Inspection on 15/10/07 for Gresley House Care Home

This inspection was carried out on 15th October 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

Gresley House Care Home 23/06/08

Gresley House Care Home 12/02/07

Gresley House Care Home 16/08/06

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

CARE HOMES FOR OLDER PEOPLE Gresley House Care Home Market Street Church Gresley Swadlincote Derby DE11 9PN Lead Inspector Janet Morrow Unannounced Inspection 15th October 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Gresley House Care Home DS0000067515.V347798.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. Gresley House Care Home DS0000067515.V347798.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gresley House Care Home Address Market Street Church Gresley Swadlincote Derby DE11 9PN 01283 212094 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) Mrs Judith Dena Griffin Stewart Westley Barker VACANT Care Home 27 Category(ies) of Dementia - over 65 years of age (11), Old age, registration, with number not falling within any other category (14), of places Physical disability (2) Gresley House Care Home DS0000067515.V347798.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 2 places within the total of 27 can be used for (PD) either sex aged 50 - 65 yrs. Plus one (1) day care placement not regulated by Commission for Social Care Inspection. An additional PD place for CW - This person is named in the noticed of proposal (CW) this agreed place will cease on the termination of this person. For the home to accommodate one named person in the notice of proposal (PS) this agreed place will cease on the termination of this persons care at the home. 12th February 2007 Date of last inspection Brief Description of the Service: Gresley House care home provides personal care and accommodation for up to 27 people aged 65 years and over, including 2 places for persons 50 - 65 years and 1 day care place. Gresley House is situated in Church Gresley town centre, close to shops and local amenities; the home does not have a car park, however there is roadside parking outside the home. Residents have access to a well set out garden area. The home is situated on 2 floors and has 25 single rooms and 1 double room. Access to the first floor is by stairs and a passenger lift. The home has 4 lounge and dining areas. Copies of the most recent inspection reports are available on request from the office at the home. Gresley House Care Home DS0000067515.V347798.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit was unannounced and took place over one day for a total of nine hours. An ‘expert by experience’ assisted with the inspection process. An ‘expert by experience’ is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. The ‘expert by experience’ was present for four hours and spoke with five service users and three relatives. Her findings are incorporated into the report. Four residents, two members of staff, one relative and two visiting professionals were spoken with by the inspector. Three visiting professionals and one relative were contacted by telephone after the inspection visit. Care records, maintenance records and staff records were examined. The home currently had no manager but the deputy manager and owners were spoken with during the inspection visit. A tour of the building was undertaken. Information required by the Commission for Social Care Inspection, in the form of an annual quality assurance assessment, had not been provided prior to the inspection visit. What the service does well: Gresley House provides a comfortable and safe environment for the people who use the service. Residents and families were encouraged to personalise their rooms with their own possessions. The home assisted residents and relatives to maintain contact and there were no unnecessary restrictions on visiting. Staff had built good positive relationships with residents and those spoken with stated that the staff were ‘lovely’ and a visiting professional described staff as ‘caring’. Comments received from visitors and staff stated that the home had a ‘friendly’ atmosphere. Gresley House Care Home DS0000067515.V347798.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Recruitment procedures were poor and staff had commenced employment without the necessary checks such as Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks being in place. This must stop as it places residents at risk of harm. The management of the home was in a state of transition and there was no manager in place. This meant that some managerial duties had not been completed and information required for the inspection visit could not be located; for example staff training information, complaints records and quality assurance data. There were insufficient staff on duty on some shifts to fully meet residents’ care needs. This must be rectified to ensure that residents receive the necessary care and attention. Care records must contain more comprehensive information and essential information, such as weight, must be available. Assessment documentation should be more fully completed to ensure that a full picture of residents’ needs is available at the time of admission. Medication administration record (MAR) charts must be accurately completed to ensure a clear audit trail of whether or not medicines have been administered and the temperatures of the medication refrigerator must be recorded on a daily basis. Meals need to offer a greater choice and have more nutritional value. There must be a clear process for dealing with complaints that shows whether or not the complainant is satisfied. All staff must received training in safeguarding adults and the owners must familiarise themselves with Local Authority procedures. Gresley House Care Home DS0000067515.V347798.R01.S.doc Version 5.2 Page 7 A programme of replacing all old beds should be implemented and handrails must be provided in the garden area to ensure residents are able to access the garden safely. Staff training must be addressed to ensure that all staff receive mandatory health and safety training and training applicable to the care they are providing; for example, in dementia care. Quality assurance processes need to be more fully developed so that it is clear what action is being taken to improve the home and how the views of other professionals, residents and relatives are being sought and acted upon. There must be a clear system for administering residents’ personal finances and this must be adhered to consistently. A manager must be appointed and become registered with the Commission for Social Care Inspection. 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. Gresley House Care Home DS0000067515.V347798.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Gresley House Care Home DS0000067515.V347798.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was insufficient admission information to establish that the home was able to meet residents’ needs. EVIDENCE: Three residents’ care records were examined and all had an admission assessment in place and information from external professionals, where applicable. However, some of the information was minimal and did not fully explain what needs were. For example, mobility needs on one assessment were explained as ‘walks with walking stick’ but there was no other information available on what the underlying difficulty was. Gresley House Care Home DS0000067515.V347798.R01.S.doc Version 5.2 Page 10 There was also minimal information on social needs. Religious needs were documented but this was usually in the form of what religion someone was and there was little other information on how these needs would be met. Risk assessments for moving and handling and falls were in place and detailed the level of risk and how this should be managed. Although the home was registered to care for people with dementia, there was little information in the assessment documentation that specified any special needs in relation to dementia. Gresley House Care Home DS0000067515.V347798.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 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were shortfalls in some aspects of care planning and personal care that compromised residents’ care. EVIDENCE: Three residents’ care records were examined. All had a care plan in place and all three had been reviewed in the last three months. None of the files had any evidence, such as a signature, that consultation about care had taken place. The information on the files seen lacked detail. For example, under mental ability, the only information recorded on one file was ‘dementia’ and under social skills, it stated ‘needs help’. There was no indication about how the help was to be given. Risk assessments for falls, nutrition and tissue viability were in place but again the information recorded was limited; for example, on one file the action recorded to address a risk of falls stated ‘two carers’. Gresley House Care Home DS0000067515.V347798.R01.S.doc Version 5.2 Page 12 Nutritional assessments were in place but records of weight could not be located and staff spoken with stated that the scales were not in an accessible place. Observation during the visit showed that personal care needs were not always being met. One resident had wet trousers for about an hour and this was pointed out to a member of staff who then provided the necessary attention. Another resident who was dependent upon a hearing aid did not have it in place and staff reported that it was broken. Visiting professionals spoken with commented that there was a lack of attention on some occasions to leg ulcers and continence needs and the general cleanliness of residents. They also stated that staff were responsive to suggestions and keen to improve the care on offer. Access to health care professionals such as opticians, General Practitioners and chiropodists was made available and these visits were recorded. One relative spoken with had some concerns about how the needs of people with dementia were met; this related primarily to lack of stimulation and restriction on their movement within the home. Staff were referred to as ‘kind’ and ‘caring’ by residents and relatives and warm relationships were observed between staff and residents. Generally, residents had their privacy and dignity respected and staff treated them with courtesy. The medication administration record (MAR) charts of five residents were examined to check the accuracy of the recording. This showed that there were a number of gaps on the charts where there was no signature so it was unclear whether or not a medicine had been given. In all, there were thirty-one gaps noted across the five charts over a two week period. Three residents medication administration record (MAR) charts were then examined in more detail and showed further inaccuracies in recording. Three medicines were out of stock for one resident, which meant that they had missed a dose on the day of the inspection visit. However, staff stated that this had been addressed and supplies were being awaited from the pharmacy. Two people were not signing handwritten medication administration record (MAR) charts to ensure they were accurate. Temazepam was stored and administered under controlled conditions and the records of Temazepam corresponded accurately with the stock held. There were no controlled drugs currently in stock. Secure storage facilities were available. Gresley House Care Home DS0000067515.V347798.R01.S.doc Version 5.2 Page 13 The medication refrigerator temperatures were not being recorded daily. Although there was a system in place to record temperatures, these were not being done routinely. Staff responsible for administering medication had received relevant training from a pharmacist. Gresley House Care Home DS0000067515.V347798.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 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The current limitation on activities did not offer residents sufficient occupation, which had the potential to lead to boredom and social withdrawal. Community contacts were well managed, which enhanced residents’ quality of life. EVIDENCE: The owner stated that there was usually an activities co-ordinator working four days per week but that they were currently off sick and there was no replacement. There appeared to be no social activities on the day of the inspection visit and one resident was told to go and sit down. One visitor spoken with was also concerned that their relative was told to sit down regularly when they were used to walking about and stated that they had only been out once during the summer. TV was the only entertainment on the day of the visit. Three residents spoken with requested further activities. Gresley House Care Home DS0000067515.V347798.R01.S.doc Version 5.2 Page 15 There were no specific activities that were arranged to cater for the needs of people with dementia, although a box of reminiscence tools was stored in the office. Routines were varied and residents were able to spend time in their rooms or lounges as they wished. Residents and staff confirmed that contact was supported with family and friends. Residents said that family and friends could visit at any reasonable time and were made to feel welcome in the home. This was observed during the inspection visit. The serving of the lunchtime meal was observed and residents were spoken with during the mealtime period. There was mixed feedback about the food; some residents did not want to discuss the food and it was noted that they ate only about half of the food on offer. Although staff stated that a choice was available, this was not apparent to residents, who stated they had no choice. The dessert in particular did not appear to contain much nutritional value, (for example, the custard was observed to be powdery and made with water), although some residents stated that they enjoyed it. One relative spoken with stated that the thought the food was ‘okay’. One relative spoken with described the food as ‘good’. The previous inspection visit in February 2007 noted that access to advocacy services was facilitated for one resident. Gresley House Care Home DS0000067515.V347798.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 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Complaints procedures and safeguarding procedures were inadequate and had the potential to place residents at risk of harm. EVIDENCE: There was a complaint procedure on display on the wall in the hall but this contained out of date information. No complaints records could be located on the day of the inspection visit. Although the owner stated that some complaints had been made, these were not recorded so it was unclear whether or not the complainant was satisfied with the outcome. Residents spoken with stated that they did not know how to make a complaint and had no recollection of being given any information on how to do this. One relative spoken with stated that they had raised an issue with the owner that had been addressed satisfactorily. There had been no complaints received at the office of the Commission for Social Care Inspection since the last inspection visit in February 2007. Safeguarding procedures were discussed with the owner and there was a lack of clarity about some aspects of the procedures, although the need to report to the relevant authority was known. This has the potential to compromise Gresley House Care Home DS0000067515.V347798.R01.S.doc Version 5.2 Page 17 outcomes of allegations. The home’s copy of the Derby and Derbyshire Local Authority Social Services safeguarding procedures was out of date. However, an up to date version was supplied during the inspection visit. Lack of safeguarding training was raised as an issue at the last inspection visit in February 2007 and the timescale for this had expired. The last date of safeguarding training was listed as November 2006 and there were a number of staff who had not completed this training. Written information received from the owner following the inspection stated that this training would be ‘arranged shortly.’ Gresley House Care Home DS0000067515.V347798.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, 20, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well maintained, which ensured that residents had safe and comfortable accommodation. EVIDENCE: The owners had made improvements to the environment since the last inspection visit in February 2007. This included fitting window restrictors in upstairs windows, fitting radiator guards throughout the home and replacing damaged carpet in the hall and dining room. The home was generally clean and comfortable, although an odour was noticeable at the entrance and in specified areas around the home. The owner Gresley House Care Home DS0000067515.V347798.R01.S.doc Version 5.2 Page 19 stated that re-decoration of bedrooms was ongoing and several rooms had been redecorated since the last inspection visit. Bedrooms were personalised with residents’ own possessions and those residents spoken with were pleased with their rooms. However, during a tour of the building it was noted that some rooms contained old beds that were in need of replacing. The home was warm and comfortable and water temperatures were noted to be at safe levels. The laundry was viewed and there was one washing machine and drier available. The owner was unclear whether or not there was a sluice wash facility on the machine but stated there was as separate sluice facility in the building. Staff spoken with were aware of infection control procedures and the location of Control of Substances Hazardous to Health (COSHH) information. The external area was pleasant and had a range of facilities for residents, such as a lawned area, fishpond and aviary. There were some steps and slopes in the garden area that had no handrails and would therefore be difficult for some residents to access safely. Gresley House Care Home DS0000067515.V347798.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 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Insufficient staff and inadequate recruitment procedures had a detrimental effect on residents’ care and safety. EVIDENCE: Staffing rotas were examined for the week beginning 15th October 2007 was examined. This showed that there were only three care staff on the morning shift instead of the four needed. The deputy manager assisted with care tasks as required, which meant managerial tasks could only be partially completed. Discussion with staff, visitors and visiting professionals also highlighted staffing shortages; staff stated that they were doing additional shifts that meant they had little time off and felt they were rushing residents, especially in the morning; a visiting professional spoken with stated that they had had to search for staff on one occasion and a relative spoken with stated that staff seemed ‘rushed off their feet’. This lack of staff affected the quality of care in the home, with residents not always being attended to promptly. The owners were aware of the shortfalls and stated they were taking steps to address this by advertising for new staff on an ongoing basis. Gresley House Care Home DS0000067515.V347798.R01.S.doc Version 5.2 Page 21 There were two night staff in duty at night and there were no problems reported in covering night shifts. There were usually two domestic staff on duty but there was only one on the day of the inspection visit. A laundry person was employed daily Monday to Friday and a handy person was also employed Monday to Friday, although he also undertook tasks at the owners’ other home. Four staff recruitment files were examined and showed major shortfalls that had the potential to compromise residents’ safety. Two did not have two written references, two did not have a Protection of Vulnerable Adults (POVA) check or Criminal Record Bureau (CRB) prior to commencing employment and three did not have a full employment history. An immediate requirement notice was therefore issued to commence the process of rectifying these shortfalls. There was no staff training information available on the day of the inspection visit. However, the written information supplied by the home after the inspection visit stated that health and safety training had been undertaken or was arranged in fire safety and first aid and that moving and handling training would be undertaken in–house. Staff spoken with confirmed that they had undertaken training in medication and further training was arranged for November 2007. A visiting professional also confirmed this. However, there had been no specific training on caring for people with dementia and there was also no evidence of other training undertaken in relation to care issues. The written information supplied by the home after the inspection visit stated that there were ten members of staff with a National Vocational Qualification (NVQ) at level 2 and a further member of staff undertaking the training and four staff had a level 3 qualification with one member of staff undertaking the training. Staff spoken with also confirmed that NVQ training took place. Gresley House Care Home DS0000067515.V347798.R01.S.doc Version 5.2 Page 22 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, 33, 35 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There were inadequate management arrangements, which meant the home was not run in residents’ interests. EVIDENCE: The home was in a state of transition as the previous manager had recently resigned. This meant that the home had had a considerable period of time without a manager who was registered with the Commission for Social Care Inspection. The changes in managerial arrangements had had a detrimental effect on the home and key managerial functions such as recruitment of staff and availability of essential records were inadequate. However, the owner stated that they hoped to appoint a manager in the next two weeks. Gresley House Care Home DS0000067515.V347798.R01.S.doc Version 5.2 Page 23 The owners stated that they were committed to providing the best quality care and that residents’ care was their first priority. They said they aimed to provide a ’friendly, family atmosphere’. However, there was no direct evidence of how the quality of care was assured; for example, although the owner stated that surveys were carried out, none could be found on the day of the visit. The owner stated that relatives and residents were spoken with regularly on an informal basis. Some feedback was seen from ‘thank you’ cards the home had received and these contained comments such as ‘always made to feel welcome’ and residents were ‘always happy’. Staff spoken with also stated that the home had a ‘lovely atmosphere’. A full audit of residents’ personal financial records was not possible as some of the information required was not available. There were records in place and receipts were available. However, although there was a procedure for two people to sign when cash was received or given out, this was not being adhered to consistently. It was clear from receipts seen that a cash card was used on occasions but it was not clear whether the residents themselves used this. One resident’s financial record was checked and this did not correspond accurately on all entries with the receipts held; for example, the entry in the record stated one amount was spent but the receipt was a different amount, although the difference was relatively small, i.e. pence not pounds. The health and safety of everyone in the home was generally addressed. Maintenance records showed that the emergency lighting was checked in August 2007 and the hoists were checked in July 2007. Written information received after the inspection visit stated that portable electrical appliances had been checked in April 2007. Mandatory health and safety training took place but there were some areas that were out of date; for example, one staff member stated that their food hygiene certificate was out of date and they needed a refresher in moving and handling training. Staff confirmed that fire safety and infection control training had taken place. Gresley House Care Home DS0000067515.V347798.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 3 3 X X X 3 3 2 STAFFING Standard No Score 27 1 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 2 X X 2 Gresley House Care Home DS0000067515.V347798.R01.S.doc Version 5.2 Page 25 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 OP18 Regulation 13.6 Requirement All staff and the Registered Manager must receive training in safeguarding Adults to met legal requirements and fully safeguard residents. (Previous timescales of 30/09/06 and 30/06/07 not met). Timescale extended. Assessment documentation must contain sufficient information to establish that the home can meet residents’ individual needs, particularly in relation to social and religious needs and needs associated with dementia. Timescale for action 31/12/07 2. OP3 14 (1) 31/12/07 3. OP7 15 (1) All care plans must contain 31/12/07 sufficient detail to show how care needs are to be met. Essential tasks to assist in monitoring health needs, such as weight, must take place and must be recorded. 30/11/07 4. OP8 12 (1) (a) & (b) 5. OP8 12 (1) (a) Residents’ care needs must be 30/11/07 attended to promptly to maintain well-being and promote health. Gresley House Care Home DS0000067515.V347798.R01.S.doc Version 5.2 Page 26 6. OP9 13 (2) There must be arrangements in 30/11/07 place for the recording handling, safekeeping, safe administration and disposal of medicines received into the care home to ensure residents’ safety: • There must no gaps on medication administration record (MAR) charts • Medicines must not be allowed to run out • Two people must sign and date handwritten records • The medication refrigerator temperatures must be recorded on a daily basis There must be a clear complaints 30/11/07 procedure in place with records that indicate the action taken and whether there is a satisfactory outcome to meet legal requirements. Handrails must be provided in the garden to ensure safe access to outside areas. There must always be sufficient staff on duty to ensure residents’ care needs are dealt with promptly. Staff recruitment information must contain the following to ensure that residents are fully safeguarded: • Full employment histories • Criminal Record Bureau (CRB) checks • Protection of Vulnerable Adults (POVA) checks • Two written references Immediate 28/02/08 7. OP16 22 (1-4) 8. OP19 23 9. OP27 18(1) (a) 30/11/07 10. OP29 19 (1) & Schedule 2 17/10/07 11. OP30 18 (1) (c) (i) All staff must receive training appropriate to the work they are DS0000067515.V347798.R01.S.doc 31/01/08 Page 27 Gresley House Care Home Version 5.2 to perform in relation to dementia and other care needs to ensure residents are cared for by a competent staff team. 12. OP31 8 (1) (a) A manager must be appointed and become registered with the Commission for Social Care Inspection to meet legal requirements and to ensure the home is well run. A system for reviewing and improving the quality of care must be implemented to ensure improvement takes place. There must be clear records of residents’ money deposited in the home for safe keeping to safeguard residents from financial abuse. All staff mandatory health and safety training must be up to date to ensure staff and residents’ safety. 31/01/08 13. OP33 24 (1) (a) & (b) 31/12/07 14. OP35 17 (2) & Schedule 4 30/11/07 15. OP38 18 (1) (c) (i) 31/12/07 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 OP7 OP12 OP15 Good Practice Recommendations Detailed social histories should be sought for all residents to assist staff with meeting needs. Activities should be arranged to suit different social needs. The menus should be reviewed to ensure greater nutritional value. Gresley House Care Home DS0000067515.V347798.R01.S.doc Version 5.2 Page 28 4. 5. OP23 OP26 Old beds should be replaced. Odour in identified areas should be eradicated to ensure residents’ comfort. Gresley House Care Home DS0000067515.V347798.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. 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