registered Manager is aware that the home must produce an annual development plan which is based on the views of the service users and other stakeholders and which reflects their desired outcomes. More consultation must take place with the service users, regular meetings must be held and service users’ views and desired outcomes obtained. Anonymous questionnaires must be sent to all interested parties: service users, their relatives, health and social care professionals, etc. The results of surveys must be published and made available to current and prospective service users. There are still no formal systems in place for the monitoring of practice in the home. Two of the service users spoken to during the inspection felt that they would be listened to and their views acted upon. They said that they had spoken to the Manager of the home when they were dissatisfied with the food. They felt that they had been heard and that the Manager acted on what they had said, as the food did improve afterwards. The home does not look after service users’ personal allowances. Service users either take charge of their own finances or it is looked after by their families. The only money handled by the home on behalf of the service users is hairdressing money. This money is collected from service users on the day of the hair appointment. There are secure facilities in place for the safekeeping of any monies or valuables. Standard 36 was not inspected fully on this occasion and is, therefore, not scored. From the staff files seen, however, it could not be evidenced that supervision is being provided at least 6 times a year to all staff. As stated in Standard 30 above, the home must produce a staff training and development programme. This must include details of the mandatory training required in moving and handling, first aid, fire safety, food hygiene and infection control. A copy of this development programme must be forwarded to the Commission. Gorway House DS0000020811.V317154.R01.S.doc Version 5.2 Page 27 Records in individual staff files show that training has taken place in moving and handling, fire safety, food hygiene and infection control within the last 18 months. A senior member of staff took part in the Appointed Person First Aid Training early in 2006. It is not, however, possible to verify from staff records that all staff hold up to date training in the required areas. There must be a member of staff trained in first aid available on each shift and from the staff files seen, a number of staff, particularly night staff, do not have this training. Records show that fire alarms are tested weekly and emergency lights each month. There is no clear record of Fire Drills taking place, although there is a record of individual staff being informed about the Fire Drill procedures. The Registered Manager is required to speak with the Fire Officer and request a visit in order to obtain the necessary advice on the home’s Fire Risk Assessment and Fire Drill Procedure. It remains a requirement that the Registered Manager attend a suitable “Fire Warden” training course. Evidence was seen of the regular maintenance of the boiler and central heating systems, the electrical system and electrical equipment. The home was unable to supply evidence of the process it uses to ensure that the water system is free of legionella. This must be forwarded to the Commission. Although the Registered Manager stated that water temperatures at outlets accessible to service users are regularly checked, records to confirm this could not be found. The Registered Manager must also forward to the Commission evidence of how the Arjo hoists are tested and maintained. Currently the Manager states that the electrician provides a “visual” check. Written verification of this is required. The Registered Manager must produce a written statement of the policy, organisation and arrangements for maintaining safe working practices and ensure that risk assessments are carried out for all safe working practice topics (Standards 38.5 and 38.6). It was noted during the inspection that an accident to a service user had not been reported to the Commission under the requirements of Regulation 37. Gorway House DS0000020811.V317154.R01.S.doc Version 5.2 Page 28 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 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X X 2 Gorway House DS0000020811.V317154.R01.S.doc Version 5.2 Page 29 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(1) Requirement The home must carry out its own assessment of service users who are self-funding. This assessment must cover all those areas detailed in Standard 3.3 of the National Minimum Standards. Unless it is an emergency, assessments must be carried out prior to the person’s admission. Timescale for action 10/11/06 2. OP4 12(1) Following assessment, the Registered Manager must write to the prospective service user confirming that, having regard to the assessment, the home is able to meet the person’s needs. (Previous timescale of 30/06/06 not met). 30/11/06 The registered person and the registered manager must consult with the Commission for Social Care Inspection if they wish to accommodate someone who has specific needs that are outside the category of their registration. The home has admitted a service user with a diagnosed dementia and a service user with a past history of a depressive illness. A DS0000020811.V317154.R01.S.doc Version 5.2 Page 30 Gorway House 3. OP7 4. OP7 5. OP7 6. OP7 7. OP8 8. OP8 Variation to the home’s Category of Registration must be sought for the person with dementia. A review meeting must be held for the person with the past history of a depressive illness. A copy of the notes of this meeting must be forwarded to the Commission. 15(2) Care plans must set out in detail the action which needs to be taken by the care staff to ensure that all aspects of the health, personal and social care needs of the service user are met. (Previous timescale of 31/07/06 not met.) 13(4)(b)(c Care plans must contain an up to ) date and accurate risk assessment, with particular attention to the prevention of falls. (Previous timescale of 31/07/06 not met). 15(2) Care plans and risk assessments must be reviewed each month and plans and risk assessments updated to reflect any changing needs. (Previous timescale of 30/06/06 not met). 15(1) Where possible, service users must be involved in the development of their care plan. Service users must be invited to sign their care plan. (Previous timescales of 30/04/05, 31/12/05 and 30/06/06 not met). 12(1) The registered manager must produce a risk assessment for pressure sores to be completed by care staff in the home and held with the care plan for the resident and reviewed on a continuing basis. (Previous timescales of 31/12/05 and 31/07/06 not met). 14(1)(2) Nutritional screening must be Schedule undertaken on admission and 3 (o) subsequently on a periodic basis, DS0000020811.V317154.R01.S.doc 30/11/06 30/11/06 30/11/06 30/11/06 30/11/06 30/11/06 Gorway House Version 5.2 Page 31 9. OP9 13(2) 10. OP9 13(2) 11. OP9 13(2) 12. OP9 13(2) 13. OP9 13(2) 14. OP9 13(2) 15. OP9 13(2) 16. OP9 13(2) a record maintained of nutrition. The home must provide written evidence that staff have read and understood the policy and procedure with regard to medication. (Previous timescale of 30/06/06 not met). Records must be kept of all medicines received, administered and leaving the home or disposed of to ensure that there is no mishandling. The MAR chart must be completed to confirm the quantities received. (Previous timescale of 30/06/06 not met). The home must keep a copy of the specimen signatures of all those staff who administer medication. Controlled drugs must be stored in a metal cupboard, which complies with the Misuse of Drugs (Safe Custody) Regulations 1973. The administration of controlled drugs must be witnessed by another designated, appropriately trained member of staff. Receipt, administration and disposal of controlled drugs must be recorded in a Controlled Drugs Register. The home must produce a policy and procedure for the administration of “homely” remedies. A photograph of each service user must be attached to their medication administration record sheet. Staff must not alter the times of medication administration without consulting with the service user’s G.P. The home must introduce a competency-monitoring DS0000020811.V317154.R01.S.doc 30/11/06 30/11/06 30/11/06 30/11/06 30/11/06 30/11/06 02/11/06 30/11/06 Page 32 Gorway House Version 5.2 17. OP12 16(2)(m)( n) 18. OP15 17(2) 4 (13) 19. OP16 22(1) 20. OP18 12(1)(a) programme to ensure that staff handle and administer medication safely and accurately. A copy of this programme must be forwarded to the Commission. There must be more consultation with service users about their interests and aspirations. Service users must be given more opportunities for stimulation through leisure and recreational activities in and outside the home, which suit their needs, preferences and capacities. Service users’ wishes and participation with regard to social care activities must be recorded in their care plans. (Previous timescale of 31/07/06 not met). Provide evidence of consultation with residents regarding dietary needs and preferences for all mealtimes and produce menus detailing the choice of foods available. (Service users’ likes and dislikes and nutritional needs must be recorded on their care plans). (Previous timescales of 28/10/05 and 30/06/06 not met). The home’s Complaints Procedure must include details with regard to timescales as to when the complainant will be responded to. The home must ensure that their Adult Protection Policy and Procedure is in line with that produced by Walsall Social Services. It must include essential telephone numbers. (It is acknowledged that the home are in the process of preparing this document now that they have received a copy of the Walsall Social Services Adult DS0000020811.V317154.R01.S.doc 31/12/06 31/12/06 31/12/06 31/12/06 Gorway House Version 5.2 Page 33 21. OP19 23(2) 22. OP19 23(4) 23. 24. OP24 OP25 23(2)(m) 13(4) 25. OP26 13(3) 26. OP27 18(1)(a) 27. OP29 19(1) Protection Procedures. A programme of routine maintenance and renewal of the fabric and decoration of the premises must be produced and a copy forwarded to the Commission. Fire resisting doors must not be wedged open. If, for the convenience of the service user, it is desirable that the door should be open, an automatic closure device must be fitted. All service users must be provided with a lockable facility in their rooms. All radiators must be guarded or have guaranteed low temperature surfaces. (Previous timescale of 31/08/06 not met). Service users’ individual creams must be kept either in the medication cupboard or in their own rooms (if they selfadminister) and not in communal bathrooms. (Previous timescale of 17/06/06 not met). The Registered Manager must be able to provide evidence, through up to date assessments of individual needs, that there are sufficient staff on duty at all times to meet the needs of the service users. The registered person and registered manager must ensure the recruitment policy is operated on a thorough procedure based on equal opportunities and ensuring the protection of service users. Application forms must be fully completed. 2 satisfactory written references must be obtained prior to appointing new staff. DS0000020811.V317154.R01.S.doc 31/12/06 31/12/06 31/12/06 31/12/06 02/11/06 30/11/06 30/11/06 Gorway House Version 5.2 Page 34 28. OP30 24(1) 29. OP30 18(1) 30. OP31 9(2)(b)(i) 31. OP33 24 Application forms must contain a full employment history. Staff files must contain all those records required by Regulation. (Previous timescales of 31/11/05 and 30/06/06 not met). The registered person and registered manager must provide a training plan and development programme for all staff. It is acknowledged that work is in progress on this at the moment. (Previous timescales of 31/12/05 and 31/07/06 not met). The registered person and registered manager must ensure all new staff receive induction training to Skills for Care specification within the first six weeks of appointment to their posts. (Previous timescales of 31/12/05 and 31/07/06 not met). The Registered Manager must have a qualification at level 4 NVQ in management and care, or equivalent, by 2005. (Previous timescales of 31/03/05 and 31/08/06 not met). It is acknowledged that there have been delays beyond the control of the Managers and that this situation should shortly be resolved. The Registered Manager must provide evidence of continuous self-monitoring at the home, involving service users and an annual internal audit. (See Standard 33.3). The home must provide evidence of feedback from service users and relatives. (Previous timescales of 30/04/05 and 31/08/06 not met). 31/01/07 30/11/06 31/01/07 31/01/07 Gorway House DS0000020811.V317154.R01.S.doc Version 5.2 Page 35 32. OP36 18(2) 33. OP38 13(4) 34. OP38 23(4) Provide formal supervision for 31/12/06 the staff at least six times a year with written records dated and signed by staff. 36.2 (Previous timescales of 28/02/04, 31/01/06 and 31/07/06 not met). The home must ensure that 30/11/06 there is a person with up to date training in First Aid available on each shift. The home must ensure that 30/11/06 suitable fire drills take place at least twice a year. Advice on the fire drills and the home’s Fire Risk Assessment must be sought from the Fire Service. The Registered Manager must attend suitable training to ensure that she is up to date with current Fire Safety Regulations. The Registered Manager must provide the Commission with a written statement of how the home intends to ensure that the water system is free of risk of legionella. Ensure the maintenance checks and certificates are completed by a competent person and made available for the Hoists. (Previous timescales of 30/04/05, 31/12/05 and 30/06/06 not met). The Registered Manager must produce a written statement of the policy, organisation and arrangements for maintaining safe working practices and ensure that risk assessments are carried out for all safe working practice topics. The Registered Manager must inform the Commission without delay of the occurrence of any serious injury to the service user. DS0000020811.V317154.R01.S.doc 35. OP38 13(3) 30/11/06 36. OP38 13(4) 30/11/06 37. OP38 12(1) 31/01/07 38. OP38 37 02/11/06 Gorway House Version 5.2 Page 36 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. Refer to Standard OP7 OP9 OP14 Good Practice Recommendations It is recommended that records be written each day for each service user. The manager should monitor the administration of medication as part of the quality assurance self monitoring and annual audit. It is recommended that a Key worker system is introduced and that monthly and six monthly review meetings involving service users and their families are regularly held. Service users’ meetings, during which menu choices, activities and other events are discussed, should be regularly held. It is recommended that, in addition to a book for recording Complaints, the home supply a Comments Books for service users and their visitors. 4. OP16 Gorway House DS0000020811.V317154.R01.S.doc Version 5.2 Page 37 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. Extracts may not be used or reproduced without the express permission of CSCI Gorway House DS0000020811.V317154.R01.S.doc Version 5.2 Page 38 - 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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