Inspection on 08/03/07 for South Church (Gloria) Nursing Home Limited

This inspection was carried out on 8th March 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 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

South Church (Gloria) Nursing... 27/07/09

South Church (Gloria) Nursing... 18/09/08

South Church (Gloria) Nursing... 12/09/07

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

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 11:15 8 & 9 March 2007 th 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.V329643.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.V329643.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.V329643.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Newly registered service first inspection. 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. South Church (Gloria) Nursing Home Limited DS0000067991.V329643.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 9 hours over two days. 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: People had their physical and personal needs met in a planned way. People had a balanced diet and liked the food. Staff were deployed in sufficient number and with sufficient skill mix to meet the needs of the people resident. They were seen to be polite and courteous to people. One reported, the staff were, “great and very caring, always happy to help,” another said they were, “really kind and will help you.” In general feedback was that people felt cared for well and they were treated properly. People were protected by the homes policies and procedures on abuse and complaints. People lived in a clean home. South Church (Gloria) Nursing Home Limited DS0000067991.V329643.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: 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.V329643.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.V329643.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 adequate. This judgement has been made using available evidence including a visit to this service. People did not have all the information they may need to make an informed decision before they moved in. EVIDENCE: All files inspected had assessment of need. The home’s statement of purpose and service user guide needed revision to make sure the information was up to date. Some people did not have contracts on file. The managers were in the process of issuing new contracts to people. Contracts/statement of terms and conditions needed revision to include a breakdown of fees and who was responsible for paying them. They were also jargonistic and should be revised in light of the office of fair trading guidance on fair contracts in care homes. South Church (Gloria) Nursing Home Limited DS0000067991.V329643.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People had their physical and personal needs met. EVIDENCE: All files inspected had care plans. There was evidence of people having access to doctors and specialist health staff as needed. Plans would benefit from being more personal and including individual preference. Some moving and handling plans did not include enough detail to ensure staff knew how to move people safely. Risk management plans needed more detail to ensure risks were managed safely. Medication was stored administered and recorded safely though the temperature in the clinical room felt too hot for the storage of medication and needed ventilation. Staff were seen to be polite and courteous with people. One reported, the staff were, “great and very caring, always happy to help,” another said they were, “really kind and will help you.” South Church (Gloria) Nursing Home Limited DS0000067991.V329643.R01.S.doc Version 5.2 Page 10 In general feedback was that people felt cared for well and they were treated properly. South Church (Gloria) Nursing Home Limited DS0000067991.V329643.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 adequate. This judgement has been made using available evidence including a visit to this service. People had a balanced diet and liked the food though they wanted more to occupy their time and meet their social needs. EVIDENCE: People said the food was good and there was a balanced diet. “My favourite food is egg and chips. There is always plenty to choose from.” People wanted more activities. There was no activities co-ordinator in post to improve this area. Discussion with the managers highlighted a desire to make activities the responsibility of every staff member rather than having a single identified co-ordinator. In order to facilitate this the home should use the hours for activity co-ordination to increase the staffing and allow more time for activities. South Church (Gloria) Nursing Home Limited DS0000067991.V329643.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 complains 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. South Church (Gloria) Nursing Home Limited DS0000067991.V329643.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 clean and there was no odour. Toilets on one corridor were broken and needed repair. Safety checks in the home were not being made in line with recommended timescales. The home needed to check gas safety. Checks and precautionary measures to manage the risk from legionella were not taking place regularly. The gas cooker had been condemned and needed replacing. The cook was able to manage with the equipment she had but only just. There was not a policy in the home for infection control. The home needed to ensure policies were in place and available for staff to reference. Some redecoration and repairs were needed. There was a refurbishment plan for the home. South Church (Gloria) Nursing Home Limited DS0000067991.V329643.R01.S.doc Version 5.2 Page 14 South Church (Gloria) Nursing Home Limited DS0000067991.V329643.R01.S.doc Version 5.2 Page 15 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. Staff agreed there were sufficient numbers to meet the needs of the people based on current occupancy levels. Recruitment and selection processes were not robustly followed and some new staff appeared to have been deployed without adequate safety checks. South Church (Gloria) Nursing Home Limited DS0000067991.V329643.R01.S.doc Version 5.2 Page 16 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, 36 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People did not benefit from good management systems to ensure their best interests were looked after. EVIDENCE: There was an electrical hard wiring certificate to say the electrical system was safe. The environmental health department had been in to check the home and found it acceptable. The home did not have management systems for identifying and developing training for staff. Supervision was not taking place at required frequency. Some health and safety checks since being taken over by the new company had not been completed. The gas safety certificate was South Church (Gloria) Nursing Home Limited DS0000067991.V329643.R01.S.doc Version 5.2 Page 17 out of date and the legionella maintenance checks were not taking place. The registered provider was not conducting monthly inspections and reports as required by regulation 26. Staff were being recruited and deployed without correct POVA or CRB checks completed. Service user money records were not accurate and the procedure was not being followed properly. South Church (Gloria) Nursing Home Limited DS0000067991.V329643.R01.S.doc Version 5.2 Page 18 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 2 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X 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 1 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 1 2 X 1 South Church (Gloria) Nursing Home Limited DS0000067991.V329643.R01.S.doc Version 5.2 Page 19 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. 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. 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. The home must be maintained in safe and well decorated order. In particular the two toilets identified as needing repair must be fixed. Staff must not be deployed without CRB or POVA first checks. Staff deployed following POVA first checks must only be DS0000067991.V329643.R01.S.doc Timescale for action 01/06/07 2 OP2 5 01/06/07 3 OP19 23 06/04/07 4 OP29 19 09/03/07 South Church (Gloria) Nursing Home Limited Version 5.2 Page 20 5 OP31 26 6 OP35 17 (2) 7 OP38 13 (4) 8 9 OP38 OP38 13 (4) 13 (3) deployed in line with POVA guidance and must not be confirmed in post until those matters detailed in regulation 19 and schedule 2 (as amended) have been satisfied. The registered provider must complete visits as required by regulation 26 of the Care Homes Regulations 2001. Reports of these visits must be made available to the manager and be available for inspection by the Commission for Social Care Inspection. Records of transactions with regard to service user monies must be maintained and accurate in line with the homes procedures. 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. The gas cooker in the Kitchen which has been condemned as unsafe must be replaced. Arrangements must be made for the prevention of legionella in the home. The home must have an infection control policy in the home and available for staff reference to ensure good infection control practice is maintained. 30/04/07 06/04/07 30/04/07 30/04/07 30/04/07 South Church (Gloria) Nursing Home Limited DS0000067991.V329643.R01.S.doc Version 5.2 Page 21 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 should have 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 management arrangements in the home are rationalised and 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. 2 3 OP12 OP31 4 OP36 South Church (Gloria) Nursing Home Limited DS0000067991.V329643.R01.S.doc Version 5.2 Page 22 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 © 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 South Church (Gloria) Nursing Home Limited DS0000067991.V329643.R01.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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