Inspection on 31/05/05 for Gwendoline House

This inspection was carried out on 31st May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 28/02/06

Gwendoline House 10/12/05

Gwendoline House 14/06/04

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

Care Home For Older People Gwendoline House 17-19 Pleasant Road Staple Hill South Glos BS16 5JN Announced Inspection 31st March 2005 Commission for Social Care Inspection Launched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: • Promote improvement in social care • Inspect all social care - for adults and children - in the public, private and voluntary sectors • Publish annual reports to Parliament on the performance of social care and on the state of the social care market • Inspect and assess ‘Value for Money’ of council social services • Hold performance statistics on social care • Publish the ‘star ratings’ for council social services • Register and inspect services against national standards • Host the Children’s Rights Director role. Inspection Methods & Findings SECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Gwendoline House Address 17-19 Pleasant Road, Staple Hill, South Glos, BS16 5JN Email address Name of registered provider(s)/company (if applicable) Mr Philip Frederick Moss Name of registered manager (if applicable) Mrs Moira Ann Moss Type of registration Care Home No. of places registered (if applicable) 16 Tel No: 0117 9571957 Fax No: 0117 9571957 Category(ies) of registration, with (number of places) Old age, not falling within any other category (16) Registration number D050000302 Date first registered 1st August 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspection Date of latest registration certificate 1st April 2002 YES NO 14/06/04 If Yes refer to Part C Gwendoline House Page 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 3 31st March 2005 09:40 am Peter Still ID Code 072879 Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspection Marian Vargheese Gwendoline House Page 2 CONTENTS Introduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspector’s Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Provider’s Response Provider’s Comments Action Plan Provider’s Agreement Gwendoline House Page 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Gwendoline House. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: • Inspection methods used • Key findings and evidence • Overall ratings in relation to the standards • Compliance with the Regulations • Required actions on the part of the provider • Recommended good practice • Summary of the findings • Provider’s response This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates. Gwendoline House Page 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. 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 Page 5 PART A SUMMARY OF INSPECTION FINDINGS INSPECTOR’S SUMMARY (This is an overview of the inspector’s findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) Brief Introduction Gwendoline House provides a pleasant, homely and comfortable environment for older people. The inspector talked to nine service users during the inspection and heard much praise for the quality of their care and commitment of the staff. The home has had difficulty over recent months due to the illness of Mrs Moss, the registered manager, who is highly regarded by service users and staff. Mrs Moss is not currently carrying out her management duties but is frequently at the home and looking forward to increasing her hours. This inspection was delayed for a few days due to an outbreak of gastroenteritis. The acting manager is highly commended for her leadership and commitment to the care of service users during this time and for the way the infection was controlled over a short space of time. It should be noted that all service users who spoke to the inspector gave high praise for the care they had received. It is also important to note that whilst the home is currently without its key registered manager, the inspectors view is that there has been no reduction to the overall quality of care provided at the home and clearly Mr Moss provides the overall commitment and support to achieve the current success of the home. The acting manager completed the pre-inspection questionnaire, which the inspector found most helpful and saved time during the inspection. Three comment cards were also completed by relatives for the inspection and service users had been properly told about the inspection and the inspectors’ role prior to his arrival. Choice of Home (Standards 1-6) 3 of 3 standards assessed were met (3 rated 3) A number of issues have been reviewed and resolved since the last inspection. Health and Personal Care (Standards 7-11) 4 of 4 standards assessed were met (1 rated 3, 3 rated 4) Care planning and recording was found to be of a high standard. The work and professional action following the outbreak of a highly infectious outbreak of gastroenteritis was seen to be excellent and much praise was given by service users for the care they received. The tight recording of the medication records and system was seen to be of a high standard and a letter sent to the home commending their work by the local pharmacist reinforced this. Daily life and Social Activities (Standards 12-15) 4 of 4 standards assessed were met (1 rated 4, 3 rated 3) The range of activity provides for the needs of service users and both service users and relatives supported this. Service users were consulted and helped to make choices. The food and approach concerning this important aspect was considered to be of a high standard Gwendoline House Page 6 and service users supported this. Complaints and Protection (Standards 16 –18) 2 of 2 standards assessed were met (2 rated 3) The standards inspected were met. Environment (Standards 19-26) 4 of 5 standards assessed were met (4 rated 3, 1 rated 1) The home has a policy of assessing new service users to ensure they have good mobility and the home does not have a hoist or other moving and handling aids. The inspector considers that this standard should be assessed more fully at the next inspection since there may be a future need and good equipment and training may be necessary. This will also need to link in with the Statement of Purpose for the home. The inspector found hot radiators, which may put service users at risk and left an immediate requirement concerning this. The provider was clear that he would take immediate steps to deal with the possible risk. The acting manager also said she would take immediate steps on the day to protect service users from possible harm. Staffing (Standards 27-30) 2 of 4 standards assessed were met (1 rated 2, 2 rated 3) New staff recently employed are expected to make a significant difference to the staffing and will take the pressure off the core established staff team. The four staff who have gained their NVQ qualification even though the college used let the staff down, should be highly praised for their commitment to persevere. The recruitment process needs reviewing with regards to references. Management and Administration (Standards 31-38) 4 of 5 standards assessed were met (4 rated 3, 1 rated1) A quality assurance system is now in place. The completed pre-inspection questionnaire was helpful with this inspection and provided much evidence. The home currently has an acting unregistered manager supporting the registered person to run the care home and it is hoped that the registered manager will return to full duties in the near future. If this is not possible then the Commission will need to be advised and steps taken to appoint a registered manager on either a long or short-term basis. Gwendoline House Page 7 Requirements from last Inspection visit fully actioned? If No please list below YES STATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report, which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Regulation Standard Required actions Timescale for action Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard 1 OP31OP3 1 The manager should achieve the NVQ Level 4 in management. Since the last inspection, Mrs Moss has not been able to continue with the training. Since homes are required to have a registered manager who has achieved the above award, it will be necessary for Mr Moss and Mrs Moss to consider the action they wish to take. It may be that Mrs Moss will restart the training but if not then the home will have to provide a new registered manager. This matter should be a requirement, however at this inspection and due to the circumstances the inspector considered that it would not be appropriate to create a requirement. However the situation must be resolved and the inspector would ask that a decision is reached swiftly and the Commission advised by letter. CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). Met (Yes / No) N/A STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Gwendoline House Page 8 Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office. STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Regulation Standard * Requirement Timescale for action That unnecessary risks to the health or safety of service users are identified and so far as possible eliminated This concerns hot, unguarded radiators. A risk assessment is to be completed on all radiators. Guidance to be sought from Environmental Health. Any guidance or requirement made is to be complied with and radiators are to be guarded or other steps taken to ensure safety of service users and that they are protected from harm. 1 13 OP38 01/07/05 RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Refer to Good Practice Recommendations Standard * Please read the note in the recommendation made above regarding compliance with the requirement that the home has a registered manager who has a qualification, at level 4 NVQ, in management and care or equivalent. It will be necessary to resolve this matter in the near future and will be subject to consideration at the next inspection, where a requirement may then need to be made. 1 OP31 * Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10. Gwendoline House Page 9 PART B INSPECTION METHODS & FINDINGS The following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling • Pre-inspection questionnaire • Records • Care plans / Care pathways • Meals • Activities • Other (Specify) ‘Tracking’ care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES YES YES YES NO YES NO YES NO YES NO YES YES YES YES NO YES NO YES 9 2 3 NO YES YES YES 6 1 31/03/05 9:40 6.45 Gwendoline House Page 10 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls) 0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. “X” is used where a percentage value or numerical value is not applicable. Gwendoline House Page 11 Choice of Home The intended outcomes for the following set of standards are: • • • • • • 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. Standard 1 (1.1 – 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users’ guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the home’s service user’s guide. Range of fees charged From (£) 331 To (£) 385 Any charges for extras If yes, please state what the extra’s are: YES Chiropody, Hairdressing & Toiletries 3 Key findings/Evidence Standard met? The proprietors are currently revising their business plan, when this is available and staff have completed their NVQ training programmes all these details will be added to the Statement of Purpose. Gwendoline House Page 12 Standard 2 (2.1 – 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? Contracts were seen for 3 service users and were satisfactory. Contracts are being updated for all service users. New service users receive a pack during their month’s trial period. This provides information about the home and includes details about complaints and who to complain to including the Commission. Charges are not made for continence products. Standard 3 (3.1 – 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? The inspector was pleased to see that points raised at the last inspection have now been addressed and guidance acted upon. Files were reviewed for three service users. They contained good detail of the assessed needs and planned care. Aspects set out within the National Minimum Standard have now been incorporated and has included a nutritional assessment. Documentation is retained and an archive file has been established to enable ease of reference for the main and current file. Loose sheets within records were found to be dated, with the service users name and entries were signed by staff. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? Not assessed as part of this inspection. Standard 5 (5.1 – 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 0 Key findings/Evidence Standard met? Not assessed as part of this inspection. Gwendoline House Page 13 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short-term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? The home does not provide intermediate care. Gwendoline House Page 14 Health and Personal Care The intended outcomes for the following set of standards are: • • • • • The service user’s health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. 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. Standard 7 (7.1 – 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 4 Key findings/Evidence Standard met? It was clear to the inspector that this standard is being well met with attention to detail on key points. 3 care plans were reviewed, which provided significant and important detail about service users needs and what was required to achieve goals and actions by staff to ensure adequate care and support is given. The inspector was pleased to note that care plans are being reviewed regularly and that the key worker has a vital role. Care Plans are person centred and reviewed each month by the key worker, who amends and updates the review sheets. The view of the inspector was reinforced by his questions to two relatives and nine service users. A number of service users particularly spoke of the care and direction provide by Marian Vargheese, the acting manager, to ensure their health care needs are properly met. One service user told the inspector that it is important to him/her that he/she is able to have trust in the care provided and that there was absolute confidence in the acting manager. One service user told the inspector that they had a specific member of staff who made sure their needs were met – a key worker. However, service users had difficulty with an appreciation of the terminology and role, yet the inspector noticed one in particular which both the service user and the key worker had signed. The inspector gained the impression that the staff team as a whole are highly regarded by service users in relation to this standard. It is likely that as the new system becomes established, services users will have more awareness of the key worker role. Gwendoline House Page 15 Standard 8 (8.1 – 8.13) The registered person promotes and maintains service users’ health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) 1 0 4 Key findings/Evidence Standard met? One service user was admitted to A & E following a fall, no issues were found and he/she returned to the home within an hour. One service user was admitted to hospital and sadly passed away. One service user is currently receiving care for a leg ulcer from the District Nurse and told the inspector he/she was very happy with the care being provided. The local Practice Nurse, Health Visitor, Chiropodist, Audiologist and Opticians visit the home. Immediately prior to this inspection, the home contracted a notifiable gastroenteritis infection. 12 service users were affected, two twice, and 3 staff. The Environmental Health and Commission were properly contacted and the home was provided with guidance. The infection lasted five days but it was ten days before the home was given clearance that the home was safe from the infection. The inspector wishes to give high praise to the acting manager for her professionalism, commitment, care and leadership during this time. Whilst the acting manager had been trained in infection control and had just completed reinforcement training, the fact that the infection was contained and managed so quickly is clear evidence of her skills. It is also most important to recognise the support provided by Mr Moss and the great commitment of the limited staff team who worked constantly during the day and night whilst the infection was at its most serious stage. The inspector heard about the infection from five service users who gave great praise to the staff team for their care. On the day of this inspection the inspector noted that all service users were well and happy. Standard 9 (9.1 – 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 4 Key findings/Evidence Standard Met? There are procedures and accurate, organised, records in place for the receipt, storage, administration and disposal of medicines. The local pharmacy advisor carries out regular checks of the homes stock and practices. The inspector read a letter of high commendation on the homes practice, provided by the local pharmacist and noted that a further visit is due to take place soon. The inspector reviewed the drugs cupboard and checked a service user file for the day, which showed medication had been provided and properly recorded. The inspector read evidence in the records of medication review dates to ensure service users continue to receive appropriate medication to meet their needs. Gwendoline House Page 16 Standard 10 (10.1 – 10.7) The arrangements for health and personal care ensure that service users’ privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 0 Key findings/Evidence Standard met? Not inspected as part of this inspection. Standard 11 (11.1 – 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? The inspector was given information about the death of a service user and how the person had been able to remain at the home as their health failed and provision was made for the direct relative to stay at the home, throughout. The inspector read a letter of thanks and giving high praise for all of the care provided during the time the person was at the home. The inspector was told that staff are provided with support and guidance concerning this standard. Gwendoline House Page 17 Daily Life and Social Activities The intended outcomes for the following set of standards are: • • • • 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. Standard 12 (12.1 – 12.4) The routines of daily living and activities made available are flexible and varied to suit service users’ expectations, preferences and capacities. 3 Key findings/Evidence Standard met? The home does not hold a central record of activities, these are maintained within individual service user files and three were reviewed. This made it difficult for the inspector to easily evidence this standard. The inspector was told that a range of activity is provided which includes: Visits out; shopping for food for the home with the proprietor; service users helping with tasks at the home; discussions about food and menus of past times and the purchase of food e.g. Chitterlings. Hairdressing is a favourite day for service users; a pianist visits twice a week and service users ‘sing along’ to the music; a relative visits once a month, providing a quiz on local interest of times past and also relating to the story behind hymns. On the day of inspection, the inspector observed service users enjoying bingo. Five service users told the inspector that they have sufficient to interest them and that they prefer to spend time at the home. No service users were in their bedrooms during the inspection, instead they were enjoying companionship in the main lounge whilst other service users sat in the conservatory and told the inspector how much they liked it. One service user told the inspector how much he/she enjoyed his/her bedroom and the view. One service user told the inspector that he/she would like there to be more male service users at the home and this would mean a lot to their overall happiness. Standard 13 (13.1 – 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users’ preferences. 3 Key findings/Evidence Standard met? One service user told the inspector that he/she enjoys weekly visits to the gardening club at Frenchay hospital where they are currently growing on flowers. The inspector used a hearing device with the agreement of this service user and found it easier to communicate. Some service users told the inspector that their relatives often take them out. Shopping trips help to keep service users involved within the local community. Some service users said they enjoy simply being at the home. Gwendoline House Page 18 Standard 14 (14.1 – 14.5) The registered person conducts the home so as to maximise service users’ capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? Service users are involved in decisions about the décor of their bedrooms and the inspector was able to view personalised bedrooms. Service users had been asked if the inspector could see their rooms and one service user checked that the inspector had done so and talked about their pleasure with their room and the way they like to keep it tidy. The inspector was told about the recent redecoration of one bedroom and that the service user chose the colour scheme. One service user has chosen to have blankets rather than a duvet, which is a demonstration of service user choice. Two service users told the inspector that Mr Moss always asks what food they would like and more told the inspector that they are always offered alternatives if they wish. One service user told the inspector that he/she goes along with the food that is being provided and that it was satisfactory but the inspector was not convinced that this service user felt fully able or enabled to make a choice. It may be helpful for staff to spend some time communicating individually with service users. Having said this, the inspector was given a lot of detail from Mr Moss and the acting manager about the steps taken to ensure individual choice. Whilst it may be thought that nothing more can be done, it is important to continue to try. This should not be seen as a negative reflection and in the brief time available to the inspector, he may not have obtained a true picture, nevertheless it is an important point. Standard 15 (15.1 – 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 4 Key findings/Evidence Standard met? The menu, which is on a three-week cycle, provides a variety of nutritious meals. Mr Moss is the cook and discusses the daily menu with service users and provides alternatives where requested. He also shops with service users. The inspector observed fresh food being provided and plenty of fruit continually available to service users. He noted that the tomatoes being used on the day of inspection were of a good red colour, being ripe and ready for use. Mr Moss should be commended for his commitment to provision of high quality food. This is a vital standard and the inspector heard from service users that it is clearly appreciated. The inspector was interested to hear about the discussions Mr Moss has with service users concerning the menu and food they enjoyed in the past and the introduction of such dishes into the menu. Service users spoke very highly of the food, and the fact that they were consulted. One service user specifically told the inspector how he/she discusses the menu and feels involved with it. The inspector observed an attractive dining room and a three-tier stand for fruit, which looked particularly impressive. Gwendoline House Page 19 Complaints and Protection The intended outcomes for the following set of standards are: • • • 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. Standard 16 (16.1 – 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 X X X X 0 X 3 Key findings/Evidence Standard met? Appropriate systems are in place to deal with a complaint if it occurs. Advice about how to contact the CSCI is given in the contract details as provided to the service users and their relative within an introduction to the home welcome pack. No complaints have been received. Gwendoline House Page 20 Standard 17 (17.1 – 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met? Not assessed as part of this inspection. Standard 18 (18.1 – 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES 0 3 Key findings/Evidence Standard met? The appropriate policies and procedures are in place for the protection of vulnerable adults. The acting manager has attended external training and is using the ‘Mulberry House’ company policy guidance, which has been purchased to provide the basis for the home policy and training programme. A representative of the Mulberry House visited the home on 22/10/04 to provide staff training. The acting manager runs a training video for all new staff and as reinforcement training. Gwendoline House Page 21 Environment The intended outcomes for the following set of standards are: • • • • • • • • 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. Standard 19 (19.1 – 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users’ individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? The home is well laid out on three floors and there are two Stannah lifts to give access. Corridors are not wide enough for a wheelchair and the home is not suitable or adapted for people with physical disabilities. There is a paved/planted courtyard with a pond at the back of the home situated in a private area. The home is close to local shops and buses. The home is well maintained and decorated and is generally homely and comfortable. The nine service users the inspector talked with expressed satisfaction with the home. Standard 20. (20.1 – 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users’ private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 0 Key findings/Evidence Standard met? Not assessed as part of this inspection. Gwendoline House Page 22 Standard 21 (21.1 – 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 0 Key findings/Evidence Standard met? Not assessed as part of this inspection, however the inspector noticed a bath panel on the first floor, which is split and the jagged edge may cause harm to a service user. The acting manager said she would draw this to the attention of Mr Moss. Standard 22 (22.1 – 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 3 Key findings/Evidence Standard met? The registered manager can refer any service user to the Community Occupational Therapist if necessary. The home has a no lifting policy and service users are assessed to ensure they have mobility prior to admission. The home does not have a hoist or moving and handling aids currently. This aspect was not fully inspected as part of this inspection and should be one focus at the next inspection. It will also be necessary to consider the Statement of Purpose for the home and criteria for admission and any training and or equipment which may be necessary where service users lose mobility and steps the home may take as set out within their Statement of Purpose and contract with service users. Gwendoline House Page 23 Standard 23 (23.1 – 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite YES NO NO 16 X 0 0 X X 0 0 0 0 3 Key findings/Evidence Standard met? A previous rating of three was recorded. The pre inspection questionnaire shows there to be no changes. Gwendoline House Page 24 Standard 24 (24.1 – 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 0 Key findings/Evidence Standard met? Not assessed as part of this inspection. Standard 25 (25.1 – 25 8) The heating, lighting, water supply and ventilation of service users’ accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 1 Key findings/Evidence Standard met? The pre inspection questionnaire confirms that all appropriate checks have been made and dates have been attached. The Environmental Health officer reported on the home on 16.11.04 and this inspector saw evidence that all points had been dealt with. The water temperature book was reviewed and found to be up to date. An immediate requirement was written and left at the home on the day of inspection concerning radiators, which were found to hot and may cause a burn or harm to a service user. The inspector was specifically concerned about those radiators in many service user’s bedrooms where the hot radiator was touching the bed and may cause a burn if a service user were to lay against it. It is possible however that other radiators may also present a risk. The inspector made an immediate requirement that a risk assessment should be undertaken of all radiators, that guidance should be sought from Environmental Health and that any guidance or requirement provided should be complied with. The inspector set a timescale of 1st July 2005 for compliance with this requirement, which is also set out at the beginning of this report under the Requirements section. On the day of inspection the inspector was pleased to hear the provider, Mr Moss to say that he would immediately start to deal with the matter and the inspector has every confidence that this will be the case. The inspector was also pleased to hear the acting manager state that she would take immediate steps on the day to reduce the risk and the step she said she would take was to cover the radiators with material. It is most unusual for an inspector to find a care home with unguarded radiators and it is most likely that this will be the guidance from Environmental Health. It is vital that the provider ensures that service users are protected from harm. Gwendoline House Page 25 Standard 26 (26.1 – 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? The acting manager has recently undertaken reinforcement training on Infection Control and she said that this training had been helpful when faced with the recent outbreak of a notifiable infection of gastroenteritis. This is a good example of how further training to update ones knowledge base can be valuable and the acting manager has already been praised in this report for her actions concerned with infection control and the outbreak. The inspector considers infection control practice to be good and the acting managers commitment to this standard to be appropriate. She also gave examples to the inspector of her practice and spoke of the importance she attaches to this standard with her staff team. The home was clean and tidy on the day of inspection and free from offensive odours. The kitchen was also well organised and clean. Gwendoline House Page 26 Staffing The intended outcomes for the following set of standards are: • • • • 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. Standard 27 (27.1 – 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours 0 X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence 3 13 X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X X 1 11 1 Standard met? 3 Gwendoline House Page 27 The staff rota provides 3 staff in the morning and 2 in the evening and is considered to be satisfactory to meet the current needs of service users. 2 staff are on call at night, including Mr Moss who lives on the premises, he also provides additional staffing cover to support staff when necessary. A maintenance person is employed at the home on a permanent basis and his time and the tasks he performs allow care staff more direct time with service users. Mr Moss is the cook and this also helps the care staff team. 5 staff were present at the start of the inspection. A new member of staff has recently started work at the home and her CRB check has been applied for – she has signed a statement ensuring that she knows she is supernumerary until the CRB check has been confirmed and she will not carry out personal care tasks. Employment of suitable staff has been difficult recently but at the time of this inspection 3 new staff had been employed and the acting manager has confidence that these staff will wish to stay and become part of the established staff team. 4 staff have been at the home for a long time and have continued to provide the crucial consistency for service users, they should also be commended for achieving their NVQ level 2 award. At this inspection the inspector concentrated his time talking with service users and at the next inspection it may be helpful to gain some feedback from the key staff team who are not part of the management structure. Standard 28 (28.1 – 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 4 50 3 Key findings/Evidence Standard met? The home currently employs a full time equivalent of 6 direct care staff that are not in management positions and therefore the inspector believes the standard to have been met. However along with many other homes, the local Collage has failed to provide the staff with their certificates and these will need to be checked at the next inspection. The inspector felt it would be most unfair at this inspection, not to give a rating of 3 since the 4 staff were let down by their college. The staff started their qualification with one collage and had completed much work, however the tutors failed to visit the students to supervise progress. Eventually the staff had to start their course again with a new collage. The files of their old work remain at the home. The inspector feels the staff should be highly praised for their commitment to continue with their training and finally gaining their award. Gwendoline House Page 28 Standard 29 (29.1 – 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2 Key findings/Evidence Standard met? Staff records sampled showed a lack of completeness with the recruitment process. The process appeared to be sound and CRB checks for staff were seen however of the two staff files reviewed, one included a reference completed by the acting manager, since she had previously known the individual, It is not appropriate for an employer to provide a reference in these circumstances. The inspector acknowledges that it can be difficult for some new staff to find appropriate people to give the informed reference but it is necessary that suitable referees be found. The particular member of staff is now known and established but for future applicants appropriate references are needed. A further issue was found in that other references seen did not show with clarity who had provided the reference and where they originated. The inspector suggested a review of the current pro forma used to ensure this is addressed. The inspector reviewed a comprehensive induction pack for a new member of staff showing detail of training provided; this was felt to show good practice. Standard 30 (30.1 – 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? Not assessed as part of this inspection. Gwendoline House Page 29 Management and Administration The intended outcomes for the following set of standards are: • • • • • • • • 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. Standard 31 (31.1 – 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 1 Key findings/Evidence Standard met? The inspector felt it was not appropriate to set a requirement at this inspection concerning the need for the home to have a qualified registered manager, however it may well need to be set as a requirement at the next inspection. It is acknowledged that this is a very difficult time for Mr Moss and Mrs Moss, due to the illness of Mrs Moss and her need to withdraw from the NVQ level 4 training she was undertaking. It is understood that Mrs Moss holds a pivotal role within the home and that service users will be concerned for her and it is hoped that she will return to her full duties as the registered manager soon. If Mrs Moss does not wish to continue with her registration, then an alternative manager must be sought. In the meantime the inspector has recognised that the acting manager has been providing an excellent managerial role within the home, supported by Mr Moss. Decisions about the manger role will need to be made soon and may be of short duration whilst Mrs Moss recovers but it is important not to leave this matter until the next inspection. The Commission will be pleased to discuss any thoughts about this with Mrs Moss or Mr Moss. Mrs Moss is not currently on the rota but visits the home regularly, which is important and it is understood that she also undertakes some sleeping in duties. The acting manager has been working 50 plus hours a week during recent staffing difficulties and it is hoped that the recent employment of new staff will make a big difference and enable Marian Vargheese to return to normal hours. It was fortunate that prior to this period, Marian had enjoyed an extended holiday. The acting manager is currently working towards the Level 4 NVQ in management and care and has currently completed: RMN 1; SC20 & D2 are almost complete; D32/33 have been completed. Marian intends to complete her training by the end of 2005. Gwendoline House Page 30 Standard 32 (32.1 – 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? Not inspected as part of this inspection. Standard 33 (33.1 – 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 3 Key findings/Evidence Standard met? The acting manager should be praised for her work to address this standard and a Quality Assurance System has now been put in place. A questionnaire has been sent out with many responses from relatives, praising the quality of care at the home. It will take time to assess the new system and a review will be needed to see if any changes would be helpful. The ‘Mulberry House system has been purchased and used as a basis for the homes system, which the acting manager has made more user friendly and simple to use. Standard 34 (34.1 – 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 3 Key findings/Evidence Standard met? The acting manager confirmed that a letter of confirmation on the financial viability of the home was sent to the Commission. The inspector had not looked in the file at the office to review it. Gwendoline House Page 31 Standard 35 (35.1 – 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders X X X 0 Key findings/Evidence Standard met? Not inspected as part of this inspection however it is understood that the home does not take any responsibility for services user’s finances and that this is dealt with by family members. Standard 36 (36.1 – 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 0 Key findings/Evidence Standard met? Not inspected as part of this inspection. Standard 37 (37.1 – 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? A previous requirement had been made that the provider produces a monthly visit and report on the home. This inspector formed the view that this was not necessary since the provider lives at the home and is in day-to-day control of the home. Records reviewed were up to date and satisfactory. The pre inspection questionnaire provided good evidence concerning this standard. Gwendoline House Page 32 Standard 38 (38.1 – 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? The completed pre inspection questionnaire, provided by the acting manager provides good evidence to demonstrate that this standard is met. Gwendoline House Page 33 PART C (where applicable) COMPLIANCE WITH CONDITIONS Condition Comments Compliance Condition Comments Compliance Condition Comments Compliance Condition Comments Compliance Lead Inspector Second Inspector Peter Still Signature Signature Signature Regulation Manager Michael Miles Date 11th May 2005 Gwendoline House Page 34 Public reports It should be noted that all CSCI inspection reports are public documents. Gwendoline House Page 35 PART D D.1 PROVIDER’S RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTS Registered Person’s comments/confirmation relating to the content and accuracy of the report for the above inspection. Please limit your comments to one side of A4 if possible I accept the contents of this report and found the Inspector Peter Still to be very helpful and understanding and would like to comment that it was very much appreciated by our Service Users that the Inspector spent time talking to them and listening to their views. However, as before, we would like to put it on record that we still find the amount of paper work we have to complete very time consuming. PS: We did not receive an Inspector Comment Card (rectified and posted on 11 May 2005). Gwendoline House Page 36 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary YES Comments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report YES YES Provider comments are available on file at the Area Office but have not NO been incorporated into the final inspection report. The inspector believes the report to be factually accurate Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan which indicates how requirements are to be addressed and stating a clear timescale for completion will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Provider’s Action Plan at time of publication of the final inspection report: Action plan was required YES Action plan was received at the point of publication YES Action plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action plan YES NO NO Other: enter details here Gwendoline House Page 37 D.3 PROVIDER’S AGREEMENT Registered Person’s statement of agreement/comments: Please complete the relevant section that applies. D.3.1 I of Gwendoline House confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Gwendoline House Page 38 Gwendoline House / 31st March 2005 Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.uk S0000003325.V204977.R01 © This report may only be used in its entirety. Extracts may not be used or reproduced without the express permission of the Commission for Social Care Inspection The paper used in this document is supplied from a sustainable source - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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