This inspection was carried out on 12th September 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.
CARE HOMES FOR OLDER PEOPLE
South Church (Gloria) Nursing Home Limited 21 Auckland Road South Church Bishop Auckland Co Durham DL14 6SP Lead Inspector
John Trainor Unannounced Inspection 10:30 12 September 2007
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 South Church (Gloria) Nursing Home Limited DS0000067991.V349073.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. South Church (Gloria) Nursing Home Limited DS0000067991.V349073.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service South Church (Gloria) Nursing Home Limited Address 21 Auckland Road South Church Bishop Auckland Co Durham DL14 6SP 01388 604055 01388 451268 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) Gloria Healthcare Limited Position Vacant Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38), Physical disability over 65 years of age (3) of places South Church (Gloria) Nursing Home Limited DS0000067991.V349073.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 8th March 2007 Brief Description of the Service: South Church Care Home provides both nursing and residential care to service users. The home has twenty-nine single bedrooms and four double rooms. There are no en-suite facilities; toilets and bathrooms are provided throughout the home, some are equipped with specialist equipment to provide additional support during personal care. The home is set over two floors; there is a dining area and lounge on each floor. There is a patio garden area to the upper floor of the home and a large car park on the ground floor. Fees at the time of inspection ranged from £364.50 to £495.00. South Church (Gloria) Nursing Home Limited DS0000067991.V349073.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection involved the home providing information to the Commission for Social Care Inspection, before a site visit, which was unannounced and lasted 6hours. During this visit records were inspected including care plans and health and safety records. Care practices were observed. People were spoken to including people resident, staff and management. There was a tour of the building. What the service does well: What has improved since the last inspection? What they could do better:
Although improvements were being made to the home these were not well coordinated and as the handyman was doing decorations they had to be fit in around his other permanent work. The gas installation needed work to ensure it met current safety standards though planning permission to install a meter
South Church (Gloria) Nursing Home Limited DS0000067991.V349073.R01.S.doc Version 5.2 Page 6 more suitable for the volume of use was holding up progress. This work must be pursued with vigour. The service user guide needed revision to reflect changes in the home and to make explicit the difference in fees for those paying privately and those having their care funded. The provider had failed to implement this despite reassurances it would be done. The service user guide must be up to date and available for service users and their families. In addition to this not all people had contracts or statements of terms and conditions. People must be given these. Care plans would benefit from clear task specific detail that tells carers exactly how a person should be looked after. They needed clear occupational plans and risk management plans needed to be explicit to ensure risks were managed well. Staff were not receiving formal supervision 6 times per year in line with the minimum standard and this needed improvement. 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. South Church (Gloria) Nursing Home Limited DS0000067991.V349073.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection South Church (Gloria) Nursing Home Limited DS0000067991.V349073.R01.S.doc Version 5.2 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People were not given everything they needed to make an informed choice before moving into the home. EVIDENCE: Most people were having a pre-admission assessment to enable the home to determine if they could be looked after. However one person had been admitted without an adequate up to date assessment. Despite reassurances in the improvement plan for this home the service user guide had not been revised and distributed. It was not available for prospective service users. Some people did not have contracts or terms and conditions and there was no evidence the home was confirming in writing it was able to look after people after an assessment.
South Church (Gloria) Nursing Home Limited DS0000067991.V349073.R01.S.doc Version 5.2 Page 9 The registration certificate was not displayed. A photocopy of an old out of date one was hung on the wall. South Church (Gloria) Nursing Home Limited DS0000067991.V349073.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People had their health and social care needs looked after. EVIDENCE: All files inspected had care plans which included their health and personal care needs. There was evidence of involvement of the doctor and nurse when needed. Staff were seen to be polite and courteous with people. Bed rails were being used safely within a risk management framework. Medication was stored administered and recorded appropriately. South Church (Gloria) Nursing Home Limited DS0000067991.V349073.R01.S.doc Version 5.2 Page 11 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 good. This judgement has been made using available evidence including a visit to this service. People’s daily life in the main met their expectation. EVIDENCE: Relatives could come and visit as they pleased and were made welcome by the staff and management. Food looked appetising and there were homemade biscuits. People said they enjoyed the food. People were enjoying bingo in the afternoon. There were some activities in the home but work was needed to ensure these were focussed on individual aspirations so people could do things they really enjoyed. South Church (Gloria) Nursing Home Limited DS0000067991.V349073.R01.S.doc Version 5.2 Page 12 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 good. This judgement has been made using available evidence including a visit to this service. People were protected by the homes policies and procedures on abuse and complaints. EVIDENCE: The home had a complaints process and all people had access to this. There were policies for the protection of vulnerable adults and the home had a copy of the multi agency strategy. A recent concern under protection of vulnerable adults had been investigated appropriately by the home. South Church (Gloria) Nursing Home Limited DS0000067991.V349073.R01.S.doc Version 5.2 Page 13 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 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People lived in a clean home but some redecoration and repair was needed. EVIDENCE: The home was in the process of being redecorated. Some work had been completed but more was needed. Completion of safety checks had improved with only the gas safety certificate outstanding. A new gas cooker had been purchased. South Church (Gloria) Nursing Home Limited DS0000067991.V349073.R01.S.doc Version 5.2 Page 14 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 good. This judgement has been made using available evidence including a visit to this service. Staff were deployed in sufficient number and with sufficient skill mix to meet the needs of the people resident. EVIDENCE: Staff were trained with over 50 at NVQ level 2 or above. There were sufficient staff on duty. People said that the staff were able to meet their needs. Recruitment and selection processes were robustly followed. South Church (Gloria) Nursing Home Limited DS0000067991.V349073.R01.S.doc Version 5.2 Page 15 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 adequate. This judgement has been made using available evidence including a visit to this service. People benefited from improved management systems in the home though further progress was necessary. EVIDENCE: A new manager had been appointed who was a first level registered nurse and had the registered managers award. During interview she was able to demonstrate an understanding of improvements necessary to the management structures in the home in order to make things better for people. Progress had been made on most health and safety issues and checks were being completed. The gas safety certificate was still outstanding due to a planning issue with the local authority. Though an area manager had been appointed
South Church (Gloria) Nursing Home Limited DS0000067991.V349073.R01.S.doc Version 5.2 Page 16 and visited the home. There were no reports under regulation 26 of the Care Homes regulations 2001 (as amended) to provide evidence this was taking place. South Church (Gloria) Nursing Home Limited DS0000067991.V349073.R01.S.doc Version 5.2 Page 17 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 1 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 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 X 1 X 3 X X 2 South Church (Gloria) Nursing Home Limited DS0000067991.V349073.R01.S.doc Version 5.2 Page 18 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 5(1(b,d)), 6 Requirement The registered provider must revise the service user guide to make explicit any difference in fee between people paying for their own care and people whose care is funded, in whole or in part, by a person other than the service user. And shall notify the Commission for Social Care Inspection and service users of the revision when completed. (Previous timescale of 1/06/07 not met.) The registered provider must provide people with a contract or statement of terms and conditions. They must also review and revise contracts and terms and conditions to make sure they are fair and give sufficient detail about peoples’ rights. (Previous timescale of 1/06/07 not met.) The home must be maintained in safe and well decorated order. The registered provider must complete visits as required by regulation 26 of the Care Homes Regulations 2001. Reports of
DS0000067991.V349073.R01.S.doc Timescale for action 01/01/08 2. OP2 5 01/05/08 3. 4. OP19 OP31 23 26 06/04/08 30/11/07 South Church (Gloria) Nursing Home Limited Version 5.2 Page 19 5. OP33 24 (1) 6. OP38 13 (4) these visits must be made available to the manager and be available for inspection by the Commission for Social Care Inspection. The provider must initiate an effective quality assurance process which gathers the views of service users and other stakeholders to inform service improvement. The gas installation must be checked for safety and the landlord gas safety certificate forwarded to the Darlington office of the Commission for Social Care Inspection. 30/04/08 30/04/08 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. Refer to Standard OP7 Good Practice Recommendations Care plans should include task specific detail and clear individual social/occupational plans. Risk management plans should be detailed and explicit about how things should be done to minimise risks. Activities should be developed based on individual aspirations. It is recommended application to register is made to the Commission for Social Care Inspection at the earliest opportunity. Systems should be put in place to ensure staff have formal supervision at least six times per year and receive training to enable them to do their jobs. Management processes should be developed and embedded to ensure smooth running of the home and improvement of standards. 2. 3. 4. 5. OP12 OP31 OP36 OP38 South Church (Gloria) Nursing Home Limited DS0000067991.V349073.R01.S.doc Version 5.2 Page 20 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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
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