Inspection on 16/10/06 for Gough House

This inspection was carried out on 16th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Gough House 25/11/05

Gough House 31/05/05

Gough House 16/08/04

Gough House 15/04/04

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

CARE HOMES FOR OLDER PEOPLE Gough House 13 Ellenborough Park North Weston Super Mare North Somerset BS23 1XH Lead Inspector Pippa Greed Key Unannounced Inspection 16th October 2006 09:15 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 Gough House DS0000008042.V315797.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. Gough House DS0000008042.V315797.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gough House Address 13 Ellenborough Park North Weston Super Mare North Somerset BS23 1XH 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) 01934 622019 01934 419244 general-manager@abbeycarehomes.org.uk WSM Free Church Housing Association Mrs Susan Shanks Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Gough House DS0000008042.V315797.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 16 persons aged 65 years and over requiring personal care only 25th November 2005 Date of last inspection Brief Description of the Service: Gough House provides personal care for up to 16 older people. The Registered Provider is Weston-super-Mare Free Church Housing Association. The General Manager is Mrs Pauline Harvey and the Registered Manager is Mrs Susan Shanks. The house is a distinctive building situated within easy walking distance of town centre, local parks and the sea front. There is a large lounge, with a baby grand piano, and a well-stocked library area. This room is used for daily prayers and a weekly church service. Although optional, the majority of service users choose to attend these services. A pleasant and homely dining room leads from the lounge. The large garden to the front of the property is mainly laid to lawn, with attractive planted borders. Ample seating is provided. There is private parking to the rear of the home. Private accommodation is provided in fourteen single and one double room. Eleven of these rooms have en-suite facilities. Although a chair lift is provided on the main staircases, there are several areas of the home, which would not be accessible to service users with impaired mobility. This is reflected in the statement of purpose and the service users guide. The current fee levels are between £300 and £336 per week. Gough House DS0000008042.V315797.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The last inspection was conducted on 25th November 2005. Five requirements and five recommendations were made at that inspection. These have been completed. The inspection was unannounced and took place over the course of one day (7.5hrs) on 16th October 2006. It was conducted by Regulation Inspector Pippa Greed. The inspector spoke to six service users, three staff, and one visitor visiting the home. The inspector was also assisted by the manager Mrs Susan Shanks throughout the inspection process Three service users files were selected for case tracking. As part of the inspection process the inspector used ‘case tracking’ as a means of assessing some of the national minimum standards. This process allowed the inspector to focus on a small group of people living in the home. All records relating to these people were inspected, along with the rooms they occupied in the home. Three staff files were checked and documents related to the running of the home were examined. A tour of the building took place and the communal areas and some service users’ rooms were viewed. Mrs Susan Shanks is the registered care manager and she is supported by two deputy care managers. Surveys were sent out to five service users, six staff, three relatives, and four General Practitioners. One survey was received from a service user, which stated ‘Our staff are very kind and helpful’. Two comment cards were received from staff members, which confirmed they were clear in their role and appropriately supervised. Two comment cards were received from relatives. The comments received from relatives were overall positive stating that they were made welcome and kept informed. A relative wrote ‘I am so happy my mother is being looked after at Gough House. They seem a very caring team and she is happy there’. The relative stated that they have not felt the need to make a complaint, however they were not aware of the homes’ complaint procedure or how to access a copy of the Inspection report. Another relative commented ‘Gough House has looked after my mother for 14 years or so, and she is well cared for.’ Two comment cards were received from GPs, one of which stated ‘I visit infrequently, but have always found the home excellent’. All the comments received from service users on the day of the inspection were complimentary about the home and included comments such as ‘They go out of their way’, and ‘Staff and the manager are very helpful. They’re very good’. Gough House DS0000008042.V315797.R01.S.doc Version 5.2 Page 6 The inspectors would like to thank the service users, staff and the manager for their support and assistance with the inspection process. What the service does well: What has improved since the last inspection? The home has recently purchased a new medical fridge for safe storage of medication. Since the last inspection, the kitchen has been redecorated and fitted with new kitchen units. The outdoor porch has also been painted. The fire alert system has been recently updated with a new zone board. Since the last inspection; the fire exit sign has been re-fitted to the third floor fire escape door, the staff team has been provided with fire training updates, records maintained for all medicine received by the home and pre-set valves now fitted on all hot water taps. Gough House DS0000008042.V315797.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Gough House DS0000008042.V315797.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Gough House DS0000008042.V315797.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a statement of purpose, and service user guide that clearly sets out the objectives and philosophy of the service. An information leaflet is also provided. Prospective service users are given the opportunity to spend time in the home prior to admission. Each service user is provided with a clear statement of terms and conditions that sets out the terms and conditions of residency. Family and friends are made welcome and visit the home at any reasonable time. Service users are provided with respite care in order to maximise their independence and prepare them for their return home. Gough House DS0000008042.V315797.R01.S.doc Version 5.2 Page 10 EVIDENCE: Each service user is provided with a written statement of terms and condition of residency. There is a trial period of four weeks to allow prospective service user the opportunity to find out if the home meets their needs. The service user is also provided with a Statement of Purpose and a Service User’s Guide, which is kept in individual bedrooms. The Statement of Purpose has also been updated recently. Care plan sampled evidenced contracts that has been signed by the service users. Several service users had visited the home prior to moving in. Most service user stated that they knew about Gough House through the Church, previously worked for Abbeycare and/ or were supported by their family in choosing the home. The care plan sampled provided evidence of pre-admission assessments for recent admissions. In all cases, the manager conducted a ‘Getting to know you’ questionnaire, which help create a care plan framework. In some care plan, additional assessment details were provided by Avon & Wiltshire NHS Trust. Gough House also provides short-term respite care. Gough House DS0000008042.V315797.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plan sampled evidenced good medical and personal care provided by the home. Controlled drugs entries were supported by two staff signatures. The home also maintain accurate receipt of all medication received. Care plans contained details about service users’ social history. Service users were observed to be treated respectfully by staff. Care plans did not include information about the service users’ death and dying wishes. EVIDENCE: The inspector sampled three service users care plan. These evidenced good standard of health care provided for the service users. Gough House DS0000008042.V315797.R01.S.doc Version 5.2 Page 12 The care plan provides information such as service user’s social history, dietary preferences, personal hygiene, special needs, social interests and relationship, and health. Further details of health care provided were seen in a personal file. These included GP, chiropody, district nurse, optician, and dentist visits. Risk assessments specific to the service user were evidenced in the care plan including falls risks. The care plan did not include nutritional or manual handling assessments. All service users spoken to confirmed that staff treated them with respect and the day-to-day routines in the home respected their dignity. The inspector observed staff interacting with service users in a friendly, professional and respectful manner. The registered manager and two deputy care managers are responsible for administering medication. Their training has been updated in August 2006. In relation to storage of medication and administration, appropriate levels of medication stock was stored. No gaps were seen on the Medication Administration Record. The booking-in-log records medication received, date, name of service user, name of drug, quantity and manager’s signature. It is recommended that the manager obtain a second signature when receiving and booking in medication. This will provide a clearer audit trail. This should be recorded on the Medication Administration Record. Two staff signatures supported all controlled drug entry on Medication Administration Record. A list of staff signature is provided which promotes good practice. The home received a visit from the pharmacy in April 2005. It is advised that a pharmacy visit be arranged to ensure continuity of good working practice. It is recommended that photograph ID of service users are placed within the Medication Administration Record file. Also, to include two staff signatures to confirm receipt of medication as good practice. It is recommended that manual handling risk assessment are written and recorded in the service users care plans. In particular, wheel chair users or those with restricted mobility. It is also good practice to document where possible in the service users care plan their wishes relating to end of life planning. Gough House DS0000008042.V315797.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The routines of the home are planned around the service users’ needs and wishes. Service users are encouraged to personalise their rooms. The home does not provide a detailed activity timetable. The service users are satisfied with the meals served at the home. EVIDENCE: The routines of the home were seen to be flexible to meet individuals’ choices and preferences as far as possible. Service users choose to access some activities provided by the home or engage in their own hobbies and pastimes. Service users are actively encouraged to keep in contact with family and friends living in the community. Visitors are made welcome at any reasonable time. Service users can choose to entertain visitors in their room, communal lounge, visitor’s room, dining area or in the garden. Gough House DS0000008042.V315797.R01.S.doc Version 5.2 Page 14 Service users are asked to complete a ‘Getting To Know You’ questionnaire when they move into the home. This outlines amongst other details their social, community and religious needs, likes, dislikes and preferences. This forms the basis of the service user’s care plan. The inspector sampled the activity diary, which has been recently implemented. The majority of entries documented family visits, and religious service. Although the manager has arranged for a craft activity on the day of the inspection, it is recommended that more activity be provided and recorded. Service users spoken with stated that there are no planned trips as such. Gough House service users survey results (August 2006) showed that most service user felt that not enough activities were being provided. More in-house entertainment, structured activity planning and planned events would provide service users with more choices, and scope for anticipation. Activities were seen during the inspection, which were hairdressing in the morning and craft activity (tile painting) in the afternoon. One service user received a visitor. The inspector received overall positive feedback through discussion with service users. The comments were related to the care provided in the home, mealtimes and laundry. The inspector spoke with a visitor on the day of the inspection. The visitor informed the inspector that staff make her feel welcome and commented ‘cannot find faults with this place. They make my sister happy, then I’m happy’. Lunchtime routine was observed during the inspection. Staff informed each service user what the lunchtime option would be. A choice of two meals and two puddings were offered. A selection of cold drinks was made available. The dining area is situated in a spacious room to the side of the premise. Tables were attractively presented with napkins, vase of flowers, and condiments. Service users were heard to say ‘oh lovely food here’. There were goodnatured banter and interaction between staff and service users. The meal option were tinned salmon or grated cheese with mashed potatoes, salad or vegetables. Mealtime was seen to be unhurried, and support was available for service users if needed. Gough House DS0000008042.V315797.R01.S.doc Version 5.2 Page 15 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 good. This judgement has been made using available evidence including a visit to this service. Service users were confident that they could raise complaints or concerns with senior staff. Systems are in place to ensure that service users’ rights are respected. The home has policies and procedures in place to ensure the protection of service users living at Gough House. EVIDENCE: None of the service users spoken to had any complaints about the home and all were clear that should they have any complaints, they would speak to the manager or another senior member of staff. Service user felt that the manager would deal with any problems. Staff spoken to were clear that they would pass on any complaints to the manager or general manager. Staff and service users confirmed that they would not hesitate to approach the manager or a senior member of staff should they have any concern. The general manager is also based at Gough House and provides on-call support. All service users are registered to vote and their legal rights protected by the homes values, policies and procedures. The majority of service users vote by postal ballot and one service user visits the polling station. Gough House DS0000008042.V315797.R01.S.doc Version 5.2 Page 16 Staff spoken with confirmed that they have received Safeguarding Vulnerable Adult training. The training record seen evidenced that the majority of staff has accessed this training. Protection of Vulnerable Adult (POVA) first and Criminal Records Bureau (CRB) checks were undertaken for newly recruited staff. The Safeguarding Vulnerable Adult and Whistle blowing policy were seen and these included the Commission of Social Care Inspection and Housing Ombudsman contact details. However, it did not include Social Services contact details. The home has a copy of ‘No Secrets in North Somerset’ Multiagency policy. CSCI has not received any complaints about the home directly. The home has a complaint log. There has been no complaint received since 2002. Regarding the last entry made, the manager has written an account describing the nature of the complaint, how the situation was resolved and re-assessed the situation through feedback from the service user. A clear audit trail was evident. Gough House DS0000008042.V315797.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides an overall safe environment. The home has a homely environment, which provides aids and equipment to meet the care needs of the service users. Communal space is adequate. Service users have some options of where to meet relatives and friends in privacy and comfort. The home was clean and hygienic on the day of inspection. EVIDENCE: Gough House is a large Victorian house. Fourteen bedrooms at Gough House are for single occupancy and one double. Most rooms have an en-suite facility. Rooms are situated on the ground, first and second floor. There is a stair lift Gough House DS0000008042.V315797.R01.S.doc Version 5.2 Page 18 for access to all levels. The home is arranged over split levels with steps to navigate therefore not suitable for those with impaired mobility. The home was clean, tidy and odour free on the day of the inspection. A tour of the premises was undertaken and the inspector viewed all the communal areas and some of the service users’ private bedrooms. All service users’ rooms viewed had been personalised to reflect individuals’ choices and preferences. Service users are able to bring in personal items including small items of furniture within the space constraints of their room and in agreement with the manager. Personal portable heaters have been Portable Appliance Tested (PATs) and risk assessed. Communal space comprises of a large spacious lounge and a separate dining room. The lounge has a library, baby piano, electric keyboard and a pet budgerigar belonging to a service user. To the front of the property is a large, well maintained lawn with summerhouse. Call bells are available in bedrooms, toilets and bathrooms and communal areas. There are four communal bathrooms. One bathroom has a chair hoist facility. This has been checked on 28th September 2006. Bath water temperature were checked and found to be within the Health & Safety Executive (HSE) recommended range. Service users have the choice of a bath or shower. The kitchen has been redecorated and fitted with new kitchen units. The outside porch has also been repainted. The kitchen area was inspected and found to be clean and hygienic. Food stored were correctly labelled and fridge/ freezer temperatures were within the correct range. Records were maintained for cooked meat temperatures. Adequate laundry facilities are provided and service users spoken to confirmed their clothes were always well laundered and returned to them promptly in good condition. The home uses an outside laundering service for bed linen. The home maintains good standard of cleanliness. However, to further enhance good practice in infection control, it is recommended that liquid soap and paper towels are provided in all hand washing areas. The home is generally well maintained and has a homely feel. Gough House DS0000008042.V315797.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels are good and the staff were qualified to provide a good level of care. Service users have confidence in the staff that care for them. All staff are clear regarding their role in what is expected of them. EVIDENCE: On the morning of the inspection, there were two general assistant, one cook, registered manager and general manager. During the afternoon, there were one care assistant and one deputy. Two sleep-in staff were rostered for night duty. The general manager provides on-call support. There are currently thirteen care staff excluding the manager, eight of which are qualified to NVQ 2 and above therefore the staff team have the skills and experience to provide a high standard of care. Three staff files were checked. All files contained Criminal Records Bureau (CRB) disclosure. These files contained photograph identification, two written references. However, it is required that that the manager ensures that all staff employed at the home have information in accordance with Schedule 2 of the Care Standards Act on their recruitment file. Gough House DS0000008042.V315797.R01.S.doc Version 5.2 Page 20 The home provided information on the pre inspection questionnaire and staff recruitment files about staff training completed recently and this included induction, mandatory training, administration of medicine (senior staff only), dementia care, infection control, abuse training, falls awareness and health & safety. Staff spoken with confirmed that the manager operated an ‘open door’ policy that is they felt able to approach her with any queries. Staff stated that they have received induction, and annual appraisals. Three staff spoken with informed the inspector that they do not receive formal 1:1 supervision. The manager informed the inspector that she conducts a ‘skill scan’, every two months, which monitors staff’s performance, and provides 1:1 supervision. It is recommended that the manager documents and evidence the supervision meeting in line with National Minimum Standards. Service users spoken to were very complimentary about staff and they commented ‘ Staff go out of their way. They will work overtime’ and ‘Staff are very helpful and the manager. Ask for help and they will’. Gough House DS0000008042.V315797.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has the required qualifications, skills and experience and is competent to run the home. Service users and staff are kept informed and involved in the running of the home. Service users are able to take responsibility for their own finances but if they are not able to do so robust systems are in place to safeguard their financial interests. The home has clear health and safety policies and regular checks take place to ensure that the home is a safe environment. Some areas of health and safety will require improvement. Gough House DS0000008042.V315797.R01.S.doc Version 5.2 Page 22 EVIDENCE: Mrs Susan Shanks is the registered care manager of Gough House. She holds the Registered Manager’s Award. Two deputy care managers support her. Service users spoken to stated that they felt the manager is approachable and that they felt listened to. The manager informed the inspector that the home currently does not directly handle the service users financial affair. One service user takes responsibility for their personal finances with relatives support. Twelve service users have power of attorney in place. Records are kept for the management of personal allowances. These were sampled and the monies checked. The record was supported by two staff signature and the final balance was correct. Staff spoken with confirmed that they felt supported and able to approach the manager and senior staff should they wish to discuss day-to-day running of the home. Three staff spoken with stated that they do not receive formal 1:1 supervision. In a discussion with the manager, the manager informed the inspector that she conducts a ‘Skills scan’ every two months. Staff performance are monitored through the Skills scan and opportunity are given to have a 1:1 supervision. However, staff recruitment files did not evidence regular supervisions. It is recommended that supervision meetings are recorded and evidenced on the staff files. The fire records seen during the inspection demonstrated that staff received fire training in April 2006 from an outside trainer. According to the internal training record dated 28th September 2006, given to the inspector, there are three staff members who have not received fire safety training since April 2005. It is required that all staff members receive up-to-date mandatory training. The Fire Brigade visited on 18th April 2006 and made four recommendations. Three from four have been completed. Fire risk assessments were seen and covered portable heaters placed throughout the home. These were dated 20th June 2006. A tour of the premises was made and the majority of areas seen were free from hazards. It was noted that some rooms have wardrobes that were not secured, therefore posing a potential risk. It is required that wardrobes are made secure in line with an environmental risk assessment. The home displays a current certificate of employer’s liability insurance. Health and Safety records were seen that showed the following; fire equipment, Lifting Operations & Lifting Equipment Regulations test (LOLER), water temperature records, Legionella survey, gas landlord register, electrical Gough House DS0000008042.V315797.R01.S.doc Version 5.2 Page 23 wiring certificate and portable appliance tests (PAT) were subject to regular checks and had been serviced. The manager maintains accident and incident records. Accident records are kept in service user’s personal files. It is recommended that an overall accident analysis in order to help identify trends. The home conducts a number of internal quality assurance audits that are ordered and methodical. The audits are carried out on service users satisfaction and family/friend’s satisfaction. The results of quality audits are displayed in the home’s Service Users Guide. Residents meetings are also offered annually to provide service users with opportunity to discuss in-house issues and any planned events. Gough House DS0000008042.V315797.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 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 2 3 2 Gough House DS0000008042.V315797.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP30 Regulation 18 1(a) Requirement Timescale for action 20/12/06 2. OP38 13 4(a) 3. OP26 13 (3) It is required that all staff members receive up-to-date mandatory training in Basic Food Hygiene, Basic First Aid, Manual Handling, Fire and Basic Health & Safety. It is required that freestanding 20/12/06 wardrobes are made secure in line with an environmental risk assessment. It is required that liquid soap and 29/11/06 paper towels are provided in all hand washing areas as part of infection control strategy. 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 It is recommended as good practice to record two staff signatures when receiving medicine into the home. This also supported by photograph of service users on the Medication Administration Record file. DS0000008042.V315797.R01.S.doc Version 5.2 Page 26 Gough House 2. 3. 4. 5. OP12 OP38 OP36 OP38 6. OP11 It is recommended that the manager consider recording in each service users’ care plan, individual and group activities attended by each service user. It is recommended that the manager consider implementing an accident/ incident analysis in order to determine and identify trends. It is recommended that staff are provided with at least six formal 1:1 supervisions a year and this be recorded in their recruitment file. It is recommended that manual handling risk assessment are written and recorded in the service users care plans. In particular, wheel chair users or those with restricted mobility. It is recommended where possible to document in the service users care plan their wishes relating to end of life planning. Gough House DS0000008042.V315797.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Gough House DS0000008042.V315797.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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