Inspection on 28/02/06 for Gwendoline House

This inspection was carried out on 28th February 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Gwendoline House 29/08/07

Gwendoline House 09/02/07

Gwendoline House 10/12/05

Gwendoline House 31/05/05

Gwendoline House 14/06/04

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

CARE HOMES FOR OLDER PEOPLE Gwendoline House 17-19 Pleasant Road Staple Hill South Glos BS16 5JN Lead Inspector Paul Clark Announced Inspection 10:00 28 February 2006 th 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 Gwendoline House DS0000003325.V274184.R01.S.doc Version 5.1 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. Gwendoline House DS0000003325.V274184.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Gwendoline House Address 17-19 Pleasant Road Staple Hill South Glos BS16 5JN 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) 0117 9571957 0117 9571957 Mr Philip Frederick Moss Mrs Moira Ann Moss Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Gwendoline House DS0000003325.V274184.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 16 persons aged 65 years and over requiring personal care only 10th December 2005 Date of last inspection Brief Description of the Service: Gwendoline House is a privately owned care home for older people situated in Staple Hill, a residential area of Bristol. It is close to local shops and a bus route. Gwendoline House is a detached property with three floors. The proprietor, Mr Moss, lives and works full time at the home, taking overall responsibility. He concentrates his time mainly on cooking and paperwork tasks. Mrs Moss is the registered manager and is significantly supported by the senior member of staff, Marian Vargheese who currently provides the main management of care to the service users. The property has been extended to provide space for sixteen service users. The communal areas comprise a lounge, dining room and conservatory. All bedrooms are single occupancy and thirteen have en-suite facilities. In addition there are three toilets, two shower rooms and a bathroom. There is a secluded courtyard garden with seating, potted plants and a water feature. There is a warm and cheerful atmosphere in the home and activities are organised on a regular basis. Gwendoline House DS0000003325.V274184.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Announced Inspection was conducted over 7 hours by an Inspector from the Commission for Social Care Inspection to check the home’s compliance with the National Minimum Standards and adherence to the Care Homes Regulations contained in the Care Standards Act 2000. Gwendoline House was seen to fully comply with these standards and the home offers a good standard of care for those people it accommodates. What the service does well: What has improved since the last inspection? What they could do better: Routine fire and environmental health inspections should be requested. Gwendoline House DS0000003325.V274184.R01.S.doc Version 5.1 Page 6 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. Gwendoline House DS0000003325.V274184.R01.S.doc Version 5.1 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 Gwendoline House DS0000003325.V274184.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 Prospective resident’s and those living at Gwendoline House have clear information about the facilities and services which are provided at the home and can be assured that following clear admission processes their needs will be met. Clear contractual arrangements are in place. EVIDENCE: The home has a clearly written statement of purpose and information brochure. The statement of purpose was detailed and fully outlined the rights of resident’s and the responsibilities of the management and staff employed at the home in order that the aims of the home are met. Information contained within the statement of purpose includes the organisational structure, management and staffing arrangements. There is also information about the admissions process and whom the home is able to care for. Information within this document outlines how each person’s needs, both from a holistic and individual perspective will be met, recorded and reviewed and updated when needed. Gwendoline House DS0000003325.V274184.R01.S.doc Version 5.1 Page 9 The information brochure for the home makes good use of photographs and provides confirmation of individual’s choices and wishes, it records that resident’s will be consulted and listened to. The aim of the home as recorded in the brochure is ‘To enable our resident’s to maintain their dignity, independence and to encourage continuing interests, hobbies and social activities whilst living in a supportive family atmosphere’. The inspector saw that clear contracts for those living at the home are in place the information held within these includes the room to be occupied, overall care and services covered by the fee, fees payable and by whom, rights and obligations of the residents and the registered provider and terms and conditions of occupancy including notice periods. Information seen in care records such as pre-admission assessment, admissions questionnaire and the views of the resident’s confirmed that new residents are only admitted to the home on the basis of a full assessment undertaken by people who are trained to do so. Those residents who have been referred through the care management process had in place a copy of the care manager’s assessment and care plan. For those who are privately funded they had in place a fully detailed care plan and an assessment of need which further demonstrated that the home was able to meet their needs. The manager confirmed information seen within the home’s admission process that individual’s are invited to look around the home prior to admission and are able to stay for a meal and to meet other residents and staff in order to determine if the home is able to meet their needs. The manager confirmed that individual’s are admitted to the home for a months trial in order that a fuller picture of the services provided can be made and also in order for the home to undertake further assessment of need. Gwendoline House DS0000003325.V274184.R01.S.doc Version 5.1 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 the following standard(s): 7-11 Care plans are well written, reviewed and updated on a regular basis. Health needs of individuals are met. Information is in place outlining the needs and wishes of resident’s in the event of their death. EVIDENCE: Care plans are in place for all residents who live at the home, these are comprehensive and clearly written in a person centred way with full information contained within the plan in order to guide and direct staff. The plan covers areas such as communication, mobility, personal care support, and significant relationships, social, emotional needs, health support and personal safety. Each person had recorded within care records their preferred daily routine; these covered each day of the week, mornings, afternoon and nighttimes. Care plans are reviewed and updated where required on a monthly basis. Well-written care plan reviews were in place. The home undertakes these care plan/placement reviews every six months with the resident fully involved, it is good practice to see that residents had signed their care plan review notes to evidence they had read and agreed with the contents. Opportunities are provided for appropriate exercise and physical activity within the home. Armchair ‘keep-fit’ sessions are offered regularly. Gwendoline House DS0000003325.V274184.R01.S.doc Version 5.1 Page 11 Manual handling risk assessments were in place for residents incorporating the risk of falls, all had been reviewed within the past few months. All of the resident’s are registered with a general practitioner; those residents who wanted them have received vaccinations against influenza and pneumonia. Resident’s have accessed hearing, sight tests and appropriate aids according to their need. Systems of medication administration and recording were seen to be well ordered and appropriate and all staff administering medication have been appropriately trained. There is information in place in case files demonstrating resident’s wishes concerning terminal care and arrangements after their death. However, many of the residents have expressed a wish that their family members decide about this. Gwendoline House DS0000003325.V274184.R01.S.doc Version 5.1 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 the following standard(s): 12-15 Residents’ lifestyle at the home matches their expectations and preferences, individuals are supported to maintain important relationships and to participate in activities of their choice. EVIDENCE: The home organises a variety of entertainment such as piano sing-along, bingo and gentle exercise. Posters were on display at the home advertising forthcoming social events, family and friends were also invited to attend. Resident’s spoken with said that these are very much enjoyed and that they are not forced to participate if they choose not to. Within the home’s brochure and statement of purpose is information on how individual’s social activities, hobbies and interests will be maintained. The home has spent time with individuals gathering information on peoples’ previous interests and hobbies and care records and discussion with residents confirmed that these have been maintained where individuals ability and health has enabled. It is recorded in the home’s statement of purpose that it is staff member’s duty to respect the rights of residents. The manager confirmed that rights of individuals are respected; an example given was that residents are able to Gwendoline House DS0000003325.V274184.R01.S.doc Version 5.1 Page 13 make choices on activities of daily living, their routines and within their rights as citizens. Gwendoline House DS0000003325.V274184.R01.S.doc Version 5.1 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 the following standard(s): 16-18 Resident’s can be confident that complaints will be listened to and acted upon. Resident’s legal rights are protected and suitable arrangements are in place to protect residents. EVIDENCE: A copy of the home’s complaints procedure was on prominent display at the home. Information on how individuals are able to raise issues or make a complaint was seen in individual licence agreements, with information including the arrangements for contacting the Commission if individuals were not happy with the outcome of a complaint. The complaints logbook for the home was viewed; it was found that reported incidents had been dealt with effectively to the satisfaction of those involved. The logbook identifies and records both formal and informal complaints, which is consistent with good practice. No staff at the home are on the protection of vulnerable adults list. No areas of concern were recorded on care documentation. All of those spoken with during the inspection were positive about the care they receive and said they were happy with no complaints or concerns raised to the inspector. The home has in place a copy of the South Gloucestershire Social Services Protection of Vulnerable Adults Policy. Staff have undertaken protection of vulnerable adults training. The home has a clear complaint procedure which records that the home operates a ‘no blame policy so that any complaint allows Gwendoline House DS0000003325.V274184.R01.S.doc Version 5.1 Page 15 full thorough and open investigation’. Compliments are also well recorded at the home. Gwendoline House DS0000003325.V274184.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19-26 The home is well managed and safe and the quality of furnishings and fittings in the home is good, providing a warm comfortable and homely environment ensuring individuals’ needs are met. EVIDENCE: The home is comfortable and homely with an array of pictures, plants and soft furnishing which enhance the environment for those who live at Gwendoline House. There is a cosy lounge where most of the residents had chosen to sit and there is a pleasant dining room and a sun lounge for resident’s to enjoy. There were sufficient toilet, bathrooms and showering facilities for residents’ use. Most of the residents’ rooms have en-suite facilities, one with a bath others with toilet and a hand basin. The manager stated that the decision had been made to use showers instead of baths because of the dangers of staff lifting. Residents spoken to confirmed that they had been consulted about this decision and had given their agreement to this. However, this decision must be Gwendoline House DS0000003325.V274184.R01.S.doc Version 5.1 Page 17 kept under review and all residents must be given the opportunity to take regular baths if they so choose. A hand test of the water temperature found the temperature was not excessive and was at a safe level, the temperature in the home was warm and comfortable. Water temperatures are checked three times per week. At the time of the inspection all areas seen were clean, tidy and odour free. All of those living at the home have access to their personal and communal space. The home has a very pleasant rear patio garden; this was seen to be well tended. Gwendoline House DS0000003325.V274184.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27-30 There is a stable, competent staff team at the home who have been appropriately recruited, supervised and trained. EVIDENCE: A staffing rota was seen which indicated that there is a full complement of staff working at the home, which is sufficient in number to meet the needs of the resident group. Staff are employed following robust recruitment and selection procedures. In place were references from the most recent employer, criminal records and protection of vulnerable adults check. Job descriptions record the duties and responsibilities of staff that they are to enable, encourage and support residents to make choices. Contracts were in place for staff which had been signed and dated by staff, this document included terms and conditions of employment, equal opportunities, disciplinary and grievance procedure. Staff are supervised on a daily basis informally, formally staff receive one to one support meetings on a regular basis. Records of these supervisions showed that appropriate subjects were discussed to ensure the needs of those living at the home are met. Staff training and development with action plans are in place. Staff are given supervision agreements which outline the responsibilities of the supervisee and supervisor including the practical arrangements for supervision and the importance of confidentiality. Gwendoline House DS0000003325.V274184.R01.S.doc Version 5.1 Page 19 The Induction Checklist for staff is fully comprehensive. Of the 10 care staff 4 have NVQ Level 2 qualifications and another is about to complete this award which will mean that the National Minimum Standard of 50 trained staff will be met. Gwendoline House DS0000003325.V274184.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31-38 There is a sound management team at the home with the registered manager being able to discharge their responsibilities fully. Routine monitoring inspections need to be undertaken by the Fire Authority and Environmental Health Officer. EVIDENCE: Mr and Mrs Moss are the registered providers who have been the owners of the home since it originally opened over twenty years ago. Mrs Moss has been unwell for sometime but has been making a recovery and has recently returned to manage the home on a part time basis. Mrs Moss has commenced her National Vocational Qualification Level 4 Award in Management; progress in this area will be further reviewed at the next inspection. Marion Varghesse has been ‘acting up’ as the manager and has achieved her registered managers award and a National Vocational Gwendoline House DS0000003325.V274184.R01.S.doc Version 5.1 Page 21 Qualification at level four in care management. Ms Varghesse is a qualified nurse and undertakes fives days training per year in order to maintain her PREP (Post Registration Education Portfolio). All of those spoken with during the inspection were full of praise for Marian and spoke of her kindness and patience. Evidence was in place to demonstrate that the home has ensured as far as is reasonably practicable the health and safety of those who live in, work at and visit the home. The fire logbook showed that routine checks are completed, however, a fire officer inspection has not taken place since 20/07/02 and it is recommended that the home write to the fire authority requesting one. The home has in place a fully comprehensive fire risk assessment; this covers the identification of hazards, who is at risk, actions taken to eliminate/reduce risk. It is recommended that this assessment be dated in order to demonstrate that this is regularly reviewed. The home’s fire policies and procedures in respect of fire were well written and included a clear night procedure should a fire occur at this time. All staff have received appropriate and sufficient fire instruction, which has included participation in fire drills, discussion, fire videos and questionnaires to ensure staff understanding of their responsibility in this area. The home has purchased a pack which incorporates policies and procedures which are required for those who provide a care service; those seen included; the management of health and safety at work, staff disciplinary and competency procedures, receiving gifts, clinical waste and missing persons procedure. These provide information to staff in order to ensure compliance and consistency. It was noted that the last Environmental Health Officer inspection visit was in November 2004 and it is recommended that the home write to them requesting a routine visit. Gwendoline House DS0000003325.V274184.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Gwendoline House DS0000003325.V274184.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 CH3434 CH3434 Good Practice Recommendations The home to write to the Fire Authority requesting a routine fire inspection visit. The home to write to the Environmental Health Officer requesting a routine inspection visit. Gwendoline House DS0000003325.V274184.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Gwendoline House DS0000003325.V274184.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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