Inspection on 25/11/05 for Gough House

This inspection was carried out on 25th November 2005.

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 16/10/06

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 Carolle Wise Scanlan Announced Inspection 25th November 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Gough House DS0000008042.V256176.R02.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Gough House DS0000008042.V256176.R02.S.doc Version 5.0 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 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.V256176.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 16 persons aged 65 years and over requiring personal care only 31st May 2005 Date of last inspection Brief Description of the Service: Gough House provides personal care for up ot 16 older people. Abbeycare, the Weston-super-Mare Free Church Housing Association own it. 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 the residents 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 a smaller garden to the rear of the home. Private accommodation is provided in 14 single and one double room. Eleven of these rooms have ensuite facilites. 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. Gough House DS0000008042.V256176.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, which took place over 7 hours. The inspector met with five of the fourteen current residents and two visitors to the home. The commission received positive feedback from the homes General Practitioner regarding the service they provide to residents in their care. Feedback from relatives and visitors all remark on the ‘excellent atmosphere’ and ‘friendly and supportive staff’. ‘Case tracking’ methodology was used and the inspector randomly selected various records to review, which are required to be kept by the home. What the service does well: What has improved since the last inspection? What they could do better: Gough House DS0000008042.V256176.R02.S.doc Version 5.0 Page 6 A health and safety audit had been undertaken in May this year and the recommendations made were in the process of being addressed which is good practice. During this inspection is was noted that a fire exit sign needed refixing to the third floor fire escape door and two staff according to the in-house training record had not received recent fire training. To avoid risks of scalding water temperature checks are undertaken however were the temperature exceeds 43oc they must be fitted with pre-set valves with fail safe devises further safeguarding the residents. An accurate receipt of all medicines into Gough House must be recorded. 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. Gough House DS0000008042.V256176.R02.S.doc Version 5.0 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 Gough House DS0000008042.V256176.R02.S.doc Version 5.0 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 the following standard(s): 1, 3 & 5 Prospective residents are well informed about the home and are assessed to ensure their needs can be met prior to moving in. EVIDENCE: Several residents said that they were aware of Gough House prior to coming to live here, either via friends recommending the home, the church or having visited other residents here themselves. They felt that they received sufficient information about the home to enable them to make a choice about living here. Each resident is offered a months ‘trial period’ allowing residents to ‘test drive’ the service and ensure it is right for them. The home has a ‘Service User guide’ and produces a Statement of Purpose outlining the facilities and services it offers. These are regularly reviewed and each resident had a copy available in his or her room. Prospective residents are met by the registered manager and a ‘home visitor’ prior to admission to the home to assess their needs and whether these can be met. Gough House DS0000008042.V256176.R02.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Each resident has a care plan and general risk assessments are completed. These are all reviewed on a regular basis safeguarding the wellbeing of the residents. These could be improved by adding further detail of the actual care provided. Medication procedures are in place which are generally robust, these could however be improved further. Residents are treated respectfully with their privacy and dignity preserved. EVIDENCE: Each resident has a care plan these are reviewed on a monthly basis, which is good practice. Residents have some awareness of the pans of care in place. The plans of care are general in their nature. On occasion the care received by the residents exceeded that which was written and did not fully reflect the levels of care provided by the staff at the home. Assessments of risk are undertaken and considerations such as changes in weight and nutrition are evaluated. Risk assessments are also undertaken. The Gough House DS0000008042.V256176.R02.S.doc Version 5.0 Page 10 care plan action to mitigate the identified risk should be incorporated into the care plan with more detail provided. The General Manager Irene Branagan and the Registered Managers of the group of homes are considering devising a new format for the care plans in the near future. Medications for the home are provided for by Lloyd’s pharmacy in weekly NOMAD boxes. All medicines were stored in locked cupboards inside a lockable room. The medication stock controls were generally robust, in two of the five cases however this could be improved. The home now records the residents Temazepam on both the Medication Administration Record and as a stock list in a separate record book. Homely remedies agreed by the General Practitioner are listed. A signature of each staff member able to administer medication is listed which is good practice. Residents were able to give examples of how their privacy and dignity is upheld by the staff. Without exception residents felt that the staff spoke to them respectfully and took account of ensuring they used the correct form of address. One resident remarked on some of the attention to detail made by the staff to ensure that they had privacy when receiving any small measure of personal care to which the home is commended. Gough House DS0000008042.V256176.R02.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 & 14 Resident’s preferences and interests are factored into the arranged activities program. Residents control their own daily routines. EVIDENCE: Residents enjoy a variety of activities arranged by the home should they choose to attend. Several residents prefer their own company and choose not to attend. Some residents liked to attend the activities arranged in-house but chose not to attend those arranged at the other homes in the group. Residents decide how to structure their own daily lives with meal times the only set routine. Christmas festivities were being planned at the time of the inspection. A florist is arranged to teach table decoration, a male voice choir is planned and a Christmas quiz. Tuesday prayers and communion is a regular feature in the home encouraged by the residents and their involvement with the church, as well as tea/coffee mornings. Gough House DS0000008042.V256176.R02.S.doc Version 5.0 Page 12 Residents 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. These are taken account of by the home, which is good practice. A few residents without close family or relations near by suggested that they would like further help with their ‘personal shopping for clothing etc’. When discussed with the manager it was noted that individual residents are assisted at times on a one to one basis into the local shopping areas to do their personal shopping. Although not inspected the residents remarked very positively on the ‘homemade meals’. The menu on the day of the inspection was that of ‘fish and chips’ with alternatives also offered. The chips were homemade and residents really enjoyed their meal in very pleasant surroundings. Gough House DS0000008042.V256176.R02.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 & 18 Residents feel that the staff would listen to any complaints or concerns they have and act appropriately. EVIDENCE: There is a complaints and whistle blowing procedure in place all of which are reviewed regularly to ensure they remain up to date. There have been no formal complaints received in the last twelve months. The homes ‘house visitor’ meets with the residents on a weekly basis. This is a further opportunity for residents to discus any issues they may have. Residents felt secure in the knowledge that should they wish or need to complain that their concerns would be taken seriously. Visitors met also found the homes management and staff approachable and felt the staff are approachable with regard to even the most minor quibbles they may have. Staff have attended Adult Abuse awareness training. New staff are introduced during their induction training to the homes policies and procedures and on where to locate them. Residents are either registered to ‘postal vote’ or choose to attend the poling stations. Gough House DS0000008042.V256176.R02.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 26 Residents benefit from and enjoy a well-presented and maintained homely environment. EVIDENCE: The home is well presented and decorated to a good standard. On each inspection the home has been immaculately clean and has a homely relaxed ambience. The home has well ordered maintenance records with evidence of prompt action taken when reports of repairs are needed. The accommodation is arranged over three floors with a stair lift to the second floor. There are steps to navigate over several areas of the home so it remains unsuitable for those with impaired mobility. Each room has access to the call bell system. The communal space is on the ground floor. This consists of a spacious lounge, well appointed to the front of the property overlooking the beautifully landscaped gardens and a separate dining room. Each of these rooms are Gough House DS0000008042.V256176.R02.S.doc Version 5.0 Page 15 reached by navigating a few steps with grab rails provided to assist with mobility. Meals are served from a recently refurbished servery area, which houses a dishwasher, several cupboards and a long worktop surface. There is a communal ‘payphone’ off the reception hallway and a resident’s notice board. Residents’ rooms are personalised with their belongings and to their own tastes and arranged to suit their needs. One resident remarked that it was lovely to ‘have my memories and belongings around me, I really enjoy being able to read, relax and have my own space, but at the same time have the company of others should I want it’. Lockable storage is available and resident’s can lock their rooms should they choose to. There are bathrooms on all floors, the toilets had ‘raiser seats’ and grab handrails available. Each of the bathrooms were well decorated in a ‘homely’ manner. The water temperatures however should be set at 43oc to avoid the risk of scalding. The homes laundry room was not visited during this inspection. As the home is an older property several rooms visited had additional portable heaters available. Residents felt with these additional forms of heating that their rooms were comfortably heated. The registered manager must ensure that the portable heaters are risk assessed for each residents use. One residents carpet had recently been cleaned and had become ‘rucked’ in a few areas, this required urgent attention as it posed a trip hazard. The registered manager advised that she would look into this immediately. Gough House DS0000008042.V256176.R02.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Resident’s benefit from staff who are competent and trained to meet their needs and the homes excellent recruitment procedures. EVIDENCE: Gough House has a low staff turnover, which enables the staff group to offer residents consistent care. The staff are professional mature and experienced carers meeting the needs of the resident’s. The staff have the skills and competence to care for residents and keep themselves up to date with care practices with training updates. Staff attend mandatory training, which is arranged and reviewed by one of the deputy managers. Staff have also received training in dementia care and abuse awareness. Staff rotas are in place with the staff coming on each shift recorded or amended on this rota. There are two General Assistants on duty each morning with a ‘senior’ and the Registered Manager or a deputy and in the afternoon there is one General Assistant and a senior. Two staff members both ‘sleepers’ cover night duty unless the residents needs increase which would then lead to a staffing level review. The pre inspection documentation confirmed that 60 of the staff have now successfully achieved NVQ level 2, with one deputy having completed NVQ Level 3. There are ten staff members who have completed first aid training. Gough House DS0000008042.V256176.R02.S.doc Version 5.0 Page 17 The home has excellent and robust recruitment practices in place. References are requested for all new staff before they take up their posts. As this is dependant on the speed of response by the referee procedures have been introduced to ensure that verbal references are obtained before an employee takes up their post, these are clearly dated and documented. Written references are always requested and followed up. Copies of birth certificates and passports are now destroyed once a Criminal Record Bureau disclosure has been obtained. POVA details are checked and recorded. Gough House DS0000008042.V256176.R02.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 & 38 The resident’s benefit from the clear management structure and reporting mechanisms within the home. Maintenance and service records are generally robust safeguarding the residents, with a few exceptions outlined in the requirements made. EVIDENCE: Mrs Susan Shanks, the registered manager is seen by the residents’ and staff as professional and approachable and is well respected. She has completed her NVQ Level 4 and is an experienced manager. Staff said they felt comfortable raising issues about the homes day-to-day events. Resident’s gave examples of how they are involved in changes to the home such as chats with the registered manager, meetings and surveys of their opinions. They understood and were clear about the homes management structure and reporting avenues. ‘House Visitors’ complete a monthly Gough House DS0000008042.V256176.R02.S.doc Version 5.0 Page 19 quality/audit report, which is now forwarded to the commission as a regulation 26 visit. The home does not manage any of its resident’s financial affairs. Residents ‘pocket money’ which, they ask the home to keep safe for them, have separate account records made, which is good practice. Residents can access their money at any time. On checking one record, the money counted was greater than the balance recorded. The Registered Manager rechecked each record to sort out this minor error. Good practice was observed otherwise, with both the resident and a staff member signing the account record. Staff supervision takes place on a regular basis, which the home calls a ‘Skills Scan’. It was discussed that this could be further developed enabling training needs to be identified and staff development, which would inform the staff appraisal process. The homes servicing and maintenance records were in good general order. Records are stored in a lockable office and cupboards. A health and safety audit had been undertaken in May this year and several recommendations made had already been addressed, others were in the process of being undertaken. Carpet ‘rucking’ was noted in one resident’s room which had just had its carpet cleaned, this required attention as it posed a trip hazard. A fire exit sign needed re-fixing to the third floor fire escape door. Water temperature checks, risk assessing and prioritising the fitting of pre-set valves with fail safe devises to avoid risks of scalding is needed. The fire records seen during the inspection record that staff received fire training in April 2005 from an outside trainer. According to the internal training record dated 15th November, given to the inspector, there are two staff members who have not received fire safety training since 2004. Avon fire Brigade Guidance must be complied with regarding fire procedures. Gough House DS0000008042.V256176.R02.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 2 Gough House DS0000008042.V256176.R02.S.doc Version 5.0 Page 21 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 OP9 Regulation 13(2) Requirement Accurate receipt of all medicines into Gough House must be recorded. Carpet ‘rucking’ must be addressed as it poses a trip hazard. Pre Set Valves with fail-safe devises to be fitted as an immediate priority to those rooms in which water temperatures exceed 43oc .To fit these devises to all other rooms to provide water close to 43oc on a risk assessed basis. Bath hoist/equipment must be regularly maintained. All staff must receive fire safety training in line with Avon Fire Brigade Guidance Timescale for action 25/12/05 2 3 OP38 OP38 13(4) 13(4) 25/12/05 25/01/06 4 5 OP38 OP38 13(4) 23(4) 25/12/05 25/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Gough House DS0000008042.V256176.R02.S.doc Version 5.0 Page 22 No. 1 2 3 Refer to Standard OP7 OP12 OP35 Good Practice Recommendations Care plans and risk assessments must reflect how the resident’s needs in respect of health and welfare are to be met. Consider further ways to assist residents with their personal clothing shopping. Residents pocket money account records could be further improved by ensuring that the money debited and deposited are clear and distinct thus avoiding errors in accounting. Re fix the fire exit sign to the third floor fire door. All residents using portable heaters, used to further support the homes central heating systems must be risk assessed. 4 5 OP38 OP38 Gough House DS0000008042.V256176.R02.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Gough House DS0000008042.V256176.R02.S.doc Version 5.0 Page 24 - 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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