Inspection on 20/10/05 for Gorway House

This inspection was carried out on 20th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 02/11/06

Gorway House 31/05/06

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 Chris Fuller Unannounced Inspection 20th October 2005 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Gorway House DS0000020811.V259418.R01.S.doc Version 5.0 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.V259418.R01.S.doc Version 5.0 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.V259418.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24.05.05 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. Gorway House DS0000020811.V259418.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This year the Commission for Social Care Inspection is making a proportional based inspection against a selected number of the National Minimum Standards. The focus remains on assessing the quality of care provided through the experience and outcomes for service users, a review of progress on meeting National Minimum Standards from the previous inspection and on aspects of service provision that require further development, or pose the most significant risk to service users. Some standards have not been inspected on this occasion. Gorway House is a family run business with Mrs Pamela Brown the registered person, her two daughters Jennifer Beale the registered manager and Susan Allen manager. Mr Richard Allen is the maintenance person for the home. Chris Fuller, Regulation Inspector was accompanied by Linda Brown, Regulation Inspector to make an unannounced inspection at Gorway House on Thursday 20th October 2005 at 8.30 a.m. A second visit was made on Friday 4.11.05 at 8.30 a.m. to complete the inspection. The registered manager was on leave on the first day and the manager assisted throughout the day the registered provider was also present. The registered manager and manager were available to assist with the second day of the inspection. Due to concerns arising during observation of the administration of medication, the Pharmacist for the Commission for Social Care Inspection agreed to make a visit on Thursday 3.11.05; the findings are referred to in the report. The inspectors visited communal areas of the premises, the two lounges, the dining room and the kitchen on this occasion. Time was spent in the lounge areas with residents. Staff were observed in their duties at lunchtime, with administering medication and in the kitchen. The homes records including residents and staff records were seen. The regulation inspector was extremely disappointed and most concerned to find that the initial progress made during the spring and early summer towards meeting outstanding statutory requirements had not been maintained. It was also identified that practice had deteriorated in significant areas of the administration of medication, kitchen records and staff recruitment procedures and records. There was no evidence of monitoring or supervision by management and the combination of these factors makes residents vulnerable and at serious risk of potential harm for their health, safety and wellbeing. Gorway House DS0000020811.V259418.R01.S.doc Version 5.0 Page 6 On the first day of the inspection two immediate requirements were issued to the manager. Confirmation that these had been addressed was received on 24th October 2005. During the second day of inspection it was noted that some issues raised were already being addressed such as provision of menus, record of choices of residents, improved recording of information on staffing rota’s. The scoring in the report reflects the fact that three years following implementation of the Care Standards Act the home still has some further work to do to meet the minimum standards required in a number of aspects of care practice. It also highlights that the owner and management of the home have not fulfilled their responsibilities and duties identified in the Care Standards Act 2000 and implemented the national minimum standards. They persist in providing care in a limited manner with the potential detriment to all involved. It is required that an action plan is submitted to CSCI stating actions to be taken, who by and proposed completion dates. The inspectors wish to acknowledge this is a small family owned and managed provision with a small established staff group. There had been some progress at the previous inspection in respect of resident’s files, staff contracts and staff training. It is advised that this report is read in conjunction with the previous announced inspection report. The staff group work hard to ensure the outcomes for residents are provided and feedback from residents is generally satisfactory though some felt able to state they would like more individual choice, for example at mealtimes. There were only fourteen residents accommodated at the time of inspection. What the service does well: What has improved since the last inspection? The gardens front and rear look very attractive. Over the summer decoration has continued in five of the bedrooms and new carpets have also been fitted. Some staff are continuing with their NVQ level 2 and one has progressed to the NVQ level 3. Staff have completed the distance learning accredited medication training. The registered manager and manager are both attending the Registered Managers Award training. Gorway House DS0000020811.V259418.R01.S.doc Version 5.0 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Gorway House DS0000020811.V259418.R01.S.doc Version 5.0 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.V259418.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4 The management must ensure all aspects of the admissions procedure are completed including the home’s assessment, written contracts and a letter to confirm needs can be met. Without this there is not assurance that care needs will be met. EVIDENCE: A sample of resident’s files were seen. The manager confirmed that the home does have as standard an annual letter with a statement of the annual increase or the current level of fee however this has not been issued. The manager stated a contract or terms and conditions are issued to the resident and or their family following admission to the home. These documents or copies were not found on all of the files seen. Gorway House DS0000020811.V259418.R01.S.doc Version 5.0 Page 10 Through case tracking for some of the records it was noted that some of the residents appear to have particular care needs that require specialist services or provision. Records on an “Overview Assessment Form” completed by a district nurse states the resident has Alzheimer’s however the manager could not state who made this diagnosis and there was no evidence on records. Other records note a resident was admitted to the home under Section/ Guardianship under the mental health act. Whilst the manager may have determined the home could meet the resident’s needs there was no evidence of this on file and there had been no request for a variation to the homes registration. The management agreed to request a review of the residents needs by health and or social care and housing services and to inform the Commission for Social Care Inspection of the findings and whether the home is able to and how they will meet their needs. Gorway House DS0000020811.V259418.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 and 9 Limited progress has been made on developing individual plans and health care plans for residents. Records did show health care is sought as needed and relatives are expected to escort residents to appointments where possible. However arrangements should be proactive and preventative to ensure the health and wellbeing of residents. Shortfalls in the administration of medication and health care practice have a potential to place residents at risk. EVIDENCE: A sample of resident’s files were seen and found to hold incomplete records. Individual care plans did not have all of the sections completed and were limited in the detail of information recorded. There was no evidence that residents and / or their relatives had been consulted in drawing up the care plans and none of them had been signed or dated by the residents. Gorway House DS0000020811.V259418.R01.S.doc Version 5.0 Page 12 One of the files had evidence of regular reviews at hospital with a consultant. All advice regarding medication was recorded by staff. There were no letters or records of appointments from hospital on file. Although the medication was one commonly used for someone with Dementia there was no diagnosis of Dementia or explanation for treatment given. Not all resident’s records had a photograph on file. There was a weight chart kept on file but it was not completed between April and October 05. Similarly medication was listed on file but not dated. The Manager stated the Care needs form was completed on admission but it was not dated or reviewed. The Care Plans on file are extremely limited in a tick box format and need to be developed further to provide details of level of need, action to be taken and by whom. Individual case records indicate that staff note changes in residents wellbeing but professional help or advice is not sought straight away. For example one resident was found on the floor, a doctor was called and medication was changed by the doctor. Case notes record the medication was to be reviewed in 6 weeks but there was no evidence of a review and no change to the medication. A second instance was over a period of 16 days where there is a record of deterioration of a pressure sore and then a further 16 days from initial contact with a Doctor to a visit from a District Nurse who assessed the resident needed a mattress and cushions. The Continence assessment forms for a resident record a diagnosis of Dementia as written by the Nurse but no diagnosis is recorded any where else in the file. There are no regular formal reviews of the care plan however the resident does have regular contact with the doctor for routine illnesses. The weight chart on file is completed 2/9/04 and 6/10/04 but not completed again until 6/10/05 one year later. There are no risk assessments for pressure sores on file. The manager checked District Nurse files and found it held no risk assessment. The record on the Overview Assessment Form completed by the district nurse states the resident has “Alzheimer’s” however the manager is unsure of who made this diagnosis and there is no evidence on records. The individual care plans held basic information of residents needs at the time of admission but there were no detailed plans of how the needs were to be met, who by and the frequency. In discussion with management and observation of regular permanent staff it was clear they had knowledge of the individual residents and their personal history and culture and this would inform their practice. However very little of this was evident in records. Gorway House DS0000020811.V259418.R01.S.doc Version 5.0 Page 13 Observation of the administration of medication raised a range of issues from unsatisfactory service from the contracted pharmacist to poor systems in the home and staff practice in the administration and recording of medication. The pharmacy labels on medication sometimes stated as instructed and no instructions were available. There was inconsistency in labelling of the medication boxes with red stickers. Weekly medication sheets were not being updated regularly. There was no system for recording receipt and disposal of medication. Staff were observed to handle medication from the box to the residents hand. Some tablets were signed off as issued but had not been issued. One resident had gone out for the day but staff had not issued the lunchtime medication. One resident had been prescribed 50 Co-Codamol and only 8 were left in the bottle none of these had been administered to the named resident. One prescription had not been issued at all but there was no indication on the records of the reason for this. One resident had left the home a week ago and medication was still held on the premises. Two actions were listed in an Immediate statutory requirement made at the time of the inspection and subsequently addressed as requested by the management. Due to the number of inconsistencies the inspector requested that the Pharmacist for the Commission for Social Care Inspection visit the home specifically to inspect and advise regarding the administration of medication. The visit was made on Thursday 3rd November 2005 and a report of the findings is provided to the home with statutory requirements and recommendations. Gorway House DS0000020811.V259418.R01.S.doc Version 5.0 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 and 15 Improvements must be made to meal provision and kitchen operations; both must be well managed to ensure safe hygienic conditions for food preparation and a wholesome balanced diet. This must reflect the residents’ choice and preferences in order to meet their dietary needs and provide variation and quality of care for people living in the home. EVIDENCE: The Inspectors were pleased to find a cook was in post, she had returned to employment at the home in July 2005. She held a current Food Hygiene Certificate that was updated in March 2005. Care staff and management confirmed there are four staff that currently cover kitchen duties and on other shifts do care work. The cook spoken with does two days cooking and three nights care shifts. The kitchen facilities and records were inspected. There were no menus available and residents confirmed that they did not know what they would be eating until they sat at table. The management were asked to provide evidence of consultation with residents regarding dietary needs, to record their preferences for all mealtimes and produce menus detailing the choice of foods available. Gorway House DS0000020811.V259418.R01.S.doc Version 5.0 Page 15 There was fresh fish, with a lunchtime meal of salmon, peas, cauliflower and potatoes. The staff offered to keep some for one of the residents who was going out for the day, as it was their favourite dish. The alternative available was frozen fish fingers seen in the freezer. A member of staff was observed to sit at table and offer assistance to someone with difficulties in eating. Some of the residents in the home are diabetic, it was stated that this is managed through their diet. However in the kitchen there were no specific instructions about dietary needs. There are no special diet arrangements evident and no separate puddings or dishes prepared. The home uses pasteurised milk in drinks and cooking, there is no evidence of choice or preference for residents. Residents confirmed that they enjoy their meals and found them sufficient. At breakfast time residents were offered cereal, toast and / or porridge. Some did express a wish for cooked breakfasts, supper options and more choice in dishes available. Gorway House DS0000020811.V259418.R01.S.doc Version 5.0 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The staff are at different levels in their knowledge and understanding of Adult Protection issues due to variations in work experience and training. An open supportive atmosphere must be developed in the home to give residents, relatives and staff confidence to raise any issues of concern. EVIDENCE: The home does have policy and procedures in respect of Adult Protection and is aware of the Local Authority Vulnerable Adults Protection Team and the local procedures. The training is usually available through this service. Management have not been able to access training for staff in Adult Protection Procedures. Staff are expected to report any concerns or issues as they arise to the management who will address the issues as necessary. Gorway House DS0000020811.V259418.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,24,25 and 26 Gorway House has a pleasant aspect overlooking attractive gardens to the rear and front of the building. The interior and exterior are generally well maintained with repairs and decoration being completed to maintain pleasant and comfortable surroundings for the residents. There continue to be some outstanding health and safety issues including Environmental Health issues and fire officers recommendations that must be met to ensure a safe environment for residents. EVIDENCE: On the day of the inspection the premises were clean, hygienic and free from offensive odours. Some of the seating in the lounge areas is in need of replacing and or deep cleaning. Gorway House DS0000020811.V259418.R01.S.doc Version 5.0 Page 18 The garden is well kept with attractive flowerbeds, bushes and lawn areas to the front and rear. The proposed work to the exterior of the house has not been completed. Window frames and facia boards are in need of decoration. Three rooms have been decorated and new carpets provided. Another two rooms have been decorated with new beds provided. General repairs and maintenance of the premises continues to be in good order The sample of files seen did not hold a risk assessment regarding the provision of keys to the door locks and drawer locks of service users rooms. The manager stated this would be done with the development of a more detailed care plan. A visit was made by the fire officer and 18 April 2005. The majority of recommendations have been met. The matters outstanding must be addressed as a priority and are listed in the statutory requirements. Gorway House DS0000020811.V259418.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 The management fail to implement the recruitment policy and procedure. The practice for the recruitment of staff is not robust and does not provide the safeguards to offer protection to people living in the home. EVIDENCE: On the first day of the unannounced visit there were two regular permanent members of staff on duty and one other. The cook was on duty and a cleaner. The registered manager was on leave and the manager and registered person came in to assist with the inspection visit. A second day was arranged to return and complete the inspection. On this occasion there were three regular permanent staff and a fourth member of staff. There was a cook and cleaner on duty. The registered manager and manager assisted with the inspection. A sample of staff records were seen. It was found that one person employed at the home had no records at all. The manager was told that this person could not work at the home until all of the required checks and information had been obtained. During the current shift they could not do personal care and must be supervised whilst on the premises. Gorway House DS0000020811.V259418.R01.S.doc Version 5.0 Page 20 Of the files seen it was found that the records were incomplete with contract, references, start date, evidence of work history not available or held on file. The contract dated 29.09.97 was no longer acceptable as the worker had left employment and then returned to the home some time later. There were some signed records such as the gift policy. There was a food hygiene certificate on file but no other induction or training information and no records of supervision or staff appraisal. A second file also held limited or incomplete information. The application form was not dated. The health declaration had not been completed. There were two references both for January 2002 but they had left their last employment 1990. There was no evidence of interview questions or discussion. The file did hold a current CRB check that was satisfactory however there was no identification or photograph on file. There was some evidence of training certificates however no training or development plan. It was also noted that there was no contract and no job description on file. The manager explained that new contracts had recently been issued and not all staff had signed and returned them. The Inspectors discussed with the management the importance and legal requirement to ensure the recruitment policy is operated on a thorough procedure based on equal opportunities and ensuring the protection of service users. They also underlined the management responsibility and accountability where they fail to fulfil these duties. A number of statutory requirements were made in respect of the recruitment, support and supervision of staff and staff records. The inspector also discussed with management the importance of Criminal Records Bureau and Protection Of Vulnerable Adult checks in the recruitment process for the safety and protection of residents. Several statutory requirements were made in respect of these matters. Management had made some progress with accessing and arranging training for staff in respect of NVQ’s and safe working practice topics. This is determined by availability of course and external funding. A training plan including induction to the home must be developed. Gorway House DS0000020811.V259418.R01.S.doc Version 5.0 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,36,37 and 38 There was no evidence of management providing guidance, supervision and support for staff to ensure residents receive consistent quality care. Similarly there are no management monitoring systems in the home to develop good practice or identify shortfalls in the service delivery. It was found there were some practices particularly in respect of administration of medication and kitchen duties that operated in a manner that do not promote and safeguard the health, safety and welfare of the residents. EVIDENCE: The registered manager for the home has lead responsibility for all the day-today operations and care practice. The manager has lead responsibility for all aspects of staffing and wages. The provider has an overview of the financial and business aspects of the provision and keeps some of the records off site. Both the registered manager and the manager have enrolled on the Registered Mangers Award Course and expect to complete March 2006. Gorway House DS0000020811.V259418.R01.S.doc Version 5.0 Page 22 Management state they provide informal guidance and instruction to the staff. The statutory requirement for Formal supervision has been discussed with management at several inspections and still remains outstanding. Formal supervision provides an opportunity for management to monitor staff care practice, provide support, advice and guidance, address personnel issues and staff development. The management have contracted the services of an independent consultant to assist with developing comprehensive policies and procedures and updating existing recording formats and systems, however no progress has been made with implementation and or quality assurance monitoring since the previous inspection. The home does not have a quality assurance system at the present time. As this is a family run business and the owner / provider visits the home on a daily basis there are no regulation 33 visits and reports. Developments at the home are discussed and agreed amongst the family the statutory requirement for an annual development plan remains outstanding. There are no formal systems for the monitoring of practice in the home. During a tour of the communal facilities in the premises, the inspectors identified serious concerns with the food storage in the kitchen where packets were not labelled with dates they had been opened. There was a lack of any records of fridge, freezer and food temperatures. The Fridge and freezer temperatures must be recorded twice daily. The door seals on one fridge were damaged and ineffective and the fridge needed to be replaced. Similarly food temperatures had not been recorded as necessary at mealtimes. The food probe was seen to be unused, dusty and unhygienic for use and must be replaced. There was no evidence that management were monitoring practice in the kitchen as these issues had not been picked up and addressed. The last records were completed in January 2005. Staff are not supervised and there was no evidence of guidance to staff. Accident records were seen and found to be completed appropriately. The registered manager was asked to ensure staff provide detail of action taken in respect of the incident. The accident record book in use was almost complete; the registered manager was asked to provide and maintain a recognised accident record book as provided by the Health and safety executive as highlighted at the previous inspection. It was noted that a resident had died recently however the Commission for Social Care Inspection had not been informed. The registered manager completed a notification for the inspector during the inspection day. The accident record book also indicated that other significant events for example admissions to hospital have not been recorded and or notified to the relevant agencies including the Commission for Social Care Inspection. Gorway House DS0000020811.V259418.R01.S.doc Version 5.0 Page 23 Four actions were listed in an Immediate statutory requirement made at the time of the inspection in respect of a fridge with damaged seals and temperature recording and evidence of consultation with residents regarding dietary needs and preferences. These were subsequently addressed as requested by the management. The registered person relies on the maintenance person for annual checks of a number of health and safety matters. This was discussed in the summer inspection and the registered manager agreed to meet minimum standards and arrange for an authorised person to make the appropriate maintenance checks and provide certificates. The registered manager had stated the 5 year electrical test was booked to be done 6.06.05 however this was not completed and remains outstanding. Similarly the Corgi testing of boilers remains outstanding. These statutory requirements need urgent attention to ensure there are no unnecessary hazards or risks in the home and ensure the health and safety of the residents. Gorway House DS0000020811.V259418.R01.S.doc Version 5.0 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 2 X 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 1 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 1 2 2 X X X 1 2 2 STAFFING Standard No Score 27 1 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X X 1 1 1 Gorway House DS0000020811.V259418.R01.S.doc Version 5.0 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 Standard OP2 Regulation 5(1)(b) Requirement Ensure an annual letter with a statement of the annual increase or the current level of fee must be issued to the service user and a copy kept on file. 2.2 Timescale of 30/04/05 not met. The registered person and the registered manager must consult 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 registered person and the registered manager must consult the Commission for Social Care Inspection for an application in respect of three of the residents currently accommodated. Ensure the care plans have the signature of the service user/ relatives and involve them in drawing up their care plan. 7.6 Timescale of 30/04/05 not met. Ensure residents Care Plans are developed to set out in detail the action which needs to be taken by the care staff to ensure that all aspects of the health, DS0000020811.V259418.R01.S.doc Timescale for action 30/11/05 2 OP4 12(1) 30/11/05 3 OP4 12(1) 31/12/05 4 OP7 15(2) 31/12/05 5 OP7 15(2) 31/12/05 Gorway House Version 5.0 Page 26 6 OP8 12-1-16-1 7 8 OP8 OP9 14(1) 13(2) 9 OP9 13(2) 10 OP9 13(2) 11 OP9 13(1) 12 OP9 17(1)(a) 13 OP9 14(2) 14 OP15 17(2) 4 (13) personal and social care needs of the resident are met. 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. Ensure a weight chart is completed regularly and kept on the residents file. Ensure all matters identified by the Pharmacist for the Commission for Social Care Inspection are addressed. Medication must be administered in a safe and hygienic manner. Provide tots for administering medication. Provide a hard back secure bound book and implement recording of the receipt and disposal of medication. To be met within 24 hours. The registered person and registered manager must ensure that a risk assessment is completed for those residents that wish to administer their own medication. Records are kept of all medicines received, administered and leaving the home or disposed of to ensure that there is no mishandling. A record is maintained of current medication for each service user (including those self medicating) The registered person and registered manager must prompt a review of the medication of residents on a regular basis and a minimum of every twelvemonths. Provide evidence of consultation with residents regarding dietary needs and preferences for all DS0000020811.V259418.R01.S.doc 31/12/05 31/12/05 31/03/06 21/10/05 21/10/05 31/12/05 21/10/05 31/12/05 28/10/05 Gorway House Version 5.0 Page 27 15 OP18 12,13 16 OP19 23 17 OP20 23(2) 18 OP24 23(1)(m) 19 OP28 18(1) 20 OP29 19(1) mealtimes and produce menus detailing the choice of foods available. Ensure staff receive training in the Protection of Vulnerable Adults. Timescale of 30/09/05 not met. Ensure all of the fire resisting doors in the premises should be upgraded so that they have smoke seals fitted as well as intumescent strips. Provide approved hold open devices to be fitted to the office, laundry and big lounge doors. Provide a “Redlam” type glass shoot bolt for the exit gate from the garden for emergency use. Provide suitable training for staff by a competent person. 30/09/05 Deep clean easy chairs in lounges and bedrooms. Replace worn and stained chairs as necessary. Place risk assessment on case files or in the care plans regarding provision of keys to the door locks and drawer locks of service users rooms. 24.6 & 24.7. Timescale of 28/02/05 not met. The home must ensure that 50 of care staff within the home achieves NVQ level 2 or equivalent by 2005. 28.1 Timescale of 31/03/05 not met. 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. • • Advertise posts. Standard questions for interviews. 31/03/06 31/12/05 31/01/06 31/12/05 31/03/06 30/11/05 Gorway House DS0000020811.V259418.R01.S.doc Version 5.0 Page 28 21 22 OP29 OP29 19(1) Sch 2 7,9,19 23 OP29 Sch 2 7,9,19 CSA Sec 62 24 OP29 25 OP30 24(1) 26 OP30 24(1) 27 OP30 18(1) 28 OP30 18(1) 29 OP30 18(1) Score system to measure and record suitability and judgement. Letters of appointment to post. Ensure staff recruitment records hold proof of identity including a photograph. Ensure two written references are obtained before appointing a member of staff and any gaps in employment are explored. 31/05/05 Ensure all persons working in the home have satisfactory CRB and POVA checks with evidence held on file. Ensure staff are employed in accordance with the code of conduct and practice set by the General Social Care Council. Provide each member of staff with copies of the Code of Conduct. 30/06/05 The registered person and registered manager must ensure all staff receive contracts and job descriptions with copies to be held on file. The registered person and registered manager must provide a training plan and development programme for all staff. The registered person and registered manager must ensure all new staff receive induction training to NTO specification within the first six weeks of appointment to their posts. The registered person and registered manager must ensure all staff receive a minimum of three paid days training per year ( including in house training). The registered person and registered manager must ensure all staff have an annual staff appraisal. DS0000020811.V259418.R01.S.doc • 31/12/05 21/10/05 21/10/05 31/12/05 31/12/05 31/12/05 31/12/05 31/03/06 31/03/06 Gorway House Version 5.0 Page 29 30 OP31 9(2)(b)(i) 31 OP33 24(1) 32 OP33 24 33 OP36 18(2) 34 OP36 18(2) 35 OP38 13(4) 36 OP38 13(4) Registered managers must have a qualification at level 4NVQ in management and care or equivalent by 2005. 31.2 31/03/05 The registered person must provide an annual development plan for the home, based on a systematic cycle of planning – action – review, reflecting aims and outcomes for service users 33.2 Timescale of 30/04/05 not met. Provide evidence of continuous self monitoring, involving service users and an annual internal audit 33.3 Provide evidence of feedback from service users and relatives 33.6 Timescale of 30/04/05 not met. Provide the Commission for Social Care Inspection with a copy of a year plan of supervision sessions for all staff. 28/02/05 Timescale of 30/03/05 not met. Provide formal supervision for the staff at least six times a year with written records dated and signed by staff. 36.2 Timescale of 28/02/04 not met. Provide and maintain a recognised accident record book as provided by the Health and safety executive. Timescale of 31/06/05 not met. Ensure the maintenance checks and certificates are completed by a competent person and made available for the Hoists. Timescale of 30/04/05 not met. 30/06/06 31/12/05 31/12/05 30/11/05 31/01/06 31/12/05 31/12/05 37 OP38 13(4) Ensure the electrical 5year test is 30/11/05 completed by a competent electrician. Timescale of 30/07/05 not met. DS0000020811.V259418.R01.S.doc Version 5.0 Page 30 Gorway House 38 OP38 13(4) 39 OP38 13(4) 40 OP38 13(4) 41 OP38 13(3) 42 43 OP38 OP38 16 (2) (g) Sc 4 (13) 16 (2) (g) Sc 4 (13) 16 (2) (g) Sc 4 (13 44 OP38 45 46 OP38 OP38 16 (2) (g) Sc 4 (13) 17(2) Sch 4(12) Ensure the regular servicing of central heating systems and boilers by a competent person e.g. CORGI. Timescale of 30/07/05 not met. The registered manager must attend the Fire Prevention Training provided by the West Midlands Fire Department. Timescale of 31/08/05 not met. All staff must receive foundation training including infection control. Timescale of 31/08/05 not met. The registered person and registered manager must provide a First Aid Box in the kitchen and suitable blue plasters for kitchen staff. The registered manager must provide a new food probe. The registered person and registered manager must ensure Fridge and freezer temperatures must be recorded twice daily. The registered person and registered manager must ensure food temperatures must be recorded as necessary at mealtimes. The registered person and registered manager must provide a new fridge. The registered person and registered manager must ensure Notifications are made to the Commission for Social Care Inspection; provide a record of events (a) – (f) 30/11/05 31/03/06 28/02/06 30/11/05 21/10/05 21/10/05 21/10/05 28/10/05 21/10/05 Gorway House DS0000020811.V259418.R01.S.doc Version 5.0 Page 31 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 Refer to Standard OP9 OP14 Good Practice Recommendations The manager should monitor the administration of medication as part of the quality assurance self monitoring and annual audit. It is recommended that Key worker systems, monthly and six monthly review records involving service users and families, residents meetings, menu choices, activity and events records and newsletters are some that could be considered. The registered manager must ensure that there is a menu (changed regularly) offering a choice of meals in written or other formats to suit the capacities of the service user. The external decoration of the home should be completed during the summer as planned. It is recommended that staff receive training in Dementia Care, report writing and care planning. It is strongly recommended that residents are encouraged and assisted to hold residents meetings. 3 4 5 6 OP15 OP19 OP30 OP33 Gorway House DS0000020811.V259418.R01.S.doc Version 5.0 Page 32 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: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Gorway House DS0000020811.V259418.R01.S.doc Version 5.0 Page 33 - 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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