Inspection on 31/01/07 for Great Western Court

This inspection was carried out on 31st January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Great Western Court 13/02/06

Great Western Court 21/04/05

Great Western Court 24/11/04

Great Western Court 28/04/04

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

CARE HOMES FOR OLDER PEOPLE Great Western Court 33a Millbrook Street Gloucester GL1 4BG Lead Inspector Sharon Hayward-Wright Key Unannounced Inspection 10:00 31 January & 1st February 2007 st 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 Great Western Court DS0000031570.V320645.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. Great Western Court DS0000031570.V320645.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Great Western Court Address 33a Millbrook Street Gloucester GL1 4BG 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) 01452 423495 01452330810 www.gloucestershire.gov.uk Gloucestershire County Council Mrs Angela Rosalyn Neilens Care Home 30 Category(ies) of Dementia (6), Old age, not falling within any registration, with number other category (23) of places Great Western Court DS0000031570.V320645.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One respite bed to accommodate service users between the ages of 60 - 65 years. One bed to accommodate service users from the age of 55 years Date of last inspection 13th February 2006 Brief Description of the Service: Great Western Court is a purpose built home for care of older people. The home is now predominately intermediate care or short-term care for service users waiting for care packages. The local Primary Care Trust provides the funding for the intermediate care beds and a multi-disciplinary team does the assessment of service users suitable for these. The Home comprises of five individual living units linked with a larger central unit, which houses the reception, offices, kitchen, laundry and day centre. The individual units accommodate six residents in each. Each unit has a lounge, dining room, kitchen and bathroom. All rooms are single occupancy, and there are six bedrooms in each unit, with four of these having en suite shower rooms. The day centre provides a service for people in the community as well as for service users in the Home, and also holds the Asian Elders Club on a weekly basis. Each room on the intermediate units has an information file that contains useful information about discharge home. Within these files a copy of the homes Statement of Purpose is contained. The highest fee for this home is £331.70, however this is dependent on an assessment of finances and other factors. Extras to the fees include hairdressing and newspapers. Great Western Court DS0000031570.V320645.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector carried out the site visit, which took two days in January 2007. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. The Registered Manager was not available, however the Deputy Manager and Team Leader were. A total of 28 standards were inspected. Several service users were spoken with to ascertain their views on the care and services provided. A number of surveys were left for service users, staff and visitors to the home. All were complimentary about the home. The comments received from service users during the inspection all indicated they are very happy living at the home. The Deputy Manager and Team Leader and care staff were spoken with throughout the inspection and were helpful and co-operative. One requirement had not been complied with since the last inspection. On this occasion the timescale have been extended as indicated in the requirements made. Unmet requirements impact upon the welfare and safety of service users. Failure to comply by the revised timescale may lead the Commission for Social Care Inspection to consider enforcement action to secure compliance. What the service does well: The home offers service users the opportunity to regain their independence to enable them to move back to their own home. Excellent links are maintained with the multi-disciplinary health care team who assist the home in providing this service. The environment is purpose built to enable rehabilitation and for service users who need to use a wheelchair. The arrangements for admission to the home are excellent with input from health care professionals to ensure service users are only admitted to the home following a full assessment and assurances that their needs will be met. A number of staff have worked at the home for a long time and this results in consistency for the service users receiving long-term care. Great Western Court DS0000031570.V320645.R01.S.doc Version 5.2 Page 6 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. Great Western Court DS0000031570.V320645.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 Great Western Court DS0000031570.V320645.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, 2, 3, 5 & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The homes Statement of Purpose and Service Users Guide is inadequate and does not provide sufficient information about the services provided by the home. Service users are not admitted to the home without first having their needs assessed and assurances by the home that their needs will be met. Service users referred solely for intermediate care are helped to regain the skills needed to assist them to return home. EVIDENCE: The home has an information file in each intermediate care room that includes information about discharge home. A copy of the homes Statement of Purpose is included in this file. The home did not have a Service Users Guide available. Great Western Court DS0000031570.V320645.R01.S.doc Version 5.2 Page 9 To meet the Care Regulations 2001 several additions are needed to their Statement of Purpose. These include: 1. 2. 3. 4. 5. 6. 7. 8. 9. The relevant experience of the registered provider and any registered manager. The organisational structure of the care home. The age-range of the service users for whom it is intended that accommodation should be provided. The range of needs that the care home is intended to meet. Whether nursing is to be provided. The associated emergency procedures in the care home. The arrangements made for contact between service users and their relatives, friends and representatives. The arrangements made for dealing with complaints. The arrangements made for dealing with reviews of the service user’s plan referred to in regulation 15(1). 10. The number and size of rooms in the care home. 11. Details of any specific therapeutic techniques used in the care home and arrangements made for their supervision. The home must devise a Service Users Guide as required in Regulation 5 of the Care Home Regulations 2001. All intermediate rooms have a copy of the home information file, but the service users on long term care do not have a copy. The home does not have a copy of this file in the main entrance for visitors to read. Once the additions have been made to the Statement of Purpose and Service Users Guide the home should display these where visitors to the home will have easy access. Just over half of the service users surveys returned said they had received enough information to be able to decide that the home was right for them. The homes terms and conditions were examined briefly and each service user receives a copy of these, which is amended to their individual circumstances. The home needs to review these in line with the Regulations that came into force in September 2006. Service users surveys received after the inspection said that in nearly all cases they had received a contract. Great Western Court DS0000031570.V320645.R01.S.doc Version 5.2 Page 10 The home now predominately provides intermediate or short-term stay care for service users waiting for care packages. A member of the multi-disciplinary team completes the assessments of proposed service users. This team includes a physiotherapist, occupational therapist and Social Worker. The home also has access to other health professionals to include a dietician, community nurses and a Consultant Physician for Elderly Care. Once an assessment and care plans have been completed they are sent to the home for review. The home then considers the assessment to determine if the home can meet the needs of the service user and if needed a member of staff from the home can visit the service user prior to admission. The home is able to facilitate admission very quickly once this process has been completed if required. An admission to the home took place during the inspection and due to the necessity to admit the service user promptly they did not visit the home prior to admission and this tends to be the case in the majority of admissions. Several service users spoken with had been at the home prior to their present stay so had a good knowledge of the home. A member of the multidisciplinary team writes to the proposed service user detailing how their needs will be met. Areas of the home are designed to help service users receiving intermediate care to regain the skills needed to return to their own home. Staff spoken with were able to discuss the individual needs of several service users receiving intermediate care. Other health professionals to include a physiotherapist and occupational therapist are involved in the care of these service users and each has a rehabilitation plan devised and reviewed on a frequent basis. This set of standards has been scored as adequate as the homes Statement of Purpose and Service Users Guide lack the information required by Care Home Regulations 2001. Nevertheless the arrangements for admission to the home are excellent due to the assessment processes undertaken and the input from other health professionals. Great Western Court DS0000031570.V320645.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): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a clear and consistent care planning system in place that provides staff with the information needed to satisfactorily meet service users needs. The health needs of service users are well met with evidence of good multidisciplinary working taking place on a regular basis. The medication systems used in the home meet the needs of the service users, but the storage arrangements could potentially place the welfare of service users at risk. EVIDENCE: The care of three service users was examined in detail. This includes examining care records, speaking to the service user where able and talking to a member of staff. One service user was a new admission for intermediate care, another was waiting for a decision about their future and the remaining Great Western Court DS0000031570.V320645.R01.S.doc Version 5.2 Page 12 service user was receiving long-term care. All three had an assessment of needs and from this care plans were devised. One assessment of needs required updating, as it did not take into account a risk assessment that had been completed following this. Care plans for two service users had monthly reviews or sooner if needed. The remaining service user was new so no reviews had taken place. All have a personal profile, information about funeral arrangements. Services users receiving intermediate care all have a rehabilitation care plan with regular reviews by the multi-disciplinary team. One service user had a risk assessment in place that was being reviewed on a daily basis. Moving and handling assessments were in place as well as Waterlow assessments and monthly reviews were seen of these. Daily records are also maintained for each service user. The home operates a ‘key worker’ system. The home has a number of health professionals that visit to include a physiotherapist, occupational therapist, dietician, community nurses and a consultant Physician in Elderly Care. A continence nurse was due to visit a service user and the stoma nurse from the local hospital had visited the home during the inspection. Each week the home has a multi-disciplinary meeting where the care of a number of service users is discussed. Service users are able to stay with their own GP’s providing they are within a certain distance of the home otherwise they need to register with a local GP. Service users surveys indicated that they always receive the medical support they need and in the majority of cases they always receive the care and support from the home they need. The medication systems were looked at. Each unit has a trolley secured to the wall were medications are administered from. The positioning of these trolleys next to heat sources and by windows could indicate that the temperature that the medication is stored at is above the recommended 25°c. The home must demonstrate that they are stored at the required temperature. From discussion with members of staff they do not administer medication unless they have undertaken training in the safe handling of medication and have had supervised practice. Service users are able to self-medicate following an assessment and lockable facilities are provided in their rooms, however this was not witnessed. Several service users were observed having medication ‘from the trolley’ so the staff are able to assess them. The Medication Administration Records (MAR) were examined. The home hand writes all of these except for service users receiving long-term care. The majority of hand-written entries were checked and signed by another member of staff. Copies of all prescriptions are kept and service users discharged from hospital also have a list of their discharge medication. The MAR sheets were examined in three units and several were found to have gaps in the administration. Great Western Court DS0000031570.V320645.R01.S.doc Version 5.2 Page 13 Records were seen of medication received, administered and returned to the local pharmacy. A specimen signature and initials list was available. A medication reference book is stored in the office with copies of the policy and procedure. The home has a central medication room where stock medication is stored. Information about the homely remedies list is in this room and it includes the consent of local GPs’. The temperature of the medication fridge is recorded daily. The home should consider storing eye medication on a separate shelf to creams etc. A tub of sudocream is kept by the home to use if a service user requires skin care prior to the community nurse visiting. To reduce any risks of cross contamination the home should have smaller tubes of cream and a protocol agreed by the community nurses for its use. However the local hospital trust has stopped the use of this cream for skin care and the Care Home Support team have sent out a newsletter in January 2007 with the details. One of the pharmacy’s used by the home has recently completed an audit of the home and identified several areas that need improvement. The home should consider completing an audit. Dates of opening were not seen on all medication stored. Privacy and dignity was discussed with several service users and they felt the staff maintained theirs and no concerns were expressed. Great Western Court DS0000031570.V320645.R01.S.doc Version 5.2 Page 14 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 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are able to maintain contact with family and friends, but the lack of designated activities programme could result in service users not having their recreational interests met. Dietary needs of service users are catered for with a balanced and varied selection of food available that meets service users tastes and choices. EVIDENCE: The home does not have a structured programme of activities in place because the majority of service users are only at the home for a short period of time. Service users are able to join in with activities at the day centre. Service users spoken with had a mixed response to activities, some said they are happy to make their own and other said they are bored. Service users surveys also had a mixed response with the majority saying that only ‘sometimes or never’ are there activities provided by the home that they can take part in. One service user had commented that ‘as they had impaired hearing and eye sight they Great Western Court DS0000031570.V320645.R01.S.doc Version 5.2 Page 15 would not be able to take part in the activities’. The Deputy manager said that outings have been arranged but service users did not want to take part. No activities were taking place during either day of the inspection other that the day centre and the hairdresser was visiting on the second day. Visitors were seen going in and out of the home and from discussions with service users it is not restricted. One service user attends a day centre and another service user said they go out with their family. One service user said they like to watch the children playing at the school next door. Service users said they are able to make choices about their daily lives. Choices are offered for mealtimes and from observations service users can get up when they like. From discussions with the Administrator the home does not manage money for service users receiving short-term care. See Standard 35. Several service users rooms were observed as part of the tour of the home, those receiving long-term are care able to bring in their own personal possessions and their rooms were very individual. Service users receiving short-term care are able to bring in some of their items. From discussions with the cook the home operates on a 12-week menu cycle devised by the County Council. The home offers a main choice for lunch and teatime, however an alternative menu is available and the cook has a likes and dislikes board in the kitchen. The cook does not have specific meetings with service users to discuss meals but they can request any meals. Each morning the plan for the day’s meals is displayed in each unit and service users are asked if they wish to have an alternative. Drinks are offered to service users through out the day. Service users spoken with all said they enjoyed the food provided and that they are offered choices. Service users surveys also said that the majority of service users ‘always’ like the meals at the home. The inspector tasted a lunchtime meal on one day of the inspection and found it to be very tasty. Part of two mealtimes were observed and found to be a sociable event; at these no service users were seen requiring assistance from the staff. The cook said that the home uses frozen vegetables during the week and fresh at weekends. The cook is aware of the changes to the food standards and has obtained new recording documentation following these changes. Health and safety checks for food, freezer and fridge temperatures were seen. Food records were examined and found that the home needs to include in these alternatives and special diets. Great Western Court DS0000031570.V320645.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 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure in place that advises service users their views will be listened to and acted upon. Arrangements for protecting service users from abuse or possible harm can be further improved with staff having knowledge of the local adult protection procedures. EVIDENCE: From discussions with the Deputy Manager the home has not had any complaints since she started at the home in the middle of last year. A copy of this procedure is included in the information file but it makes reference to the National Care Standards Commission and Social Services. The home said they are in the process of obtaining a copy of the new complaints procedure for Community and Adult Care Directorate. No copies were seen of the complaints procedure in the main entrance of the home. Service users spoken with said if they were unhappy they would know who to speak to. Service users surveys said that in the majority of cases they would know who to speak to if they had a complaint. Relatives and visitors surveys said that one person was not aware of the homes complaints policy. Great Western Court DS0000031570.V320645.R01.S.doc Version 5.2 Page 17 The home has policies and procedures in place for whistle blowing and raising concerns and these are available on the Internet for the local council. The home is updating their polices and procedures manual. Staff that have completed NVQ training have covered the types of abuse and how to recognise it. However there was no evidence that staff have undertaken a training course in the local adult protection procedures. At this inspection the training records indicated that only two members of staff in 2003 had received abuse training. One member of staff was asked about the procedure to follow if an allegation of abuse has been made and some prompting was needed. Eight staff surveys were returned and two of these said they were not aware of the adult protection procedures. Gloucestershire County Council who own this home provide training in safe guarding vulnerable adults, however the home was not aware of this. The home must address this as a matter of urgency to ensure service users are not put at risk. No copies of the ‘Alerters Guide’ were seen in the home. From the information obtained at the inspection no staff have been referred to POVA. Great Western Court DS0000031570.V320645.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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, safe and well maintained, however this can be further improved by ensuring that the actions of staff do not put service users at risk. EVIDENCE: A tour of the home took place with several service users rooms seen. Each unit has six bedrooms with four of them having en-suite facilities. All have a lounge and dining area with a small kitchen. Rooms of service users receiving long-term care were all individual with a lot of their personal belongings on display. Assisted bathing facilities are provided and one service user who does not have an en-suite said that the toilet is just opposite their room and not far for them to go. A number of aids were seen in service users room to assist them. Great Western Court DS0000031570.V320645.R01.S.doc Version 5.2 Page 19 In Apperley Unit in the assisted bathroom, on the bath the end by the taps, part of the plastic covering behind the taps was coming away meaning that water could penetrate and the shower curtain was discoloured. This was also the same in Blaisdon and Deerhurst in relation to the shower curtain. The bath racks on Apperley and Blaisdon were rusty in places with a build up of soap. These need to be replaced, as they are an infection control risk. On Apperley unit the front of the cooker had visible signs of food debris. The staff undertakes the washing up of the units as this was observed following the evening meal. Each fridge has their temperature taken weekly on the units by the maintenance person but these records were not examined. The fridge on Blaisdon had several food items that were not covered or labelled. All cereals stored had labels on when they were placed in the containers. The laundry is sited away from food preparation areas. Two commercial washing machines are in place and a domestic washing machine for more delicate items of clothing. Laundry baskets were seen on the units and these are stored in the sluice areas. The procedure for dealing with soiled lined was not inspected. The laundry area was well organised and one service user said they receive a good service. Staff were observed wearing protective aprons and boxes of gloves were seen in the home. No issues were identified with the cleanliness of the home other than what is mentioned above and service users surveys said that the home is always clean and fresh. Consideration should be given to the domestic staff being more aware of where they are leaving their cleaning products as this could potential place service users and visitors to the home at risk. Great Western Court DS0000031570.V320645.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 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is confident that the numbers of staff on duty meet the needs of the service users, and the staff receive the appropriate training. The home needs to demonstrate that their vetting and recruitment practices ensures that the appropriate checks are being carried out to prevent service users being put at risk. EVIDENCE: From discussions with the Deputy Manager and from reading duty rotas there are six care staff on an early shift, five on an afternoon shift and three waking night staff. The Deputy Manager and Registered Manager when on duty are extra to these numbers. Each member of staff is allocated a unit whilst on the day shifts and on the morning shift the extra staff member helps out on all the units. On the morning shift there is at least two rehabilitation officers and at least one on afternoon shift. These members of staff can administer medication. For staff to take a break they need to leave the unit they are allocated to which leaves them without a staff member. The Deputy Manager said that service users are encouraged to ring their call bells for assistance at this time as each member of staff will inform service users if they are leaving the unit. Ancillary staff are employed for cleaning, cooking, maintenance and a driver for the day centre. Great Western Court DS0000031570.V320645.R01.S.doc Version 5.2 Page 21 Service users all complimented the staff. The comments received from the service users surveys include ‘staff caring, sympathetic, excellent and kind’. Another comment was that the ‘domestic staff are good’. Comments from relatives/visitors to the home on their surveys included ‘staff very pleasant, care about the wellbeing of service users’ and ‘staff are extremely helpful and lovely’. Staff said that the home is a nice place to work as staff work as a team, and support each other and the management of the home. One comment on the staff surveys said they would like to improve the communication between them and the local hospital. The Deputy Manager said that six members of care staff have NVQ 2 training and three are undertaking this training. Eleven care staff have NVQ 3 and six are doing this course. The home also has a number of staff with equivalent to this training. The Deputy Manager is currently doing the NVQ 4 training. The personnel files of six recently appointed members of staff were examined. None of these contained all the required recruitment checks as directed by the Care Home Regulations 2001. Checks missing included proof of identity and copies of Criminal Records Bureau disclosures (CRB) and POVA checks, however copies of these were sent from the human resource department during the inspection. Also evidence of their health was missing. Several members of staff were working for Gloucestershire County Council in other areas to include children’s services. Evidence was seen of a CRB, POCA and POVA check, however for one member of staff this has been done for a secretarial role and as they are now in a care role they must have another one undertaken. The home should refer to the Department of Health guidance ‘protection of vulnerable adults’. The Registered Manager was addressing this straight after the inspection. These staff members did not have two written references, proof of identification or proof of fitness. Following the inspection the Registered Manager said that it is the policy of the Council only to obtain verbal references if staff move with in the organisation. Identification and fitness records of staff are held at their human recourses office. Interview records were seen on two staff members. No written agreement has been made between the home, the Council and the Commission that the personnel records of staff can be held centrally at their human resources office. This needs to be addressed as the home at the time of this inspection has inadequate recruitment procedures. Training records were examined for several staff members. They Deputy Manager at the present time is in the process of updating all records as the fire training records did not indicate that all staff have received this training. The Deputy Manager said that she was certain all staff have had this training. Staff spoken with confirmed that training is provided and they receive updates. A comment received on a staff survey said the home provides good training. Great Western Court DS0000031570.V320645.R01.S.doc Version 5.2 Page 22 A new induction checklist is due to be introduced. The home uses the Councils induction programme and all staff are booked on mandatory training to include fire, food hygiene, moving and handling and first aid. Staff confirmed that they have a mentor during induction and their name is included on their induction checklist. Domestic staff also have training in COSHH. Each month the home receives a list of training provided by the Council and staff said they could request training from this. Great Western Court DS0000031570.V320645.R01.S.doc Version 5.2 Page 23 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, 32, 33, 35, 36, 37 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager is open and approachable, however due to the hours worked she is not able to discharge her responsibilities fully. The systems for consultation with service users are satisfactory with evidence that service users views are sought. The home is not able to demonstrate that care staff are appropriately supervised. The home ensures so far as is reasonably practicable the health, welfare and safety of service users and staff. EVIDENCE: Great Western Court DS0000031570.V320645.R01.S.doc Version 5.2 Page 24 For a number of months the Registered Manager has been working eighteen and a half hours a week and a pilot scheme is in operation for the Deputy Manager to job share this role. To date no application has been made to the Commission for the Deputy Manager to be registered along side the Registered Manager. The Deputy Manager is in the process of undertaking the NVQ 4 training. At this inspection a number of areas of concern have been identified and need to be addressed. Service users and staff said they feel they can approach the management team of the home. Staff said they are well supported in their roles. The Deputy Manager said that when service users leave the home they are sent a survey asking for their views. A number of these were seen and they were all complimentary about the home. The results of these were not collated. Monitoring systems used include auditing of accident records, however it was identified on one audit that a certain time scale had a large number of falls, if this is the case the home would need to identify actions to be taken to address this. The Deputy Manager and Team leader said they do check care plans and medications but do not maintain records of this. Consideration should be taken to recording these checks undertaken and used as part of their quality assurance. The home manages monies for a number of long stay service users. Each service user can be identified and an audit trail is in place. Appropriate records are maintained. This bank charges the home a small fee for statements, however the administrator said that the Council pays this. Supervision records were examined. It was found that records of supervision sessions are not being maintained for care staff. Two ancillary staff had regular documented sessions. Staff spoken with said they do receive regular supervision sessions. A requirement issued at the last inspection for the home to ensure records are kept up to date for medications and staff training remains outstanding. Maintenance records were examined along with the information given by the home prior to the inspection. All were up to date. A recent review of the building has taken place and the home is waiting for the report. A fire risk assessment was in place but it was not checked in detail, however it is recommended that the home check this with either the fire service or their web site. Great Western Court DS0000031570.V320645.R01.S.doc Version 5.2 Page 25 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 2 4 X 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 2 2 3 Great Western Court DS0000031570.V320645.R01.S.doc Version 5.2 Page 26 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 OP1 Regulation 4 Requirement The registered person must add the additions listed in Standard One to their Statement of Purpose to ensure it contains the required information. The registered person must devise a Service Users Guide as required in this Regulation and give a copy to all service users. The registered person must ensure that medication is stored at the temperature required by the manufactures to prevent any risks to service users. The registered person must ensure that all staff receives training in the local adult protection procedures to follow, to ensure they are safe guarding vulnerable adults. The registered person must replace the shower curtains in the identified units and bath racks as they are an infection control risk to service users. The registered person must demonstrate the following pre employment checks are taking place: DS0000031570.V320645.R01.S.doc Timescale for action 31/03/07 2. OP1 5 31/03/07 3. OP9 13(2) 20/02/07 4. OP18 13(6) 09/04/07 5. OP19 13(4c) 19/02/07 6. OP29 19 20/03/07 Great Western Court Version 5.2 Page 27 1) Proof of the person’s identity to include a photograph. 2) Two written references, including where applicable, a reference relating to the person’s last period of employment of not less than three month’s duration which involved work with children or vulnerable adults. 3) Where a person has previously worked in a position which involved contact with children or vulnerable adults, written verification (so far is reasonable practicable) of the reason why he ceased to work in that position. 7. 8. OP36 OP37 18(2a) 17(1a) The registered person must demonstrate that care staff are receiving supervision. The registered person must ensure that medication records are accurate and up to date. This requirement is repeated from the last inspection. 20/03/07 01/03/07 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. Refer to Standard OP2 OP9 OP9 Good Practice Recommendations The home needs to revise their terms and conditions in line with Regulation 5 of the Care Homes Regulations 2001. The home should undertake audits of their medication systems used to identify any areas that need addressing. The home should devise a protocol agreed by the DS0000031570.V320645.R01.S.doc Version 5.2 Page 28 Great Western Court 4. 5. 6. 7. 8. 9. 10. 11. 12. OP18 OP19 OP19 OP26 OP29 OP31 OP33 OP36 OP38 community nurses for the use of creams for skin care and hold stocks of smaller tubes to prevent the risk of cross infection. The home should obtain copies of the ‘Alterters Guide’ to display around the home and ensure staff read them. The home should ensure that the cookers in the units are checked for food debris. The home should ensure that all food is labelled with a date on it in unit fridges to ensure the safety of service users. The domestic staff in the home need to ensure they do not leave their cleaning products unattended as this is a risk to service users and visitors to the home. The home must obtain written agreement between them, the Council and Commission that personnel files can be held centrally at their human resources department. The home should ensure that the registered manager is able to fulfil her job role within her hours or make alternative arrangements. The home should document all the checks they undertake as part of their quality assurance. Records should be maintained of all supervision sessions. The home should check their fire risk assessment is in line with the guidance issued by the fire service. Great Western Court DS0000031570.V320645.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Great Western Court DS0000031570.V320645.R01.S.doc Version 5.2 Page 30 - 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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