Inspection on 12/10/06 for The Gloucester

This inspection was carried out on 12th October 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Gloucester 24/07/07

The Gloucester 03/05/06

The Gloucester 24/05/05

The Gloucester 15/02/05

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE The Gloucester 83 Gloucester Road North Filton South Glos BS34 7PT Lead Inspector Odette Coveney Key Unannounced Inspection 12th October 2006 09:15 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 The Gloucester DS0000061774.V309083.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. The Gloucester DS0000061774.V309083.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Gloucester Address 83 Gloucester Road North Filton South Glos BS34 7PT Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0117 9699626 Alutarius Ltd To be appointed. Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places The Gloucester DS0000061774.V309083.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd May 2006 Brief Description of the Service: The Gloucester is registered with the CSCI to provide care and accommodation for up to 13 older people. In October 2004 there was a change of service provider. The home is now operated by Alutarius Limited and was managed by Mr Neil Plummer, Karen Headington the previous deputy manager at the home has been promoted into the managers position and has submitted an application with the Commission and is awaiting an interview date in order that her ‘fitness’ can be assessed. The property is situated on the A38 Gloucester Road approximately 4 miles North of the centre of Bristol. The home is on major bus routes and the M32 and M4 are easily accessible from the home. Local amenities are within walking distance of the home. Accommodation is provided on three floors. There is a passenger lift. There are nine single and two double bedrooms. The home has two lounges, a dining room and a kitchen on the ground floor. There are bathroom and toilet facilities on each floor. There is level access to a decking area to the rear of the premises and steps to a small garden area. There is access to the garden from the side of the property. Car parking is provided at the rear of the home. The Gloucester DS0000061774.V309083.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the visit was to establish if the home is meeting the National Minimum Standards and the requirements of the Care Standards Act 2000 and to review the quality of the care provision for the individual’s living in the home. This inspection employed key elements of the national inspection methodology with the objectives of focusing on outcomes for the individual’s. This is evidenced through evaluation of core standards and verification through a surveying and case tracking approach that included talking with and the observation of individuals who live at the home and the views of the manager and staff on duty. Time was also spent with visitors to the home and 19 comment cards were received from residents, health/social care professionals and relatives of those who live at the home. An opportunity was taken to view the home and a number of the records relating to the management of the home and plans of care for four of the individuals were reviewed. Recruitment, supervision and training records of staff were also viewed. At this inspection three immediate requirements were made in respect of health and safety at the home, these were issued to ensure that residents were protected from potential scalding and to ensure staff competency in the event of a fire. At this inspection it was found that hot water temperatures in both residents private rooms and bathrooms exceeded 43 centigrade and the risk assessment in respect of this area was not satisfactory. It was further identified that eight staff members had not received sufficient amounts of fire safety instruction. Prior to returning to the home the inspector received an updated ‘hot water’ risk assessment and confirmation of those staff identified having received fire training. Furthermore the inspector re-visited the home on October 26th in order to review the requirements made. It was found that contractors were on site and had fitted temperature mixer valves to all areas. All three requirements had been met. Throughout the inspection process the manager and staff spoken with were informative and engaging and participated fully with the inspection. Residents spoke favourably of the care and attention they receive from the staff at the home. The Gloucester DS0000061774.V309083.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Residents can be assured that their needs will be met and that clear guidance is in place for staff as the care plans viewed accurately reflected resident’s personal, healthcare and social needs. The care plans recorded how identified needs are to be met. The wishes and choices in the event of end of life for residents will be adhered to and respected as this information had been obtained and is recorded on individual’s records. Residents are offered a suitable alternative to meals and improvement in this area has been made, comments made by both residents and relatives prior to and during the inspection demonstrated improved satisfaction in this area. Those living and working at the home can be assured that the organisation are committed to providing a well maintained, hygienic and safe environment as the following requirements made at the last inspection have been met: Radiator covers have been fitted to ensure residents personal safety, the identified toilet frame seat had been replaced, a lock had been fitted on the ground floor toilet door ensuring individuals privacy, the identified vanity unit was replaced and the source of odour in this area was eliminated. Also hot water pipes in a bathroom area have been covered. The safety of both residents and staff has improved as manual handling risk assessments have been completed for all residents and current risk profiles in place have been improved to include the date and also recorded who had completed the assessment. Resident’s valuables and money are now safer as all residents have been provided with a lockable facility to enable them to keep valuables safe if they wish and also as records of monies held on resident’s behalf for safekeeping are accurate with receipts being kept of monies spent. Residents can be assured that staff had been appointed following robust recruitment and selection as the home have ensured that criminal record The Gloucester DS0000061774.V309083.R01.S.doc Version 5.2 Page 7 bureau checks are in place for all staff before they commenced employment with full staff records being in place and the organisation have ensured these documents are available for inspection. Those living at the home can be assured that staff have received sufficient, appropriate training as the home has a training plan in place that audits all training undertaken. What they could do better: In order that prospective and current residents have up to date information it is required that the home update its statement of purpose in order that it fully reflects the staffing and management of the home. In order that residents can be confident that complaints are dealt with effectively it is required that any complaints received are fully recorded. In order to ensure continuity of care, effective communication and clarity in respect of staff role and responsibility it is required that the manager must ensure that that the homes induction training matches the National Skills for Care standards and also that staff received regular, recorded supervision. In order that residents can be assured that staff are aware of their contract of employment it is required that all staff must receive a statement of their terms and conditions of employment. In order that a safe, hygienic and well maintained environment is provided for those who live and work at the home the following requirements were made; • • A residents bedroom had a frayed, damaged carpet that was a potential trip hazard, it is required that this carpet be replaced. Another residents bedroom had a crack in the wall and another in the ceiling, it is required that these cracks are monitored for movement, that this is recorded and when it is deemed appropriate (i.e.; no continued movement) then this room must be redecorated. The bathroom on the first floor is ‘functional’ and the décor is worn, it is required that consideration be given to the redecoration of this room. A number of residents bedroom doors and hallway landing doors have been undercoated, it is required that these doors are painted and finished off to the required standard. The kitchen floor has missing tiles and is a potential trip and hygiene hazard, it is required that attention is given to this area with the floor being repaired or replaced. • • • The Gloucester DS0000061774.V309083.R01.S.doc Version 5.2 Page 8 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 Gloucester DS0000061774.V309083.R01.S.doc Version 5.2 Page 9 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 The Gloucester DS0000061774.V309083.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5. The quality outcome in this area is adequate; this judgement has been made using available evidence including a visit to this service. The home provides clear information about the services and facilities that are provided at the home. Clear admissions processes and contractual arrangements are in place. EVIDENCE: Intermediate care is not provided at this home. The home is registered with the Commission to provide care and accommodation for up to 13 older people. The homes statement of purpose was reviewed at this inspection and this document was found to contain all of the required information in respect of the Schedule 1, such the range of needs that the home are able to meet, the admission criteria for the home, including trial visits and assessment of need. The document also outlined the arrangements for dealing with complaints and the arrangements made for respecting the privacy and dignity of residents. However a requirement was made at this inspection that the homes statement The Gloucester DS0000061774.V309083.R01.S.doc Version 5.2 Page 11 of purpose must be updated in order to reflect the staffing information contained within it and to include the details of the new manager in post. There has been an outstanding requirement from previous inspections that have been in place since May 2005. This was that ‘Contracts between the home and residents must be discussed and agreed with each resident and/or their representative and signed by all parties’. A review of these documents, including discussion with the manger confirmed that these documents are in place and are issued to those concerned. The documents reviewed clearly outlined the terms and conditions with the home and included information about the overall care and services covered by the fees, the amount of fees payable and additional services to be paid for over and above those included in the fees, notice periods and the rights and obligations of both the residents and the registered provider are also recorded. The manager demonstrated to the inspector that if the home was unable to meet the care needs of any resident the procedure they would follow and gave examples of when this situation may occur, an example given was that in the event that a resident would require ongoing nursing care or if the home were unable to support an individuals mental health needs. The manager told the inspector that the home would support individuals who are ill and have in the past supported terminally ill individuals who have required short-term care. The manager was aware of the ability to access extra support for individuals should this be required, such as district nurses, community psychiatric nurses and the GP. During the inspection staff were observed interacting with residents, using the appropriate use of language and tone of voice. A resident spoke of high regard for the care and support that she has received from staff at the home. The Gloucester DS0000061774.V309083.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 11 The quality outcome in this area is good; this judgement has been made using available evidence including a visit to this service. The home offers care and support to residents throughout their lives and towards the end. It also protects residents and ensures needs are met by reviewing health needs with good care planning. Medication administration practice is satisfactory. EVIDENCE: Requirements have been made at previous inspections that all care plans must accurately reflect resident’s personal, healthcare and social needs and how they were to be met, and record the way in which residents prefer. A review of residents care plan documents reviewed at the last inspection undertaken in May 2006 found that information seen recorded varied in both detail and guidance for staff with also significant differences in the quality of person centred information being recorded. The care plan records of four residents were reviewed at this inspection and it was evident that the manager and staff team had worked diligently in order ensure that residents needs, wishes and choices had been ascertained and recorded. Time had been spent with residents to complete these plans and each had been written in an individualised, person centred way. The current care plans provided clear The Gloucester DS0000061774.V309083.R01.S.doc Version 5.2 Page 13 guidance to staff in order to direct them to support residents in the way they choose. It was required at the last inspection that residents care plans must be reviewed every month, all care plans had been recently developed with a good system in place to monitor and review the plans. Upon examination of care records at the last inspection it was clear that the home had sought the views of some residents as to their wishes in the event of their death, however not all of the residents had their views recorded, it was recommended that the home seeks to rectify this. A review of documents held at this inspection found that the home had responded to this recommendation and that all individual’s wishes and choices in this sensitive area had been sought and recorded. There was evidence of visits from the Doctor, optician, chiropodist and other health professionals on the care files reviewed. Residents spoken with said that they see the doctor when they request it and confirmed support received from other health professionals. Medication administration, storage and recording procedures was reviewed systems in place were found to be satisfactory. It was also noted at this inspection that clear medication policies were in place, there was evidence of receipt and disposal of medication and were properly recorded. The Gloucester DS0000061774.V309083.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. The quality outcome in this area is good; this judgement has been made using available evidence including a visit to this service. Residents are able to maintain contact with family and friends; they are able to exercise choice over their lives. Standards of meals provided at the home have improved. EVIDENCE: It was observed and information seen recorded that routines of daily living and activities made available are flexible and varied to suit residents needs. One resident had a visitor and chose to have their meal later, another resident enjoys sleeping in the afternoon, another resident wakes and gets up during the night. Residents and staff spoken with confirmed that these routines are respected. Care plans and daily records demonstrated that residents like and dislikes are recorded and individual’s religious observances are also respected. Discussion took place with the manager about equality and diversity and she was able to give examples of how individual’s rights are responded to within the home. The visitor’s book showed that there are regular visitors to the home and residents spoken with confirmed they are able to choose whom they see and do not see. Residents are able to have visitors at any reasonable time and The Gloucester DS0000061774.V309083.R01.S.doc Version 5.2 Page 15 individuals are able to receive visitors in private. Visitors spoken with said they are always made welcome by staff at the home that staff are polite and they are offered refreshments. A requirement was made at the last inspection that improvements must be made to the quality of cooked meals and residents must be offered choices. This was fully reviewed at this inspection, as this has been an ongoing issue from previous inspections. The organisation has appointed a catering manager whose responsibility it is to monitor and improve standards in this area. The inspector ate lunch at the home, reviewed menus and spoke with residents and relatives, spent time with the cook and the catering manager. The comment cards received from residents prior to the inspection indicated improvements in this area. A review of menus demonstrated that residents are offered two alternatives at mealtimes and a resident confirmed that portion sizes had increased. Residents comments included; ‘we have much better choices now’, ‘I am asked what I would like’, ‘I enjoy the meals better now and get plenty’. There was evidence of the fridge and freezer temperature recordings daily and the food noted in the fridge was labelled to ensure that staff are aware of the disposal date. The kitchen was found to be clean and tidy, however it was noted that tiles on the floor were missing and were a potential safety and food hygiene hazard. A requirement was made that attention must be given to repair or replace the floor to a satisfactory standard. The Gloucester DS0000061774.V309083.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The quality outcome in this area is adequate; this judgement has been made using available evidence including a visit to this service. Residents are protected from abuse and complaints are dealt with, however recording in this area must be improved. EVIDENCE: There was evidence in place to show that staff have attended Protection of Vulnerable Adults from abuse training and the home has a clear Protection of Vulnerable Adults policy, this was on prominent display in the managers office and a copy of the homes complaints procedure was on display in the entrance hall. Residents and visitors at the home raised no complaints or concerns to the inspector during the inspection. Prior to visiting the home the inspector received 19 comment cards these indicated that residents, relatives and health professionals knew who to speak with if they were not happy. The manager was clear about her responsibilities when dealing with a complaint and there was information at the home to show that complaints are dealt with. However, the complaints book had no recorded incidents yet there had been issues raised at, and dealt with by the home. It is required that complaints are recorded fully including the details of the complaint, who is dealing with it and outcomes of investigations must also be recorded in accordance with the homes own complaints procedure. The Gloucester DS0000061774.V309083.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25, 26. The quality outcome in this area is poor; this judgement has been made using available evidence including a visit to this service. The home have worked diligently to meet requirements made at the last inspection, however further requirements were made at this inspection in order to ensure the safety of residents and to demonstrate a commitment from the owners of the home in providing a well maintained environment. EVIDENCE: The Gloucester is registered to accommodate thirteen older people; the home is set within the residential area of Filton, is close to local amenities and is situated on good public transport routes. The home has two comfortable lounges and dining area. There is a small garden at the front of the home and a well-tended garden at the rear, this has recently benefited from a decked area for residents use and gates have been fitted to provide additional security. The inspector was able to view some of the resident’s bedrooms during the inspection, the rooms are spacious and all were individual in style and The Gloucester DS0000061774.V309083.R01.S.doc Version 5.2 Page 18 furnishings. Rooms are located over three floors of the home, with two rooms accommodating two residents. A screen is provided for a degree of privacy. One of the residents in a shared room told the inspector they get on well with the other person and sharing with them has never been a problem with privacy or dignity. Each room seen reflected the personal tastes, hobbies and interests of residents. The inspector saw in resident’s room’s pictures, soft furnishings and photographs of individuals and their family members. During the inspection residents were observed making full use of their own room. All rooms have furnishings of a good standard, rooms were comfortable. Rooms were clean, tidy and odour free when the inspector saw them. The manger confirmed that some redecoration had occurred at the home since the last inspection and that there is an ongoing programme of improvement and renewal at the home. A number of requirements were made at the last inspection that was undertaken on 3rd May 2006 in respect of improvements needed within the environment: • The ground floor toilet must have a lock fitted to ensure privacy for residents when in use. This has been fitted, demonstrating compliance in this area. The registered person was required to ensure that radiator covers are fitted to radiators where there is a risk to resident’s personal safety. At the last inspection four covers had been fitted to radiators. On 22nd May the home were issued with an enforcement notice in order to comply, due the season and the rise in external weather temperatures it was agreed with the provider that the home were given an extended notice period in which to comply, this was given as 30th July 2006. The inspector saw that these had been fitted in all areas of the home. Identified toilet frame to be repaired or replaced to ensure residents safety and eliminate the risk of infection. Frames within the home have been replaced. Vanity unit to be made safe and to be cleaned. This had been replaced with a suitable alternative in place for the individuals use. A lockable facility must be provided in all residents’ rooms to enable the resident to keep valuables safe if so wished. All residents had had locks fitted to bedside units. • • • • The registered provider had worked diligently in order to ensure that the requirements made at the last inspection. Following a review of the premises The Gloucester DS0000061774.V309083.R01.S.doc Version 5.2 Page 19 at this inspection which included; viewing bathrooms, communal areas, the kitchen and residents private rooms the following observations and requirements were made: • • A residents bedroom had a frayed, damaged carpet that was a potential trip hazard, it is required that this carpet be replaced. Another residents bedroom had a crack in the wall and another in the ceiling, it is required that these cracks are monitored for movement, that this is recorded and when it is deemed appropriate (i.e.; no continued movement) then this room must be redecorated. The bathroom on the first floor is ‘functional’ and the décor is worn, it is required that consideration be given to the redecoration of this room. A number of residents bedroom doors and landing door have been undercoated, it is required that these doors are painted and finished off to the required standard. The kitchen floor has missing tiles and is a potential trip and hygiene hazard, it is required that attention is given to this area with the floor being repaired or replaced. • • • The Gloucester DS0000061774.V309083.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29, 30. The quality outcome in this area is poor; this judgement has been made using available evidence including a visit to this service. Staff have not received appropriate support in their induction. Contracts of employment would ensure staff understanding of their role and furthermore staff supervision would ensure continuity of service delivery for residents. EVIDENCE: There is a well-established staff team at the home. The use of agency staff is not required at the home, there are no staff under the age of 21 left in charge at the home and staff providing personal care to residents are over the age of 18. At the time of the inspection there were sufficient numbers of staff on duty to meet the needs of the residents. At night there is a waking staff member and a sleep in member of staff who is on call for additional assistance if required. Domestic and catering staff are employed at the home. Many favourable comment were received about staff at the home from both residents and visitors to the home; comments included; ‘Staff are kindness itself’, ‘there have been a number of improvements at the home since the new owners have taken over’, ‘the health of my relative has improved since moving into the home’. The following requirements were made at the inspection that was undertaken on 3rd May 2006: That the home must maintain staff records and make them available for inspection. And that all staff must have Criminal Record Bureau The Gloucester DS0000061774.V309083.R01.S.doc Version 5.2 Page 21 checks in place before they commence employment. The staff files for six individuals were reviewed; including the most recently recruited staff member all of the required documentation was in place and the requirements have been met It was required at the inspection undertaken in May 2005 that The manager should ensure that the home’s induction-training matches National Skills for Care standards to ensure residents benefit from good safe working practices. A review of staff files found that only the most recently appointed staff member had commenced a formalised, recorded induction; therefore this requirement will remain and will be reviewed at the next inspection. Furthermore the review of staff files found not all staff had a contract of employment in place. It is required that all staff receive a copy of their terms and conditions of employment in order that they are fully conversant with these and work within their job description and within the organisation’s policies and procedures. A requirement was made at the inspection undertaken in November 2005 that a training programme should be developed to provide staff with training to be provided that is appropriate to residents needs. Prior to the inspection the home forwarded to the inspector the training plan for staff working at the home, this provides an overview of staff training undertaken and evidenced that staff have completed protection of vulnerable adults awareness, basic food hygiene, first aid and fire safety. Staff spoken with and certificates seen in staff files provided confirmation that the training had been undertaken and staff were positive about how training, including National Vocational Qualification in care practices, had influenced their practice and improved their skills in caring for older people. The Gloucester DS0000061774.V309083.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37, 38. The quality outcome in this area is good; this judgement has been made using available evidence including a visit to this service. The home is well managed ensuring that individual’s interests and rights are promoted and protected by a knowledgeable and experienced staff team. EVIDENCE: A requirement was made at the last inspection that a manager must be appointed to fulfil the role of the registered manager. Karen Headington has been employed as the deputy manager of the home since 1997 and has many years experience within the care provision for older people. Ms Headington has completed the following training; NVQ level 3, manual handling, first aid, protection of vulnerable adults and fire safety. Residents spoken with said that Karen was approachable and caring. Positive interaction was observed between the manager and residents and staff, it was clear that relationships were well established. The Gloucester DS0000061774.V309083.R01.S.doc Version 5.2 Page 23 A requirement was made at the last inspection that staff must receive formal recorded supervision. It was evident from staff files reviewed that this has not been occurring for all staff on a consistent, formalised recorded basis, it is essential that processes are in place to ensure continuity of care, effective communication and clarity of staff roles and responsibilities. Therefore this requirement remains and will be reviewed at the next inspection. Resident’s valuables and money are now safer as all residents have been provided with a lockable facility to enable them to keep valuables safe if they wish and also as records of monies held on residents behalf for safekeeping are accurate and receipts are kept of monies spent. Accidents were well recorded and dealt with appropriately with incidents being reported where required. A requirement was made at the last inspection that manual handling assessments must be completed for all residents and contain full information and that resident’s risk profiles to contain full information be dated and signed. A review of thee documents held in residents files found that these requirements had been met with sufficient information in place to guide and direct staff practice. It was recommended at the last inspection that: Records of fire drill should contain the names of those who have attended. Records of fire safety checks and instruction were found to have been well recorded. The Gloucester DS0000061774.V309083.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 3 3 X 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 1 3 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 3 3 The Gloucester DS0000061774.V309083.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP30 Regulation 18 Requirement The manager should ensure that the home’s induction-training matches National Skills for Care standards to ensure residents benefit from good safe working practices. (Outstanding since may 2005). Care staff must receive formal recorded supervision The homes statement of purpose must be updated to ensure that management and staffing information is correct. Carpet in identified room to be replaced. Room identified to have cracks in the wall monitored and recorded, when appropriate this room to be redecorated. Doors identified to be painted and finished. Consideration to be given to the redecoration of the first floor bathroom. All staff must have a statement of their terms and conditions of employment. DS0000061774.V309083.R01.S.doc Timescale for action 16/01/07 2. 3. OP36 OP1 21 4(1) c 16/11/06 16/12/06 4. 5. OP19 OP19 23(2) b 23(2) b 16/12/06 16/02/07 6. 7. 8. OP19 OP19 OP29 23(2) b 23(2) b 17(2) 16/12/06 16/02/07 16/01/07 The Gloucester Version 5.2 Page 26 9. 10. OP16 OP19 17(2) 23(2) b Complaints must be fully 16/11/06 recorded. Attention must be given to repair 16/01/07 or replace the kitchen floor. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Gloucester DS0000061774.V309083.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Gloucester DS0000061774.V309083.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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