Inspection on 31/05/05 for Gough House

This inspection was carried out on 31st May 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 25/11/05

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 Margaret Dean Unannounced 31 May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Gough House D53_D02 S8042 Gough House V226609 31.05.05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Gough House Address 13 Ellenborough Park North Weston Super Mare North Somerset BS23 4BG 01934 622019 0934 419244 generalmanager@abbeycarehomes.org.uk WSM Free Church Housing Association Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Susan Shanks Care Home - Personal Care Only 16 Category(ies) of Old Age (16) registration, with number of places Gough House D53_D02 S8042 Gough House V226609 31.05.05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate up to 16 persons aged 65 years and over requiring personal care only. Date of last inspection 16 August 2004 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 D53_D02 S8042 Gough House V226609 31.05.05 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and was the first statutory inspection for the year. It took place over 6 hours and sought resident’s views of living in the home. A tour of the building was undertaken and a selection of records were inspected, particularly in response to issues raised at the last inspection. Three staff, in addition to the manager, nine of the fifteen residents and the visiting minister were spoken to. This included joining the residents for lunch. What the service does well: What has improved since the last inspection? What they could do better: To ensure that residents receive the correct medication, medicines must only be administered from the package or container in which they are dispensed. Gough House D53_D02 S8042 Gough House V226609 31.05.05 Stage 4.doc Version 1.30 Page 6 Residents said that they were able to raise any issues with staff before it became a problem but where significant complaints had been made, these should be recorded. Any monies held by the home on behalf of residents were well managed but excess funds should be transferred to an individual’s own banking facility. 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 D53_D02 S8042 Gough House V226609 31.05.05 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Gough House D53_D02 S8042 Gough House V226609 31.05.05 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3 and 5 Service users are provided with all the relevant information before and on entering the home to assist them in making a decision about staying permanently. They are visited at home or in hospital, if necessary, before admission so that their needs can be assessed and they are familiar with what the home can provide. EVIDENCE: A copy of the home’s statement of purpose and service user’s guide had been placed in each resident’s room. It was therefore readily available for them to consult and is updated with the summary from each new inspection report, when published. It explained that the full copy of the report was available from the manager. This document clearly stated that the home would be unsuitable for those with impaired mobility and they had been unable to offer a service user a place recently for this reason. The registered manager and a ‘home visitor’ visit any prospective service user prior to admission to assess their needs, whenever possible. Information collected at that time is used to plan how the new resident’s needs are to be met. Gough House D53_D02 S8042 Gough House V226609 31.05.05 Stage 4.doc Version 1.30 Page 9 New residents are admitted for a one-month trial period in the first instance. This allows the resident and the home time to ensure that their needs can be met and permanent residency is a right decision for them. The terms and conditions of residency are therefore provided at the end of this period. A copy of this document was included in the service user’s guide in each room for residents to read. The home does not provide intermediate care services so this standard will not be assessed. Gough House D53_D02 S8042 Gough House V226609 31.05.05 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 Each resident had been involved in discussing his or her care needs and was aware as to how these were to be met. Each resident had their own supply of medications but these must be administered from the original container in which they were dispensed. EVIDENCE: Care records reviewed demonstrated that each resident’s needs had been identified and a plan put together as to how these were to be met. This care was reviewed on a regular basis and records kept up to date. Discussions with residents confirmed that they were aware of the assistance, which they required and this was mainly of a personal nature. In each instance, they had signed their records at the time of the initial assessment. Appointments were made for other aspects of healthcare and noted in the daily diary so that these were not forgotten. A specialist nursing service was providing support to ensure that specific health needs were monitored and treatment adjusted as necessary. Any activity, which presented a risk to individual residents, had been assessed to ensure the risk was minimised and residents were able to maintain independent lives. Gough House D53_D02 S8042 Gough House V226609 31.05.05 Stage 4.doc Version 1.30 Page 11 Each resident had his or her own supply of medication but these must be administered from the original container or package in which they were dispensed to avoid any error. Gough House D53_D02 S8042 Gough House V226609 31.05.05 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 Residents were able to make choices in all aspects of their daily lives and remain in control of what they did. They particularly enjoyed the religious services in the home and liked to remain in contact with community groups. All were agreed that the choice of meals was very good and they enjoyed the home cooked food. EVIDENCE: Each resident had been involved in completing a ‘getting to know you’ questionnaire, when they entered the home. This helped the staff to offer a range of activities to suit individual interests. Many had entered the home because of its religious interests and said that they looked forward to the church service each week. Some were able to attend local churches and joined in their social activities. Visitors were welcomed at any time and were able to join the resident for a meal for a small charge. Residents welcomed this opportunity to share a meal with their families. Staff had developed a comfortable rapport with residents and encouraged them to select their choices in what they did so that they remained in control of their lives. The majority of residents had their meals in the dining room and discussions confirmed that a varied and appetizing menu was offered. Residents were asked each day for their choice of meal and they said that they were able to Gough House D53_D02 S8042 Gough House V226609 31.05.05 Stage 4.doc Version 1.30 Page 13 change their mind if they wished. Meals were ‘home-cooked’ with a selection of fresh vegetables, which was ‘the way they liked it’. Gough House D53_D02 S8042 Gough House V226609 31.05.05 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 17 Residents are able to raise any concerns with the manager and felt assured that these would be addressed. It was recommended that any formal complaints be recorded to demonstrate the action taken and outcome. Residents are able to participate in the electoral process if they wish. EVIDENCE: Each resident had a copy of the complaints policy in his or her room and these had been updated to reflect the Commission’s move to Taunton. Discussions with residents confirmed that they were able to raise any issues, which concerned them, with the manager or staff and they knew they would be dealt with. It was recommended that all complaints should be recorded so that the home was able to demonstrate what action had been taken and the outcome. Several residents had participated in the recent national elections. Some had walked to the local polling station. Gough House D53_D02 S8042 Gough House V226609 31.05.05 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 22, 24 and 26 Residents enjoyed living in a comfortable and homely environment and appreciated the opportunity to have reminders of family and their own home around them. The majority used the large lounge and it was the centre of activity throughout the day. EVIDENCE: A general tour of the home was undertaken and all areas seen were clean and well maintained. Chair lifts were available on the main staircases but there were small flights of steps connecting some parts of the home. It was recognised that this home would not be suitable for people with impaired mobility and this is clearly highlighted in the Statement of purpose. The large lounge is a popular area with the residents. It is situated at the front of the home and leads out onto the well-maintained gardens. Several residents said that they enjoyed sitting outside in warm weather and commented on the annual strawberry tea held in July. Residents had brought in small items of furniture and personal possessions for their rooms. They said that they appreciated having photographs of their family and items from their own homes around them. Several had their own Gough House D53_D02 S8042 Gough House V226609 31.05.05 Stage 4.doc Version 1.30 Page 16 telephone enabling them to keep in contact with family and friends, who were not able to visit very often. Gough House D53_D02 S8042 Gough House V226609 31.05.05 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 Robust recruitment procedures are followed for all new staff to ensure that residents are protected from harm. Training is provided on commencement of employment and on an on-going basis to ensure that staff are competent to fulfil their roles. EVIDENCE: There were always sufficient staff on duty to care for the residents. The staff are known as ‘general assistants’ as their role includes domestic and laundry duties in addition to assisting with care when required. The senior staff undertook most of the care work, as the residents were independent in many aspects of their lives. Robust employment procedures are followed to ensure that residents are protected from harm. References are requested for all new staff before they take up their posts but referees can be slow in replying. To overcome this problem, procedures have recently been introduced to ensure that verbal references are obtained before an employee takes up their post. Written references are always requested and were available in the records seen. Copies of birth certificates and passports are now destroyed once a Criminal Record Bureau disclosure has been obtained. All new staff undertake a comprehensive induction and foundation programme in care, which has to be completed in the first months of employment. The staff on duty on this occasion had continued to complete an NVQ in care at level 2. Further training is then provided on an annual basis to ensure that staff have the skills to care for residents. Gough House D53_D02 S8042 Gough House V226609 31.05.05 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 35, 37 and 38 The home is well managed and the home is run in the residents’ best interest. Robust procedures are followed so that the health, safety and welfare of residents and staff is promoted and protected. EVIDENCE: Mrs Shanks has a clear leadership style and is well respected by both residents and staff. Residents were able to approach her at any time with issues that were of great concern to them and she gave them her immediate attention. Records were maintained of any monies held on behalf of residents and all transactions recorded. It was recommended that only small amounts of money be retained with balances being transferred to a resident’s banking facilities. A health and safety audit had been undertaken in May this year and the management had just received the report. Action was already being taken following verbal feedback from the auditor. It was pleasing to see that Mrs Gough House D53_D02 S8042 Gough House V226609 31.05.05 Stage 4.doc Version 1.30 Page 19 Shanks and her staff were congratulated on maintaining a high standard of cleanliness in the home. Records demonstrated that fire systems are tested regularly and training provided as recommended by Avon Fire Brigade. Residents are involved in drills if conducted during the day and this is to be commended. Other routine maintenance and servicing of major systems in the home are undertaken annually to ensure the safety and comfort of residents. Gough House D53_D02 S8042 Gough House V226609 31.05.05 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 2 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x 3 x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 x x 3 3 x 3 x 3 3 Gough House D53_D02 S8042 Gough House V226609 31.05.05 Stage 4.doc Version 1.30 Page 21 No 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 9 Regulation 13(2) Requirement All medicines must be administered from the package or container in which they were dispensed. Timescale for action 31/05/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 16 35 Good Practice Recommendations All complaints should be recorded to demonstrate what action is taken and the outcome. Residents funds, which are in excess to their requirements should be transferred to their individual banking facilities. Gough House D53_D02 S8042 Gough House V226609 31.05.05 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Riverside Chambers Castle Street Tangier 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 D53_D02 S8042 Gough House V226609 31.05.05 Stage 4.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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