Inspection on 30/08/05 for Gresham Residential Care Home

This inspection was carried out on 30th August 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Gresham Residential Care Home 28/02/07

Gresham Residential Care Home 09/02/06

Gresham Residential Care Home 17/01/05

Gresham Residential Care Home 01/06/04

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

CARE HOMES FOR OLDER PEOPLE Gresham Residential Care Home 47-49 Norfolk Road Cliftonville Margate Kent Lead Inspector Christine Grafton Announced 30/08/05 at 10:00hrs 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. Gresham Residential Care Home H56-H05 S35039 Gresham Res Care Home V238508 300805 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Gresham Residential Care Home Address 47-49 Norfolk Rd, Cliftonville, Margate, Kent. 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) 01843 220178 Jonathan Anthony Smith Jonathan anthony Smith Registered Care Home 31 Category(ies) of Older persons registration, with number of places Gresham Residential Care Home H56-H05 S35039 Gresham Res Care Home V238508 300805 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17/01/2005 Brief Description of the Service: Gresham Residential Care Home is a detached building with accommodation for residents on three floors. Bedrooms are mainly singles with some double rooms, currently occupied as singles. 23 out of the 26 bedrooms in the home have ensuite toilet facilities and there are plans to provide ensuite toilets in the other 3 bedrooms over the next 18 months. There is a shaft lift to all floors. All bedrooms have a call bell, television point and some have telephone points. There is a large lounge/diner, a separate TV lounge, a conservatory area, where residents may smoke and a small enclosed garden with fish pond, raised flower bed and seating area. The home is located within easy reach of local shops and all public amenities, with the seafront at the end of the road. This is a family run business that has been operating as a residential care home for 13 years. The staff team is lead by the registered provider/manager, Mr Jonathan Smith and a team of carers, who work a rota that includes one staff member on waking duty at night and one person on sleeping in duty. Additional staff are employed for cooking and cleaning. According to the homes statement of purpose, it aims to provide a good, safe environment, with a happy atmosphere, where residents are encouraged to be interested in each other and staff offer encouragement, to enable residents to maintain their independence, but offer care as needed. Gresham Residential Care Home H56-H05 S35039 Gresham Res Care Home V238508 300805 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over one and a half days. The total time spent at the home was 10 hours 10 minutes. Additional time was spent in preparation and report writing. The inspection consisted of speaking with the registered provider/manager, 5 staff members and 15 residents. Records were seen and an accompanied tour of the building was made. The inspection focussed on checking the majority of the key standards. As part of the pre-inspection process, the registered provider completed a preinspection questionnaire, which has been used in the preparation of this report. The pre-inspection process also involved consulting with residents and relatives for their views of the home. One relative and two residents returned their comments cards and contained positive comments about the home. At the time of this inspection there were 25 residents, including 2 in hospital. The care of seven residents was case tracked. The outcome of this inspection indicates that the registered providers and manager are committed to providing a good quality of environment and care for residents. What the service does well: Commendable standards were evident relating to the maintenance of the environment and the ethos of the home (standards 19 and 32), which have both been rated as 4’s (standard exceeded). The home is comfortably furnished, well decorated and has a friendly, relaxed atmosphere. The registered providers and manager have worked hard on the refurbishment of the building (see below) resulting in a majority of bedrooms that are spacious, with ensuite toilet facilities, new furniture, carpets and curtains. Residents praised the management and staff, saying that they are all very approachable and listen to them – to quote one, “nothing is too much trouble”. Several of the staff have worked at the home for a number of years and know the residents well. Staff are well motivated in their work and this, plus the management commitment to staff training and development, benefits residents by making sure they receive good quality care. There were numerous comments about the food, ranging from “very good”, “very nice” to “excellent”. Residents can take part in a variety of activities to keep them occupied and stimulate their minds. Gresham Residential Care Home H56-H05 S35039 Gresham Res Care Home V238508 300805 stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: It was disappointing that with all the above good things that have been achieved, new staff were being employed before police checks had been obtained and without protection of vulnerable adults (POVA) register checks. This places residents at risk from being cared for by staff that had not been properly vetted. Also there were no records to show whether during interviews, a full employment history had been obtained and any gaps in employment checked out. In exceptional cases, where a staff member may start work following a POVA first check, prior to the return of the full police check, the management must be able to demonstrate that stringent vetting procedures have been followed and that the new staff member is being properly supervised. The home’s recruitment procedure and records need to be improved to ensure that these matters are covered. Records should be kept of the named supervisor/s and evidence that the new person is on the same shifts as their supervisor. This is necessary to ensure that residents are properly protected. The manager made a commitment to rectify this and submitted his revised recruitment policy and proposed new recruitment records within two days of this inspection. Gresham Residential Care Home H56-H05 S35039 Gresham Res Care Home V238508 300805 stage 4.doc Version 1.40 Page 7 Procedures to prevent the spread of infection in the home are generally satisfactory, but need to be tightened to make sure that appropriate facilities are available for staff when dealing with soiled articles, or clinical waste. Some improvements had been made following the last inspection, but the management must make sure that supplies of liquid soap and paper towels are readily available for hand washing, in all areas where soiled articles are handled. These are necessary to protect residents and staff from the risk of infection. 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. Gresham Residential Care Home H56-H05 S35039 Gresham Res Care Home V238508 300805 stage 4.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Gresham Residential Care Home H56-H05 S35039 Gresham Res Care Home V238508 300805 stage 4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 The home has a thorough assessment process that makes sure that the care needs of new residents can be met upon admission to the home. EVIDENCE: The care plans for three new residents were seen as part of the case tracking process. From checking the records and speaking with the residents and staff, it was clear that a detailed assessment of needs had been carried out. The assistant manager starts this process prior to admission, by carrying out and recording the pre-admission assessment. Copies of the care management assessments are also obtained. The care plan documentation indicated that this information is used to inform the needs assessment carried out following admission. From this, care plans had been drawn up that identified any risks and showed the risk management strategies. The documentation seen covered all the components specified in the standards. Care staff spoken to had a good understanding of the new residents’ needs. A new resident said, “it is very nice here, I don’t think I could have found a better place.” The resident went on to say that they were being well looked after by the staff, who are all very nice and friendly. Gresham Residential Care Home H56-H05 S35039 Gresham Res Care Home V238508 300805 stage 4.doc Version 1.40 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 & 10 The home’s care planning system provides staff with the information they need to meet residents’ needs. The personal and health care needs of residents are being met. Safe systems are in place for the storage and administration of medications. Personal care is given in a manner that protects residents’ privacy and dignity. EVIDENCE: From the seven care plans case tracked it was possible to trace the residents’ needs and changes that had occurred over periods of time. The care plan files contained detailed information, including informative personal profiles, full needs assessments and action plans. They reflected the care needs evident from speaking with the residents and with some of their key workers. The assistant manager and care staff have obviously worked hard since the last inspection, to ensure that the plans are updated and changes are now being recorded in more detail. Monthly review sheets are being completed, but some of the useful information from the daily records and the doctors and nurses appointments, or visits, sections had not been referred to in the reviews, or updated in the care plans, making it more time consuming to case track. That said, there was lots of evidence of contacts with health care professionals and of the care provided, showing that the residents’ health care needs were being Gresham Residential Care Home H56-H05 S35039 Gresham Res Care Home V238508 300805 stage 4.doc Version 1.40 Page 11 met. Weight records are recorded and the home has a set of ‘sit on’ chair scales. Improvements have been made to the medication storage since the last inspection. The room where medications are stored has been completely refurbished. There are new cupboards, new work tops, a new wash hand basin, liquid soap, paper towels and an air cooling unit. A new lockable drugs fridge has been purchased with a minimum/maximum thermometer. Appropriate locks have been fitted to cupboards and there is a metal cupboard with a controlled drugs unit. Residents’ photographs have been put on the blister packs and on the medication administration sheets and a staff initials and signatures list kept. Staff were seen giving out the lunch time medications in an appropriate way. Staff have a good understanding of the residents’ needs and know what is to be achieved when offering care. Staff were seen treating residents with kindness and respect. Residents commented that the staff are always very helpful and assist them with the things they cannot do for themselves. A resident spoke about their care needs and said, “they’ve done a lot for me here.” Gresham Residential Care Home H56-H05 S35039 Gresham Res Care Home V238508 300805 stage 4.doc Version 1.40 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 & 15 Opportunities are provided for residents to take part in a varied range of activities. The home encourages visits from families and friends. Residents are helped to maintain choice and control of their lives. Residents are provided with a good, well balanced, varied diet and enjoy their meals. EVIDENCE: Residents spoke about the various activities that they enjoy in the home. Two residents enjoy gardening and look after the raised flower beds in the back garden. A resident enjoys doing errands for other residents and goes to nearby shops to buy newspapers and other items. A manicurist visits weekly and three ladies were seen having their nails manicured. Several residents spoke of their enjoyment from taking part in the music and movement sessions run by a lady who comes to the home twice a week. A group of residents were seen participating in a game of bingo. Residents also spoke about their individual interests that they pursue – one resident enjoys watching sport on the wide screen television in the TV lounge. Others were seen reading their newspapers, or large print library books. Several residents spoke about a recent outing to the sea front in the home’s minibus, where they had strawberries, ice cream and scones. Residents spoke about their visitors, saying that staff always welcome their relatives and friends to the home. Some of the residents use either their own or the home’s motorised scooters to go out to local shops, or to the seafront. Gresham Residential Care Home H56-H05 S35039 Gresham Res Care Home V238508 300805 stage 4.doc Version 1.40 Page 13 Fifteen residents were spoken to and it was clear that they are able to choose how they spend their time, for example, they can stay in their bedrooms, sit in any of the lounges, or garden, get up when they want to and go to bed when they want. A four week menu plan is followed that provides a varied, balanced diet. A resident said how much they like breakfasts and commented about the wide choice offered at breakfast time, including grapefruit, choice of cereals, a full cooked breakfast, toast and tea. A three course dinner is served at lunch time and there is always a cooked tea with a choice of sandwiches as an alternative. Many of the residents spoken to praised the food, comments included: “ the food is very nice, I’ve not left anything since I’ve been here.” “The food is lovely.” “The food is excellent.” A set menu is provided, but alternatives are offered if residents do not like anything on the planned menu. The alternatives are not recorded on the menu. Therefore, the home is reliant upon residents’ comments to verify choice. Standard 15 has been judged as met, but this could be improved by keeping records of alternatives and of the residents that have had something different to what is on the menu, plus what they had. Residents’ food likes and dislikes are recorded in their care plans and the cook knows residents’ preferences. Gresham Residential Care Home H56-H05 S35039 Gresham Res Care Home V238508 300805 stage 4.doc Version 1.40 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 & 18 Residents know that their complaints will be listened to and acted upon. Staff have a good understanding of adult protection procedures, which protects residents from abuse. EVIDENCE: Residents spoken to were anxious to praise the home, saying what a good place it is to live in and that they had no complaints. Several residents said that everyone, staff employed and the management, are very approachable. From their conversations, it was clear that they are comfortable in speaking with staff members, the manager or assistant manager, if they had anything they were not happy with. Several residents said “ I just speak to … (the manager) and he puts it right.” The home’s complaints procedure is displayed and is included in the service users’ guide, a copy of which is kept on the hall table beside the visitors’ book. The manager said there had been no complaints since the last inspection. Two staff spoken to demonstrated good knowledge of what constitutes adult abuse and what actions they should take if they suspected a resident were being abused. A staff member was aware of the home’s whistle blowing policy, but went on to say that there was a good staff team and that everyone working at the home has the residents’ best interests at heart. The home has formal adult protection policies and procedures, which all new staff have to read during their induction. Gresham Residential Care Home H56-H05 S35039 Gresham Res Care Home V238508 300805 stage 4.doc Version 1.40 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 & 26 There have been many improvements to the home over the last year that have been completed to a high standard, adding to the homeliness, comfort and safety of the building, providing residents with a very pleasant environment in which to live. This is commendable and has greatly enhanced the residents’ quality of life. Infection control procedures are generally satisfactory, but hand washing facilities need to be improved in some areas, to ensure safe hygiene. EVIDENCE: Since the last inspection, work on the refurbishment of the premises has continued. With the creation of four enlarged bedrooms on the top floor, the home’s registration number was increased from 28 to 31 on 8th March 2005. This was in line with the home’s business plan agreed when the providers were registered in November 2002. At that time, the home had 7 ensuite facilities in 23 bedrooms, whereas there are now 23 ensuite facilities in 26 bedrooms. As part of the improvement programme, several bedrooms have been enlarged and where possible, corridors widened. The latest development plan for the home covers an eighteen month period, during which it is planned to provide 3 more ensuite facilities, so that all rooms will have ensuite toilets. As the Gresham Residential Care Home H56-H05 S35039 Gresham Res Care Home V238508 300805 stage 4.doc Version 1.40 Page 16 refurbishment work has been completed, new furnishings, curtains and carpets have been provided. Several residents said that they have a “lovely bedroom.” One resident said their room “is perfect”. As well as this, the entrance hall has recently been redecorated and the back garden is very attractive, with fish pond, raised flower beds and a shaded area for residents to sit. An airconditioning unit has been fitted in the conservatory lounge and the conservatory roof has been painted with solar reflective paint. Residents and staff said that this has been a great improvement and now provides a more comfortable temperature on hot days. The home was clean and free from unpleasant odours. Laundry procedures include the use of water-soluble alginate bags for soiled articles. There is an industrial washing machine, which has a sluice cycle. Liquid soap and paper towels have been provided in all communal areas where soiled articles and clinical waste are handled, but these were absent in bedrooms where staff have to handle contaminated items. The laundry floor was covered with a number of laundry items that would be better kept either in cupboards, or on shelving, so that the floor is easily cleanable and things are not contaminated. Eight staff have completed training in infection control. Gresham Residential Care Home H56-H05 S35039 Gresham Res Care Home V238508 300805 stage 4.doc Version 1.40 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 & 30 Staff morale is high resulting in an enthusiastic workforce that works positively with residents to improve their whole quality of life. Recruitment policies have not been consistently followed resulting in residents being cared for by some staff who have not been appropriately vetted. The home’s induction and training programme makes sure that staff are properly trained and competent to care for residents. EVIDENCE: From rotas seen and observations made during the inspection, it was clear that there were sufficient numbers of staff on duty to care for the residents. This included care staff, cleaning and cooking staff, plus the manager and assistant manager. Care staff spoken to said that the Gresham is a good place to work and that they work together as a team, to provide good care for the residents. There is a nucleus of staff who have worked at the home for a number of years and they know the residents well and clearly like their work. Dependency assessments are not currently being completed in residents’ care plans, but the manager does use the Department of Health Guidance to calculate the staffing numbers required. The calculation provided on the preinspection questionnaire indicates 21 residents with low dependency needs and 1 with medium needs, for which, 350 care hours per week were being provided. The assistant manager also works with the care staff. However, without individual residents’ dependency assessments, there is no way of validating the information provided by the manager. The case tracking indicates that there is more than one resident with medium dependency needs. Therefore standard 27 has been judged as ‘almost met’. Gresham Residential Care Home H56-H05 S35039 Gresham Res Care Home V238508 300805 stage 4.doc Version 1.40 Page 18 Two staff files were checked for carers who had been employed within the last six months. A thorough recruitment procedure had been followed, with the exception of obtaining police checks prior to employment. Evidence seen included application forms, two references on each file (received prior to the start date) and a record of the criminal reference bureau (CRB) reference number. In one case the CRB check had been received two months after employment commenced and in the second case, within one month. In neither case had a protection of vulnerable adults (POVA) first check been carried out and although induction records were seen, there was nothing to show that the carers had been supervised as specified in the regulations. There was also no evidence to confirm whether full employment histories had been obtained, or that gaps in employment had been checked out. Three staff hope to complete their national vocational qualification (NVQ) in care level 2 by the end of November and two new staff have commenced their NVQ level 2, plus one is doing NVQ level 3. Another new staff member is doing an NVQ level 4. Evidence of induction training to the Skills for Care specification was seen and the staff training matrix indicates attendance on a variety of short courses. Gresham Residential Care Home H56-H05 S35039 Gresham Res Care Home V238508 300805 stage 4.doc Version 1.40 Page 19 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 & 38 The manager has a clear development plan and vision for the home, which he has effectively communicated to residents and staff. He has created an open, positive and inclusive atmosphere, which is commendable. Good systems are in place to protect residents’ financial interests. The health and safety practices in place safeguard residents, staff and visitors to the home. EVIDENCE: Residents and staff were complimentary about the manager’s approach to the running of the home. A staff member praised the team working spirit that has been developed, saying: “I like working here, there is a friendly atmosphere, all the staff are nice and the management are very nice – they are very good, sort any problems out”. A resident said, “it’s really nice here, from the manager all down, they are so nice, they have time for you. We’re very lucky, nothing’s too much trouble.” The development plan for the home, dated 1st February 2005, covers the period to August 2006. This has clear goals that are being worked through in Gresham Residential Care Home H56-H05 S35039 Gresham Res Care Home V238508 300805 stage 4.doc Version 1.40 Page 20 priority order and are split into environmental and care related objectives. Some of these have already been achieved and referred to in this report, such as the refurbishment of the care office, the conservatory air conditioning unit and staff enrolment on their NVQ level 2. The home’s quality monitoring processes include regular residents’ meetings, staff meetings, formal staff supervision and questionnaires. A resident said they had read the last inspection report. Records of residents’ monies held on their behalf were seen to be well kept. Good fire safety records were seen. A resident said that the fire bells are tested every week and described the fire procedure to be followed, saying: “if the fire bells go off we’re told to come down and assemble across the road”. Information in the pre-inspection questionnaire indicates that the prescribed maintenance checks have been completed. The staff training matrix indicates that sufficient staff have been trained in fire safety, first aid, moving and handling, health and safety and food hygiene. Gresham Residential Care Home H56-H05 S35039 Gresham Res Care Home V238508 300805 stage 4.doc Version 1.40 Page 21 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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 4 x x x x x x 2 STAFFING Standard No Score 27 2 28 x 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 4 3 x 3 x x 3 Gresham Residential Care Home H56-H05 S35039 Gresham Res Care Home V238508 300805 stage 4.doc Version 1.40 Page 22 Yes 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 OP26 Regulation 13(3) Requirement Timescale for action 30/9/2005 2. OP27 18 3. OP29 19 The registered persons must make suitable arrangements to control the spread of infection, in accordance with relevant legislation and published professional guidance. Appropriate hand washing/drying facilities must be in place and regularly topped up in all areas where soiled items and clinical waste is handled. In order that staffing numbers 30/11/05 can be calculated properly according to residents dependency needs, care plans must include dependency assessments. A summary of residents dependencies to be kept and used to calculate staffing numbers to meet residents needs. New staff must not be employed 30/9/2005 unless they are fit to work at the care home and information is obtained as specified in Schedule 2. Recruitment procedures must ensure that gaps in employment are checked out and CRB/POVA checks are carried out for all employees prior to their start date. Where an employee starts Version 1.40 Page 23 Gresham Residential Care Home H56-H05 S35039 Gresham Res Care Home V238508 300805 stage 4.doc work after a POVA first check, before return of the CRB, they must be properly supervised as specified in the Miscellaneous Amendments Regulations 2004 and records kept. (Previous requirement from 17/1/2005 partially met). 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 OP7 & 8 OP15 Good Practice Recommendations That care plan reviews are more meaningful, to include information from the daily records, doctors visits/appointments and contacts from community nurses. That dinner alternatives are recorded on the menu and that a record is kept of actual meals to include any special diets and alternatives. Gresham Residential Care Home H56-H05 S35039 Gresham Res Care Home V238508 300805 stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection 11th Floor, International House Dover Place Ashford Kent. TN23 1HU 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. 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