Inspection on 06/10/08 for Gorway House

This inspection was carried out on 6th October 2008.

CSCI found this care home to be providing an Poor service.

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 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 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 27/02/2009.

CARE HOMES FOR OLDER PEOPLE Gorway House 40 Gorway Road Highgate Walsall West Midlands WS1 3BG Lead Inspector Dawn Dillion Unannounced Inspection 6th October 2008 08:25 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.V372290.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.V372290.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.V372290.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP) 28 The maximum number of service users who can be accommodated is: 28 14th August 2007 Date of last inspection Brief Description of the Service: Gorway House is a residential home located in Walsall, West Midlands. The two-storey detached property is located in quiet residential area and provides accommodation for 28 elderly people. The home provides 24 single bedrooms and two shared rooms; the majority of rooms are equipped with en suite facility. The property comprises of two large lounges and a separate dining room. A well-maintained garden is situated at the rear of the property. Ample car parking is located at the front of the home. Staffing is provided on a 24 hours basis to ensure the total supervision of people who use the service. Fees charged for the service provided at Gorway House was not made available; the reader is advised to contact the home directly for this information. Gorway House DS0000020811.V372290.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 Star. This means the people who use this service experience poor quality outcomes. The unannounced key inspection of Gorway House was undertaken within 11 hours. The emphasis of the inspection was to look at quality outcomes of people’s lifestyle and practices that promote equality and diversity. The inspection methods used to establish the quality of care provided and the effectiveness of the management of the home, involved the examination of records, which provided information about how the service was managed. We looked at the service Annual Quality Assurance Assessment (AQAA). The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the service. We spoke to 6 people who used the service and 2 staff members to obtain their views and opinion about the service provided. A tour of the property was undertaken to ensure the environment and systems in use were safe and suitable to meet people’s needs. One of two Registered Managers was present on the day of our visit. What the service does well: We observed staff interacting with people in a positive and professional manner. People who used the service were complimentary about the home; these were some of their comments: “Politeness is always there.” “The staff are very good, some are better than others, they always knock on my door.” “I have a lock on my door but I don’t use it, staff do knock on my door.” “The meals are very good, sometimes we have a choice but not always.” “The food is alright, most days we have a choice.” “The food is good.” Gorway House DS0000020811.V372290.R01.S.doc Version 5.2 Page 6 “I have never had any reason to complain.” What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Gorway House DS0000020811.V372290.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Gorway House DS0000020811.V372290.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of access to information and assessment may compromise the quality of the service provided to meet people’s care needs effectively. EVIDENCE: The Registered Manager told us people who accessed the service did not have a copy of the home’s Statement of Purpose; the home did not have a Service User Guide. Information contained in the service AQAA did not reflect this, it stated; “Our Statement of Purpose is displayed and is provided on admission to all new service users.” “This document contains information to enable people to make an informed choice about the facilities that we provide.” Gorway House DS0000020811.V372290.R01.S.doc Version 5.2 Page 9 We spoke to six people who used the service, we explained what these documents were and all confirmed they had never seen them. People wishing to use the service were not provided with sufficient information to enable them to establish if the service would be suitable to meet their care needs and to ensure their welfare. Two of four care plans we looked at showed a needs assessment had been undertaken before people had moved into the home. This assessment enables the service to understand what people’s care needs are and the level of support needed to promote their health and welfare. “The service AQAA stated, “No new service user are admitted without a full assessment of his/her needs.” The Registered Manager confirmed this assessment had not been carried out for the other two people. The lack of consistency of assessment fails to show that people’s care needs will be met. The Registered Manager told us they provided intermediate care, the home’s Statement of Purpose did not show this. We did not see any rehabilitation facilities such as, equipments or adaptations to promote people’s independence or mobility. Gorway House DS0000020811.V372290.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People cannot be confident their care needs will be met to promote their independence and rights. Poor medication practices may compromise the health and safety of people. EVIDENCE: The service AQAA stated, “Care planning and risk assessment systems are in place and staff are working nicely with these now.” The care plans we looked at and discussions with the Registered Manager showed a needs assessment was not always undertaken, to ensure the service was suitable to meet people’s care needs. We saw an assessment undertaken Gorway House DS0000020811.V372290.R01.S.doc Version 5.2 Page 11 by Social Services, this was not dated and there was no written confirmation by the home to confirm they would be able to meet the persons assessed care needs. We looked at four care plans which, showed staff were not always provided with guidance to enable them to meet people’s care needs. For example “X needs help to get in and out of the bath.” The Registered Manager told us this person required the use of an assisted bath. The care plan did not tell us this. The lack of detail could compromise the care, health and safety provided to this person. We saw a letter on a person’s file showing they had a diagnosis of Alzheimer’s and challenging behaviour; this information was not included in the care plan. This person could not be confident they would receive the necessary support concerning their mental health because of the lack of information contained within the care plan and also the Registered Manager’s lack of knowledge of the person’s diagnosis. One care file showed the person had been referred to the Community Mental Health Team but there was no mention of this on their care plan. The Registered Manager told us this person was “slightly confused.” People couldn’t be confident their care needs would be met at all times because of the lack of information contained in their care plan to provide staff with the necessary guidance of people’s care needs. There was no evidence people were involved in planning their care, we spoke to six people about care planning, we explained what this was. They all confirmed they had never seen their care plan. This showed people were not involved in how their care needs would be met to promote their welfare and independence. The service AQAA did not reflect what we saw and what people told us, it stated, “Our care plans are always planned together with our service users and their families.” The service AQAA stated, “Service users and or their advocates are involved and sign to say they have agreed with the care plan/risk assessment put into place.” Care plans showed people had access to healthcare services, for example doctor, dentist and optician. People we spoke to confirmed this. On the day of our visit we saw a Medical Consultant assessing a person’s mobility. Discussions with the Registered Manager and the records we looked at confirmed risk assessments were not in place for everyone. The home could not be sure, people would be provided with the necessary support to promote Gorway House DS0000020811.V372290.R01.S.doc Version 5.2 Page 12 their independence and safety whilst undertaking daily activities within or outside the home. We looked at the home’s medication system and practices which, showed people cannot be confident they will receive their medicines safely, to promote their health. For example, we saw a number of medication administration records had not been signed to show if and when people had received their medicines. We looked at a medication administration record that showed a signature to indicate the medication had been given to the person but the tablet was still in the cassette/container. The failure to give this person their medicines as directed by the doctor could compromise their health. Records also showed ‘when required medicines’ were being given to one person on a regular basis. Staff told us a record would not have been maintained to show why this person was given these tablets on a regular basis. Staff said the person wanted the tablets everyday. The Registered Person should ensure the doctor reviews this person’s medicines to promote their health and safety. The service AQAA stated, “Our medication recording has improved and we have worked on all the items brought up in the last inspection report.” At the previous inspection visit a requirement was identified that medication given to people should be clearly recorded. The home failed to comply with this requirement. A Code B Notice was issued, this is a notice given to the home when we believe an offence has been committed. We observed staff interacting with people in a professional and respectful manner, we saw them knocking on doors before entering private rooms. Some bedroom doors were fitted with a security lock to promote people’s privacy. People told us the staff respected their privacy, these were their comments: “Politeness is always there.” “The staff are very good, some are better than others, they always knock on my door.” “I have a lock on my door but I don’t use it, staff do knock on my door.” Gorway House DS0000020811.V372290.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are able to continue with pastimes of their choice, however, the lack of independent support could have a negative impact on people with limited capacity to promote their independence and rights. The lack of choice of meals does not reflect people’s preference to promote individualism. EVIDENCE: The routine in the home was relaxed with people engaging in pastimes of their choice. We heard one person saying she was going into the garden to feed the birds. The care plans we looked at provided very little information about people’s culture or religious beliefs. We spoke to a number of people who told us they Gorway House DS0000020811.V372290.R01.S.doc Version 5.2 Page 14 did not have any religious needs. The Statement of Purpose stated, “We do have an inter denominational religious service once a month for any service user to attend, which the majority do enjoy.” We saw an ‘Activities file’ which showed activities such as religious singing, piano, jewellery parties, reminiscence and keep fit. We saw and heard staff interacting and talking to people friendly and respectfully. People confirmed they were able to have visitors at anytime. We looked at a number of bedrooms, which showed people were able to personalise their rooms, with pictures, ornaments and photographs. Discussions with the Registered Manager confirmed some people do not have regular contact with their family and friends. We spoke to a number of people about having access to a self-advocacy service who confirmed they were not aware of this service. This is an independent service, which provides additional support to people. The homes menu did not show an alternative choice. For example, Monday eggs, poached or scrambled and a piece of cake. Tuesday was cheese salad with mayonnaise. We looked at the minutes of a meeting, which was undertaken on 29 May 2008, that stated, “Residents said they would like something different at teatime.” The Registered Manager told us people are provided with a choice but this was not always recorded. The service AQAA stated, “Our meals are well balanced and well presented and there is always an alternative available.” We observed afternoon tea being served. One person asked staff for a biscuit, this was promptly provided to her and others. People were asked how they like their tea and were able to sit where they wanted. People were very complimentary about the meals provided but confirmed they very rarely had a choice. These were some of their comments: “The meals are very good, sometimes we have a choice but not always.” Gorway House DS0000020811.V372290.R01.S.doc Version 5.2 Page 15 “The food is alright, most days we have a choice.” “The food is good.” “The food is lovely, it’s very good.” “We don’t have a choice.” “The food is alright, don’t know what’s for dinner today.” Gorway House DS0000020811.V372290.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The lack of access to a complaint procedure could compromise people’s rights and fail to protect them from potential abuse. Insufficient safety checks on staff could leave people at risk of possible harm. EVIDENCE: The home’s complaints procedure was located in the office, it showed complaints should be shared with the Registered Manager, which would be investigated and replied to within 28 days. Some people told us they would talk to staff if they were not happy but confirmed they were not aware of the home’s complaint procedure. One person said, “I have never had any reason to complain.” The service AQAA stated, “We have a good complaints procedure in place and we feel by following these procedures we are protecting the service users legal rights.” “We ensure our complaints procedure is made known to all service users and their advocates.” The home’s Statement of Purpose did provide some information about how to make a complaint but people did not have access to this document. Gorway House DS0000020811.V372290.R01.S.doc Version 5.2 Page 17 People cannot be confident their concerns or complaints will be acted upon because of their lack of awareness of the home’s complaint procedure. Discussions with the Registered Manager and information contained in the service AQAA told us they had not received any concerns, complaints or safeguarding issues since the last inspection visit. We have not received any complaints or safeguarding issues about this service, since our last inspection visit. We saw a ‘Policy and Procedure for Adult Abuse.’ This provided staff with information about want to do in the event or suspicion of abuse. One staff told us they had received Adult Abuse training. This should ensure staff can recognise and protect people from potential abuse. We looked at two financial records of people who use the service; these showed accurate records were maintained. The service AQAA stated, “We have good recruitment and selection process that we follow ensuring that all statutory requirements are followed and maintaining and promoting equality.” “We now always obtain the two written references and the POVA first check, followed by the relevant risk assessment being put in to place (followed by the full CRB), prior to employment.” Staff files showed safety checks were not consistently undertaken to ensure people are suitable to work in the home and to ensure people are protected from potential abuse. For example two written references, Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA 1st) were not always obtained. These checks would provide some assurance that people would be protected. Gorway House DS0000020811.V372290.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The design and layout of the premises is suitable to meet people’s needs to promote their independence and safety. EVIDENCE: Gorway House is situated in Walsall, West Midlands. The property is set within its own grounds in a quiet residential area. The two-storey property is registered to provide accommodation for 28 people, single and shared bedrooms were on both the ground and first floor level. Some bedrooms were equipped with en suite. Toilets and bathrooms were in close proximately to bedrooms and communal areas. Gorway House DS0000020811.V372290.R01.S.doc Version 5.2 Page 19 Some bathrooms were equipped with an assisted bath and grabs rails were also provided. A passenger lift was in place to ensure people had access to all the facilities within the home. Two lounges and a separate dining area were provided on the ground floor, there were a kitchen and laundry room. People had access to a well-maintained garden; we saw one person feeding the birds and another person sitting in the garden. Sufficient car parking was available at the front of the property. The home was clean and tidy and appropriate systems were in place to promote infection control. For example washing machines were equipped with a sluice programme. Personal Protective Equipment (PPE), such as disposal gloves and aprons were available to staff. Gorway House DS0000020811.V372290.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are sufficient to meet people’s care needs to promote their welfare. Poor recruitment practices could put people at risk of potential abuse and fail to ensure their safety and welfare. EVIDENCE: The home is registered to provide a service for 28 people; on the day of our visit the Registered Manager confirmed there were 25 people in residence. We looked at the staff-working rota, which showed sufficient staffing levels were maintained throughout the day and night, to ensure people were provided with the necessary support to assist with their care needs. The service AQAA showed 70 of the staff team had obtained the National Vocational Qualification Level 2/3. One staff confirmed she was currently doing this training. Gorway House DS0000020811.V372290.R01.S.doc Version 5.2 Page 21 The homes recruitment and selection practices did not ensure people’s protection from potential abuse. For example we looked at three personnel files, which showed two staff, had been appointed with one written reference. We saw a new Care Assistant had been appointed, we looked at their file, which showed the home had not received a Criminal Record Bureau (CRB) or Protection of Vulnerable Adults (PoVA 1st) clearance; there was one written reference on file. We saw this person working in the home and we looked at the staff rota, which showed she was working 8.00am until 4.00pm and was scheduled to work the next day. We issued a Code B Notice; this is notice given to the service if we believe an offence has been committed. One staff member told us she had received the following training in the last 12 months: Fire Awareness, Adult Protection, Health and Hygiene and Health and Safety. We looked at a number of training records, which showed staff were provided with periodical training. This should ensure staff have the skills to undertake their roles effectively. The Registered Manager said new staff were given an induction into their post. One of three staff files we looked at showed an induction had taken place. Gorway House DS0000020811.V372290.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are not guaranteed their care needs will be met or practices within the home will protect them from potential abuse. Poor health and safety practices could put people at risk of potential harm. EVIDENCE: One of two Registered Managers was present on the day of our visit. The AQAA stated, “Both the Managers here have now completed their Registered Managers Award.” Gorway House DS0000020811.V372290.R01.S.doc Version 5.2 Page 23 Discussions with the Registered Manager confirmed they had recently developed some quality assurance questionnaires, which would be distributed to people and other stakeholders. We were not provided with any other evidence of systems and practices to monitor the quality of the service to ensure people’s welfare. The information provided in the service AQAA did not give accurate information to reflect the service provided. Due to the number of short falls identified at this inspection visit. People cannot be confident their care needs will be met because of poor assessment and care planning. Poor recruitment practices failed to ensure people are protected. We looked at two financial records of people who use the service; records were consistent with funds held in safekeeping. Practices within the home were not entirely thorough in promoting people’s health and safety. For example we observed an unsecured storage room contained chemicals, one of which was identified as corrosive. The bottle did not have a secure top and we saw cling film covering the opening. We also observed other chemicals stored on the radiator in this room. To ensure the safety of people living in the home, we asked the Registered Manager to either secure this area or remove the chemicals, she removed them. Gorway House DS0000020811.V372290.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 2 X 2 X X 1 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 1 Gorway House DS0000020811.V372290.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 OP3 Regulation 14(1)(a)( b)(c)(d) Requirement Timescale for action 01/12/08 2. OP9 3. OP9 4. OP7 5. OP8 6. OP15 People should have an appropriate assessment to ensure the care provided reflects their assessed care needs and promotes their health. 13 (2) When medication is administered to people who use the service it must be clearly recorded, to ensure that people receive the correct levels of medication. This is an outstanding requirement with a timescale for compliance of 10/09/07. 13(2) Medication practices should be reviewed to ensure people receive their prescribed medicines to promote their health. 15(1)(2)( Care plans should provide a)(b)(c)(d sufficient information to ensure ) staff have a clear guidance of people’s care needs to ensure their welfare. 13(4)(b)(c Individual risk assessments ) should be put in place, to ensure the safety of people who use the service and to promote their independence. 16(2)(i) Menus should be revised to DS0000020811.V372290.R01.S.doc 06/10/08 01/12/08 01/12/08 01/12/08 01/12/08 Page 26 Gorway House Version 5.2 7. OP29 19 and Schedule 2 ensure people are provided with a choice of meals to reflect their preference. Appropriate safety checks such as a Protection of Vulnerable Adults (PoVA 1st), Criminal Record Bureau clearance and 2 satisfactory written references should be obtained for all new staff, to ensure their suitability to work in the home and to ensure people are protected from potential abuse. 01/12/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard OP1 OP6 OP7 OP14 OP16 Good Practice Recommendations To ensure people have access to the home’s Statement of Purpose and Service User Guide. Information about Intermediate Care provided at the home should be identified in the Statement of Purpose. People should be encouraged to be actively involved in their care planning. To ensure people have access to a self-advocacy service. To ensure people have access to the home’s complaint procedure. Gorway House DS0000020811.V372290.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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.V372290.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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