Inspection on 24/05/05 for Gorway House

This inspection was carried out on 24th May 2005.

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 02/11/06

Gorway House 31/05/06

Gorway House 20/10/05

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 Announced 24 May 2005 th 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 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 E55 S20811 Gorway House V229336 240505 Stg4.a .doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Gorway House Address 40 Gorway Road, Highgate, Walsall, West Midlands, WS1 3BG Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01922 615515 01922 725059 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 E55 S20811 Gorway House V229336 240505 Stg4.a .doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th November 2004 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 E55 S20811 Gorway House V229336 240505 Stg4.a .doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection was made on Tuesday 24th May 2005 at 8.30 am. The registered manager, manager and registered person were informed of the visit and attended to assist the process of the inspection. 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. The registered manager made available the pre inspection questionnaire prior to the inspection. The inspector made a brief tour of the premises and spent time in the lounge area with service users and also had the opportunity to speak with relatives. The administration of medication was observed at lunchtime. Only two feedback questionnaires were received from residents. No questionnaires were received from relatives. All of the unused questionnaires were returned to the inspector. Records and policy and procedures were seen. The management of the home had made some progress in respect of the statutory requirements of the inspection reports in the previous inspection year. 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 is required that an action plan is submitted to CSCI stating actions to be taken, who by and proposed completion dates. The inspector wishes to acknowledge the progress made by management and staff is evident. It is beginning to make an impact on the daily lives of residents and the quality of care provided. What the service does well: What has improved since the last inspection? The management have begun to make progress with the outstanding statutory requirements many of which had recurred over several inspection visits and reports. There is a visible improvement in the presentation of the home and grounds, with gardens front and rear looking very attractive. New furnishings and lighting were provided. Decoration in the lounge and one of the bedrooms has been completed. Some staff are completing their NVQ level 2 and they are Gorway House E55 S20811 Gorway House V229336 240505 Stg4.a .doc Version 1.30 Page 6 using learnt knowledge and skills in daily care practice. Staff are completing the accredited medication training. The homes administration systems and records are being gradually updated making information more readily accessible and comprehensive. 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 E55 S20811 Gorway House V229336 240505 Stg4.a .doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection Gorway House E55 S20811 Gorway House V229336 240505 Stg4.a .doc Version 1.30 Page 8 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 standard(s) 2,3,4 and 5 There has been some progress with the procedure for admissions to the home through improvements to the assessment format and a letter of confirmation giving assurance that the residents needs can be met. There is greater clarity in contractual arrangements and letters held on file providing confirmation for the resident of the terms and conditions and financial agreement. EVIDENCE: There were twenty six residents accommodated on the day of the inspection. The home has two shared rooms occupied by a sole person. In the pre inspection questionnaire the information on residents needs was incomplete with no response stating whether any residents have dementia, mental health needs or are incontinent of urine. It was stated that none of the residents require the assistance of two or more members of staff to undertake their care. A sample of resident’s records were seen. It was found that files had been restructured with clear labelling and index with dividers. The home has developed a comprehensive assessment of needs format and this will be implemented with new residents. For those currently living at the home assessments of residents needs had been provided by the health authority and Gorway House E55 S20811 Gorway House V229336 240505 Stg4.a .doc Version 1.30 Page 9 by the placing authority. These varied in detail and information presented. The registered manager makes the initial assessment at the time of referral / enquiry and during the introductory visit of the prospective resident and their relatives. The registered manager states that a letter has been provided to be used for new admissions to the home confirming that their needs can be met. Contracts have been reviewed to include the required information of room numbers and relevant signatures. Letters are also to be provided and held on file for each resident to inform them of annual fee increases. The home does not provide intermediate care. Gorway House E55 S20811 Gorway House V229336 240505 Stg4.a .doc Version 1.30 Page 10 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 standard(s) 7,8,9 and 10 The home maintains basic records of the health needs of residents. All relevant health care services are contacted and accessed as the need arises to ensure the health and well being of the residents. Informal care practice is gradually being reinforced by formal systems and procedures to ensure quality of care is provided. EVIDENCE: Individual care plans have been updated in format to be comprehensive covering all aspects of health, personal and social care, including pressure sore treatment. Basic details are recorded with brief comment of how these needs are to be met. It is proposed by the registered manager, these will be further developed by staff with residents and their relatives at the time of reviews. Relatives had said “ Staff call the GP out if my relative is unwell and let us know straight away.” Records seen held details of the frequency of personal care provided in respect of bathing, bed change, chiropody, nail care, hairdresser, keep fit and communion. Care plans were not signed and dated by service users or their relatives to demonstrate their involvement and consultation in this process. Daily logs recorded significant events including visits from relatives, community psychiatric nurse and significant others. Gorway House E55 S20811 Gorway House V229336 240505 Stg4.a .doc Version 1.30 Page 11 Residents said “the staff are always very helpful and will do anything they can for you”. Two of the service users administer use of inhalers. None of the other residents self administer their own medication. Some staff have completed accredited training in the safe handling and administration of medication; there are five currently completing a distance learning programme. The recording, storage and administration of medication was seen to be in good order. There is a policy and procedure for the administration of medication and staff sign to say they have read it. Two double rooms have been retained for sole occupation at the present time with due respect to the individuals personal preference. The residents were seen to be treated respectfully by staff and appropriate facilities and space is provided for their personal care needs and private or personal visitors. Gorway House E55 S20811 Gorway House V229336 240505 Stg4.a .doc Version 1.30 Page 12 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 standard(s) 12,14 and 15 There are well established daily routines within the home which enable staff to meet the residents needs. The new activities programme has made a difference to daily lives of residents and staff engaged in the programme; improving the quality of relationship between them and the atmosphere in the home. EVIDENCE: There has been a significant improvement in the atmosphere at the home with an activities programme being introduced covering different leisure interests. The inspector observed a seated exercise programme led by one of the care staff with residents seated in the main lounge. Most residents enjoyed the activity some chose to observe. The care staff chatted easily with the residents and was enthusiastic about the warm response from residents to new activities such as poetry reading and music. Some of the residents enjoying dancing with staff or taking a walk around the garden. There is a weekly art / craft session with a prize for the chosen winner. By popular request from residents two new budgerigars have been provided in the main lounge and one of the residents contributes to the care of the pets. Residents also enjoy the manager’s pet lap dog. Records note the visits from a local church and celebration of communion. This should be further developed to record and reflect individual choice and preference. Gorway House E55 S20811 Gorway House V229336 240505 Stg4.a .doc Version 1.30 Page 13 Visitors are welcome at the home and information is available in the home’s brochure of visiting arrangements. The visits of children to the home are greatly enjoyed by all. One of the visitors said “ they can come at anytime and have visited at different times of day. The home is pleasant, tidy and clean and their relative seemed happy here”. Residents said the food was very good and there was plenty to eat. None of those spoken with were able to say what they expected for lunch. Menus have been provided but do not reflect an alternative available. A list of alternative meals is held in the menu folder. Staff have informal knowledge of service users preference’s and will offer an alternative if this is required. Residents knew there was a set time for meals and were eager to make their way to the dining room at the appropriate times. The home does use an intercom system throughout the premises to inform staff and residents of events within the home and to contact staff or residents if necessary. Residents spoken with said they did not mind this and it served as a helpful reminder. The home did not have a full time cook at the time of inspection but had advertised the post. A member of care staff was designated kitchen duties and had the relevant qualification. Gorway House E55 S20811 Gorway House V229336 240505 Stg4.a .doc Version 1.30 Page 14 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 standard(s) 16 and 18 The home has produced a complaints procedure with timescales and contact details for the Commission for Social Care Inspection and made this available through the home’s brochure and on display in the office. The management encourage staff to address issues as they arise or refer direct to the manager. There has been an improvement with the administration and operational systems of adult protection through policy and procedures and a raised awareness of issues in the home; these contribute to safeguarding the well being of the residents. EVIDENCE: The home’s complaints policy and procedure has been made available in the home’s brochure and placed on the office notice board. There have been no complaints received by the home since the last inspection and none have been made directly to the Commission for Social Care Inspection. The home did have an Adult Protection Investigation held within the past twelvemonth period. The outcome found there was no evidence to uphold the complaint. Some regulation issues were highlighted during the inspection and were reflected in statutory requirements in the previous inspection reports. The registered provider and management have made an effort to address issues raised. The home has provided Adult Protection policy and procedures. The inspector advises that management and all staff should attend training provided by the local authority adult protection team. Some staff have a basic knowledge of adult protection issues through module covered in their NVQ level 2. Gorway House E55 S20811 Gorway House V229336 240505 Stg4.a .doc Version 1.30 Page 15 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 standard(s) 19,20,21,25 and 26 The home provides a safe and pleasant environment for residents to live comfortably with suitable facilities to meet their needs. Communal lounges and individual rooms have a pleasant aspect overlooking attractive gardens to the rear and front of the building. There is an ongoing programme of repair and decoration to maintain pleasant and comfortable surroundings for the residents. There are some outstanding health and safety issues including fire officers recommendations that must be met to ensure a safe environment for residents. EVIDENCE: New planting in the garden is evident in attractive displays front and rear. The general repairs and maintenance of the premises continues to be in good order with a record of maintenance kept in the home. The front door has been painted however there are plans for paintwork to be done to the exterior of the building window frames and facia boards during the summer months. Gorway House E55 S20811 Gorway House V229336 240505 Stg4.a .doc Version 1.30 Page 16 Since the last inspection the home has provided new lighting from chandeliers in the front lounge and removed the carpet to resurface the wooden flooring. A new sofa has been provided in the front lounge with six new chairs in individual rooms. The main lounge and one bedroom have been redecorated. New furniture has been provided in four of the bedrooms including new beds. The flooring in two bathrooms has been resurfaced and some pictures hung. The office has been decorated and modernised with new furniture and fittings. On the day of the inspection the premises were clean, hygienic and free from offensive odours. The laundry facilities were in good order and residents confirmed they had no problems with laundering arrangements at the home. The home has provided policies for the control of infection and provides protective clothing and disposable gloves. The registered person relies on the maintenance person for annual checks of a number of health and safety matters. To meet minimum standards an authorised person must make the appropriate maintenance checks and provide certificates as listed in the statutory requirements. 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 E55 S20811 Gorway House V229336 240505 Stg4.a .doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28,29 and 30 The home does not meet the national minimum standards in respect of the recruitment, competence and support of staff. This is a very serious shortfall in service delivery and leaves residents and staff vulnerable to accident and incident and poor qualities of care. The systems in the home are not robust and do not provide the safeguards to offer protection to people living in the home. EVIDENCE: Incorrect information and incomplete information was provided regarding staffing in the pre inspection questionnaire. A sample of staff records seen at the home are incomplete and difficult to access relevant information. The manager takes a lead on staff recruitment, wages, records and staff arrangements. It was stated at the inspection that there are ten care assistants, six night care assistants, one of the care staff is covering the duties of the cook and one maintenance person. The cook chose not to return to work after a period of leave. The home has recently employed two new members of care staff. Two people were employed by the home with no Criminal Records Bureau checks and none had been requested. A further three were employed at the home and Criminal Records Bureau checks had been requested but not returned since April 2005. There is a self employed gardener who is contracted by the home. Gorway House E55 S20811 Gorway House V229336 240505 Stg4.a .doc Version 1.30 Page 18 There has been some progress with staff files being provided and an index of records to be maintained. A sample of files seen, were incomplete. Staff have been issued with job descriptions and a statement sheet with the core values of the home. Also provided are the core policy and procedures for foundation topics. Residents spoken with said “staff are helpful and friendly but were very busy”. The focus in the home is on group events and activities. Events or outings outside the home are organised or by escort from relatives and friends. Twelve staff are enrolled to complete their NVQ level 2 on a distance learning course with an independent assessor. Four staff have almost completed their NVQ 2 and intend to enrol for their level 3. The manager is beginning to gather copies of staff training certificates on their individual files and gather a training profile for the service. Five staff are currently completing the Protocol distance learning in the safe handling and administration of medication training. The home has recently introduced an induction package; new staff will be asked to complete. All staff then complete foundation training in the safe working practice topics; those recently covered are Manual handling, food hygiene and first aid. Gorway House E55 S20811 Gorway House V229336 240505 Stg4.a .doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,35,36,37 and 38 The management duties and functions are fulfilled at a basic level to maintain the day-to-day business of the home. There remains a significant number of statutory requirements to be met to achieve effective and efficient management of the home and provide consistent quality of care and quality assurance 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. Neither of the managers have the required qualifications for the role however they confirmed they are due to enrol September 2005. Managers will attend in-house training with staff to update their skills and knowledge in foundation topics. Gorway House E55 S20811 Gorway House V229336 240505 Stg4.a .doc Version 1.30 Page 20 Traditionally the management provide informal guidance and instruction to the staff to ensure the health and well being of the residents. There has been some progress in this area; the management has contracted the services of an independent consultant to assist with developing comprehensive policies and procedures and updating existing recording formats and systems. There are set daily routines and practices. Individual arrangements can be agreed and made where specific requests are made by residents or family. The registered manager states all residents and or their families manage their own finances. The management and staff do not handle residents monies for hairdressing or other services, they are billed directly and make payment themselves. No monies or valuables are held for safe keeping in the office. 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. As developments at the home are discussed and agreed amongst the family an annual development plan has not been considered necessary. There are no formal systems for the monitoring of practice in the home. There has been some progress with the provision of policies and procedures. An effort has been made by the registered manager to address some of the statutory requirements from the previous inspections. The individual supervision of staff was not assessed on this occasion. The report dated 18.04.05 of the Fire Officer’s visit had a range of issues to be addressed. The registered manager confirmed the majority of these had been completed those remaining are listed in the statutory requirements. The Fire equipment was last checked 11.11.04. The Fire Alarm is checked weekly. A Fire Risk Assessment has been provided. The Health and Safety poster was displayed in the office. Basic maintenance of safe working practice topics is covered by the maintenance person. This includes checking and maintenance of the call system and wheelchairs. A repairs and maintenance record is made, signed and dated. The PAT Testing was done 25.01.05, Emergency lighting service 2.05.05. Environmental health visited 20.12.04. The lift service is due on 2.06.05. This however does not fulfil all of the statutory checks to be made by an authorised person. Those outstanding are listed in the statutory requirements and must be given a priority in order to ensure the health, safety and welfare of the residents. The registered manager states the 5 year electrical test is booked to be done 6.06.05. Gorway House E55 S20811 Gorway House V229336 240505 Stg4.a .doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 2 15 2 COMPLAINTS AND PROTECTION 3 3 3 x x 2 3 3 STAFFING Standard No Score 27 1 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 1 x 1 x 3 2 3 2 Gorway House E55 S20811 Gorway House V229336 240505 Stg4.a .doc Version 1.30 Page 22 Yes Are there any outstanding requirements from the last inspection? 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 2 Regulation 5(1)(b) Requirement 1. 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. 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. 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) Ensure staff receive training in the Protection of Vulnerable Adults 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 Timescale for action 30/06/05 2. 7 15(2) 30/06/05 3. 9.3 17(1)(a) 30/06/05 4. 5. 18.1 19.5 12,13 23 30/09/05 30/09/05 Gorway House E55 S20811 Gorway House V229336 240505 Stg4.a .doc Version 1.30 Page 23 6. 24 7. 27 8. 27 9. 28 10. 29.2 11. 29.3 12. 29.4 13. 31 14. 33 shoot bolt for the exit gate from the garden for emergency use. Provide suitable training for staff by a competent person. 23(1)(m) 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. 18(1) Ensure suitably qualified and experienced cook(s) are employed to cover the kitchen duties. 18(1) The home must ensure that in instances where staff undertake dual functions within the home, the proportion of time spent on each function is clearly identified on the rota. 27.7 18(1) The home must ensure that 50 of care staff within the home achieves NVQ level 2 or equivalent by 2005. 28.1 31/03/05 Sch 2 Ensure two written references 7,9,19 are obtained before appointing a member of staff and any gaps in employment are explored. Sch 2 Ensure all persons working in the 7,9,19 home have satisfactory CRB and POVA checks with evidence held on file. Care Ensure staff are employed in Standards accordance with the code of Act conduct and practice set by the Section 62 General Social Care Council. Provide each member of staff with copies of the Code of Conduct. 24(1) Registered managers must have a qualification at level 4NVQ in management and care or equivalent by 2005. 31.2 31/03/05 24(1) The registered person must provide an annual development E55 S20811 Gorway House V229336 240505 Stg4.a .doc 30/06/05 31/07/05 30/06/05 30/11/05 31/05/05 31/05/05 30/06/05 30/09/05 31/06/05 Page 24 Gorway House Version 1.30 15. 33 24 16. 36 18(2) 17. 36 18(2) 18. 38 13(4) 19. 38 13(4) 20. 21. 38 38 13(4) 13(4) 22. 38 13(4) 23. 30 12,18 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. 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. Ensure the electrical 5year test is completed by a competent electrician. Ensure the regular servicing of central heating systems and boilers by a competent person eg CORGI The registered manager must attend the Fire Prevention Training provided by the West Midlands Fire Department. All staff must receive foundation training including infection control. 30/09/05 30/06/05 31/07/05 30/06/05 31/07/05 Immediate 30/07/05 31/08/05 31/08/05 Gorway House E55 S20811 Gorway House V229336 240505 Stg4.a .doc Version 1.30 Page 25 24. 25. 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 9 14 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. 15 19.2 30 33 Gorway House E55 S20811 Gorway House V229336 240505 Stg4.a .doc Version 1.30 Page 26 Commission for Social Care Inspection Mucklow Office Park West Point Mucklow Hill Halesowen 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. 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