CARE HOMES FOR OLDER PEOPLE
Gorway House 40 Gorway Road Highgate Walsall West Midlands WS1 3BG Lead Inspector
Mrs Wendy Grainger Key Unannounced Inspection 21 May 2007 8:30 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.V338127.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.V338127.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.V338127.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 2nd November 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. Within the home are two lounges one used more frequently for any social events. The dining room is central to the home and off the kitchen area. Car parking is located at the front of the home. From the information provided by the care manager the current fees range from £350.00 to £400.00 per week. Additional costs would include hairdressing, personal newspapers, private chiropody and toiletries. Gorway House DS0000020811.V338127.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out be Mrs Wendy Grainger Inspector on the 21st May 2007 from 8.30 6.15pm. This was the first visit to the home by this inspector who was assisted by one of the care managers initially followed by the other joint manager for the remaining part of the day. The provider also visited the home during the inspection. The previous inspection report was fully discussed, the numerous requirements were part of the main focus for the inspection to ascertain their compliance. Records where available were provided, documents were inspected, discussions as how the home is to move forward took place. A tour of the home was undertaken with the care manager. Staff were spoken with as were a small section of the 28 residents. Staff were observed during the day and found to be sensitive to the needs of the people who use the service. What the service does well:
It was obvious to the inspector that people who use the service were satisfied with the daily, relaxed routine of the home. Service users spoken with confirmed that they “enjoyed going into the garden”, this was evidenced during the day. Breakfast was a choice of a cooked meal, residents were asked their preference by the staff prior to serving a bacon sandwich. Senior staff administered the morning medication; she was polite and spoke to individuals, each time thanking them after the tablets had been taken. The home, it appears operates for the benefit of the people who use the service. One resident told the inspector that “she liked it here” “ she had settled down well” “the owner mended my skirt which was so kind of her” another resident said “the staff are so nice” “the home is spotlessly clean” Gorway House DS0000020811.V338127.R01.S.doc Version 5.2 Page 6 People who use the service were aware of the management and who to approach in the event of a concern. People who use the service could access the well -tended tranquil garden, with lawns and areas to relax in. The people who use the service were provided with exceptionally high standards of hygiene through out the home, which was a credit to the housekeeping staff. Staff were observed to knock and wait to enter rooms occupied by individuals. One of the recommendations previously was to consider having a key worker system this has been considered by the management, who will not be pursuing this practice, What has improved since the last inspection? Since the last inspection the home had continued with the rolling programme of refurbishment and decoration of bedrooms when they have been vacated. The management had arranged for professional help to develop the care plans and other documents required to comply with requirements made by the Commission. The staff had completed a course for the care of people with dementia. The majority of the requirements made on the last inspection had been addressed. There remained areas of concern, which will be identified in this inspection report. The management had commenced some meetings for the staff and people who use the service; notes for each session were made available. Records for the medicines received and administered into the home were now completed. Gorway House DS0000020811.V338127.R01.S.doc Version 5.2 Page 7 The staffs on duty throughout the day were observed to assist discreetly, they were friendly and respected an individual’s choice to relax and appreciate their life style. What they could do better:
The provider and management had not responded within the time scale for the previous requirements made; a number of them were six months out of date. Previous requirements were to protect the people who use the service health and safety and remained a concern on this inspection. The home had not requested a variation to the present registration, to accommodate one person that was not within the homes category. Further non- compliance could result in the Commission taking enforcement. There remains no evidence of people who use the service being involved in their care plans or reviews. The management had changed the documentation but had not actioned the proposed plan. The risk assessments remained incomplete, management did not appear to recognise the calculated risks taken by people who use the service take within and external to the home. The entire mandatory training programme remained out of date this could leave people who use the service at risk. Staff had recently received some training for the care of people who use the service with a dementia. The senior staff on duty on the day of the inspection commenced action from the previous requirement to have a copy of specimen signatures of the staff on file for the administration of medicines. The home had not completed attaching photographs of each people who use the service to the medication record sheet. There was limited evidence of people who use the service involvement in a meeting it is important that these meetings continue and include the dietary requirements and preferences for all mealtimes, and to produce full menus detailing the daily choice of food available. The previous inspection date of 31/12 06 to ensure that the radiators were guarded had not been completed. During the inspection on the 2105/07 the manager had a telephone call to arrange a date for the covers to be fitted. The quality audit and self monitoring of the home had not been fully developed since the previous inspection. No evidence of the feedback from the people who use the service and or relatives was available. Three of the staff records were evidenced chosen at random by the manager. They were unsatisfactory with an incomplete application form, no personal
Gorway House DS0000020811.V338127.R01.S.doc Version 5.2 Page 8 photograph, and no copies of birth certificates. Two had no references; there was no evidence of a written induction programme where a mentor or manager had confirmed competency of the new member of staff to work with older people. No job descriptions were evidenced on the files, it was not ascertained if they were maintained in another folder. Formal staff supervision had not been undertaken this remains outstanding since 2004. The inspector was told that the home now had documents in place to commence this on the 24/05/07 Records evidenced that the home continues to fail to ensure that fire drill for the staff and people who use the service were undertaken twice yearly. The management had not attended a fire training course to ensure they were current with Fire Safety Regulations as required on the previous inspection. 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.V338127.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Gorway House DS0000020811.V338127.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor Standards 1,3,4 were reviewed. This judgement has been made using available evidence including a visit to this service. The home could not provide a current Statement of Purpose that would enable a member of the public to make an informed choice where to live. The management had a basic letter to use when a person who will use the service has been assessed prior to admission. The home had previously admitted a resident that was out of category without an assessment of their needs, which could be complex; this action could result in the person being at risk. EVIDENCE: Gorway House DS0000020811.V338127.R01.S.doc Version 5.2 Page 11 At the time of the inspection the managers could not identify the location of the current Statement of Purpose, the service users guide was incomplete and was not given to each of the people who use the service. This was discussed with the managers at the time of the inspection. A basic letter to confirm a placement had been constructed, at the time of the inspection there had been no reason to use the letter. The contents of the letter was discussed, and advised that the manager refer to the National Minimum Standards to ensure that the letter referred to the assessed needs of people who use the service . Previously the managers had admitted a person who was out of category to the registered certificate. From today’s discussions and evidence in the care plan the previous requirement to vary the certificate had not been addressed, this could leave the needs of this person not being met. Further noncompliance could result in the Commission considering enforcement action. Staff training may be required to meet the needs of this individual. While the daily personal needs were being met, the mental health needs may need to be monitored. Gorway House DS0000020811.V338127.R01.S.doc Version 5.2 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate, Standards 7,8,9,10 were reviewed This judgement has been made using available evidence including a visit to this service. The sample of plans seen remained incomplete a structure including risk assessments had been developed on paper since the previous inspection; implementation in full was not evidenced. Arrangements were in place for the continued health care needs for people who use the service. The medication routine was satisfactory; there remained two areas that could be a potential hazard for the safe keeping of the medication. Staff were seen and heard to be respectful, helpful and knowledge based in their care of individuals. EVIDENCE:
Gorway House DS0000020811.V338127.R01.S.doc Version 5.2 Page 13 The managers had employed a private consultant to assist in the construction of the care plans and risk assessments. At the time of the inspection they were not being used fully by the home. Care plans should also include the social, emotional, spiritual and any special needs of individuals. Risk assessments were very underdeveloped and the managers need to revisit the needs of all the people who use the service at Gorway, to ensure each personal calculated risk was assessed. The risk assessments evidenced on the homes computer and then transposed into the care plans were corporate and not individualised. This was discussed with the manager. With the exception of one care plan evidenced that the plans were reviewed monthly. At the time of the inspection three of the people who use the service were receiving care from the district nursing service. Records seen evidenced that people who use the service could receive care from a general practitioner, optician and chiropodist. The morning medication procedure was observed, the senior care staff demonstrated her awareness of individuals’ requirements. Records were satisfactory. The previous requirement to have a copy of the staff signatures of all the staff that administer medication had not been completed. The senior care person commenced the record at the time of the inspection. It will be a recommendation to ensure the safe keeping of medicines that the medicine trolley and the box holding any controlled drugs are secured to the wall and inside the trolley. Any creams and eye medication received should be dated at the time of opening. Any person that chooses to self-administer their medication must have a completed risk assessment, which is reviewed on a regular basis. There was a need to develop a protocol for residents that are prescribed PRN medication. The inspector had concerns that the home had accepted medication with “as directed” instructions. This is poor practice; prescribed medication received into the home should contain the accurate prescribing details to reduce the risk of mistaken administration During the inspection the staff were observed to show respect when speaking to individual people. Staff knocked on doors prior to entering bedrooms. The staff on duty during the inspection were polite and demonstrated their commitment to the people who use the service. Assistance was provided in a sensitive manner respecting individuals privacy and dignity. The people who use the service told the inspector that the staff “were excellent” “I would not stay if the staff were not nice to me” Gorway House DS0000020811.V338127.R01.S.doc Version 5.2 Page 14 Gorway House DS0000020811.V338127.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): Quality in this outcome area is adequate. Standards 12,14,15 were reviewed This judgement has been made using available evidence including a visit to this service. People who use the service were generally supported by the staff in activities, it would appear that some activities did not relate to personal preferences. As part of the homes policy, visitors were welcome to visit the home at any time except meal times. The meal of the day was well presented; some people who use the service chose alternatives. Menus however could be more varied with a continued daily-recorded choice. EVIDENCE: During the inspection it was obvious that people who use the service had autonomy to exercise their choice to go into the community. One resident went to post a letter. One other person attends the church of her choice weekly. At the time of the inspection it was discussed that while the home advertises an art/craft session on a Friday it was not attended by the people who use the
Gorway House DS0000020811.V338127.R01.S.doc Version 5.2 Page 16 service. It was suggested on this visit as on previous inspections that the home seeks the interests of individuals and accommodate them. One resident told the inspector that she “enjoyed the keep fit it keeps my knees going” The manager told the inspector that the spiritual needs were catered for on a monthly basis. There were no activities observed during this inspection. Visitor were welcome at any time and welcome to take out their relative; no visitors were available to speak to during the inspection, feed back about the home and service was not provided from this section. Upon arrival breakfast was being served, people who use the service were asked their preference for a bacon sandwich or cereals and toast. Breakfast was very relaxed; the dining room could be more homely with tablecloths. The manager told the inspector that they found tablecloths to be impracticable and the tables were “Formica”. It is planned to have new dining room furniture. The meal of the day was well presented with two alternatives, which was chosen by some people who use the service. The meal was followed by apple crumble and custard. Menus provided by the manager were not pertinent to the meal of the day. No evidence of a record for the alternatives could be provided. The temperatures for the fridge and freezer were not always consistent and need to be monitored to ensure that food is stored correctly. Gorway House DS0000020811.V338127.R01.S.doc Version 5.2 Page 17 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate Standards 16,18 were reviewed This judgement has been made using available evidence including a visit to this service. The home had a reviewed and up dated the complaints procedure, an alternative format had not been produced to enable people who use the service ease of access. There was a need for all the staff to have training around the safeguarding of adults, without this knowledge inconsistencies could leave individuals at risk. EVIDENCE: The home had obtained a copy of the Walsall Social Services Adult Policy since the pervious inspection. The homes complaint procedure now contained the timescales to which a complaint would be addressed. Discussed was the need to consider an alternative format for people who have a disability ease of access. One resident felt that she could go to the managers to discuss concerns. It is important that further staff training is implemented in particular to the protection and awareness of the need to protect people who use the service. At the time of this inspection the manager told the inspector that only three of the staff had undertaken this training.
Gorway House DS0000020811.V338127.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. Standards 19 20 23 24 25 26 were reviewed. This judgement has been made using available evidence including a visit to this service and tour of the home. The home provides a comfortable environment where people who use the service can relax. High standards and personalisation were observed during the tour of the home. The concerns identified during the tour of the home were a potential hazard for people who use the service. EVIDENCE: Gorway House DS0000020811.V338127.R01.S.doc Version 5.2 Page 19 Located in a quiet area of Walsall near to a local college Gorway House is a detached home that has been over the years extended. Parking is at the front of the home. The gardens at the rear were tranquil and easily accessed by the people who exercised their autonomy as observed during the inspection. The environment observed was comfortable, one of the lounges had a more homely, well designed ambience than the lounge near to the dining room, the housekeeping staff should be congratulated for the exceptionally high standards they achieve. During the tour of the home and from comments by the people who use the service it was obvious that they were encouraged to personalise their rooms. Within the bathroom area there evidenced were a number of toiletries, sponges, continence equipment and uncovered toilet rolls. This practice is unacceptable and a potential cross contamination and infection control issue. A number of the toilet roll holders were broken. From the testing of the water taken on the day of the inspection from the bathroom on the ground floor it was identified as being above the recommended temperature, as was the water from the wash hand basin in the toilet near to the office (50o) this was again a potential hazard to the people who use the service. Each bathroom requires a thermometer; staff should test the water prior to each bath; and not to use an elbow as is the present practice used as explained by one member of the staff. If the wardrobe located on the first floor landing is to remain there then it must be secured to the wall. The corridor to the office and rear of the home required attention to secure the join, this was pointed out to the handyman at the time of the inspection. The inspector was concerned that there remained a number of radiators, which had not been covered as required on previous inspections the last time to comply with the requirement was 31/11/06. During the inspection the manager received a telephone call from the people who had been commissioned to protect the radiators. Observed during the inspection was one zimmer frame with the ferrules in a poor condition. The manager needs to ensure that homes audit includes the frames and walking sticks to ensure that the ferrules were in good order and not a potential hazard for the individuals and or carpets. Gorway House DS0000020811.V338127.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. Standards 27,28,29,30 were reviewed This judgement has been made using available evidence including a visit to this service. Staffing levels appeared to be adequate to meet the needs of the present people who use the service. The staffs as individuals or a group do not have the necessary mandatory training skills to ensure the safety and protection of the people who use the service. Recruitment practices are not robust and potentially expose the people who use the service to workers who may not be suitable. EVIDENCE: At the time of this inspection there appeared to be sufficient numbers of staff on duty to meet the personal and health care of the people who use the service. the dependency levels of the residents appear to be low with the majority of the people who use the service mobile independently. Care staff were supported daily by the housekeeping and catering staff. At the time of the inspection there were no staff vacancies. The manager had devised
Gorway House DS0000020811.V338127.R01.S.doc Version 5.2 Page 21 a form to use when interviewing new staff. Each new member of the staff were handed the Codes of Practice. The inspector was concerned as to the lack of mandatory training provided for the staff. Training was out of date; staff had completed a course for Dementia awareness with an exam at the end in September 2006. The inspector was unable to evidence any records for Moving & Handling, Infection Control, Health & Safety, and First Aid. The catering staff were the only staff that had current Food & Hygiene training. Three of the staff records were evidenced chosen at random by the manager. They were unsatisfactory with an incomplete application form, no personal photograph, and no copies of birth certificates. Two had no references; there was no evidence of a written induction programme where a mentor or manager had confirmed competency of the new member of staff to work with older people. No job descriptions were evidenced on the files. Gorway House DS0000020811.V338127.R01.S.doc Version 5.2 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor Standards 31 33 36 38 were reviewed. This judgement has been made using available evidence including a visit to this service. The managers continued to develop their skills in care and management,. There remains no progress in the development and implementation of a quality assurance system to ascertain feedback from other agencies or people who use the service. There was inadequate supervision of the staff; the lack of mandatory training could leave staff and people who use the service at risk. The lack of fire training in particular for the night staff could put the people who use the service at risk. Gorway House DS0000020811.V338127.R01.S.doc Version 5.2 Page 23 EVIDENCE: Standard 35 was not inspected on this inspection, therefore it will not be scored. The registered managers continue with the Registered Managers Award, there has been administrative problems but the training is back on line to complete at the end of the year. During the inspection it was obvious that the people who use the service were aware of the managers who responded to the individuals well being and welfare during the day. There remains no development in the formal obtaining of feedback on the service the home provides. Stakeholders, residents and families were not surveyed. It is important that the provider and the managers seek feedback and make the surveys available to the Commission on the next inspection. The inspector following a discussion with the morning staff could not evidenced that they had received formal staff supervision, which should take place a minimum of six times each year. Records in respect of the weekly and monthly testing for the protection and prevention of fire were current. There was a concern that records for any of the night staff being involved in a fire drill could not be evidenced. There was an urgency for this to take place. Failure to address this could leave the people who use the service at risk. The inspector evidenced records that identified that the homes water at the time of the inspection was legionella free. There was a need for the home to maintain records of the water temperatures in the event that the equipment i.e baths/showers used for full emersion did not have a thermostatic control. This record should be maintained on a monthly basis, to ensure the safety of the people who use the service. Gorway House DS0000020811.V338127.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 3 2 X 3 3 2 2 STAFFING Standard No Score 27 2 28 3 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X 2 X 2 Gorway House DS0000020811.V338127.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP4 Regulation 12(1) Requirement 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 Variation to the home’s Category of Registration must be sought for the person with dementia. Outstanding 30/11/06. Timescale for action 16/06/07 2. OP7 15(2) Care plans must set out in detail 16/06/07 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. Failure to do so could leave people who use the service at risk and not receiving the appropriate care (Previous timescale of 31/07/06 30/11/06 not met.) Arrangements must be made by the manager to ensure that staff
DS0000020811.V338127.R01.S.doc 3 OP30 18 (a)(c)(i) 16/06/07
Page 26 Gorway House Version 5.2 4 OP38 13(4) are trained in the mandatory training requirements to ensure that the people who use the service are not at risk. Ensure the maintenance checks 16/06/07 and certificates are completed by a competent and qualified person and made available for the Hoists, personal equipment used by individuals and water accessed by the people who use the service must be checked on a regular monthly basis to ensure the safety of individuals. (Previous timescales of 30/04/05, 31/12/05 and 30/06/06 30/11/06 not met). 16/06/07 5 OP7 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 30/11/06 not met). 13(2) A photograph of each service user must be attached to their medication administration record sheet. This practice will prevent the potential missadministration of medicines All radiators must be guarded or have guaranteed low temperature surfaces. Failure to complete this leaves the people who use the service at risk (Previous timescale of 31/08/06 31/12/06 not met). Personal toiletries of the people who use the service should be returned to their rooms, to protecting other people from harm. The home must ensure that there is a person with up to date training in First Aid available on
DS0000020811.V338127.R01.S.doc 6 OP9 16/06/07 7 OP25 13(4) 16/06/07 8 OP26 13(3) 16/06/07 9 OP38 13(4) 16/06/07 Gorway House Version 5.2 Page 27 each shift. People who use the service are at risk without the appropriate training of the staff outstanding 30/11/06 10 OP38 23(4) The home must ensure that 16/06/07 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. outstanding 30/11/06 11 OP9 13 The home must ensure that on receipt of any medication that labels are fixed with the full administration details. “as directed” leaves the people who use the service at risk and a potential mis-administration of medication. 16/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations The manager should monitor the administration of medication as part of the quality assurance self monitoring and annual audit. To ensure that the areas where food is stored maintains a constant temperature and the surfaces were cleaned as part of the kitchen schedule for cleaning. To ensure that the home receives feed back of the service provided the system to be implemented for this should be activated as soon as possible and will be part of the core
DS0000020811.V338127.R01.S.doc Version 5.2 Page 28 2 3 OP15 OP33 Gorway House 4 OP9 issues for the next inspection. To ensure that medication was stored appropriately the container and medicine trolley should be secured at all time when not in use. It is recommended that, in addition to a book for recording Complaints, the home supply a Comments Books for service users and their visitors. 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. 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). Provide formal supervision for 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). 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). 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). The home must keep a copy of the specimen signatures of all those staff who administer medication. Nutritional screening must be undertaken on admission and subsequently on a periodic basis, a record maintained of nutrition. Provide evidence of consultation with residents regarding dietary needs and preferences for all mealtimes and produce menus detailing the choice of foods available. ( (Previous timescales of 28/10/05 and 30/06/06 not met).
DS0000020811.V338127.R01.S.doc Version 5.2 Page 29 5 OP16 6 OP29 7 OP36 8 OP4 9 OP7 10 11 OP9 OP15 12 OP3 Gorway House 13 OP12 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). 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 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 home must develop a record/system for the people who use the service and their administration of any PRN medication. The manager must provide a training plan and development programme for all staff this should be forwarded to the Commision. Failure to provide appropriate training could leave the people who use the service at risk. (Previous timescales of 31/12/05 and 31/07/06 30/11/06 not met). 14 OP28 15 OP38 16 17 OP9 OP30 Gorway House DS0000020811.V338127.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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.V338127.R01.S.doc Version 5.2 Page 31 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
