Inspection on 24/07/07 for The Gloucester

This inspection was carried out on 24th July 2007.

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

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

Other inspections for this house

The Gloucester 12/10/06

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 24th July 2007 08:10 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.V337988.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.V337988.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 neilplumm@tiscali.co.uk Alutarius Ltd Karen Jane Headington Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places The Gloucester DS0000061774.V337988.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th October 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 is managed by Karen Headington, she is supported in her role by a deputy staff member and a full staff team; area manager, Mr Neil Plumber, visits the home on a weekly basis and completes a report on behalf of the registered providers, Mr and Mrs Coombes, on a monthly basis and copies of these reports are forwarded to the Commission. 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.V337988.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key standard inspection was carried out in two days over an 8-hour period by one inspector for the Commission. This inspection was very positive and overall a judgement of good was made. 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. Prior to the site visit the Commission received from the Registered Manager a completed an annual quality assurance assessment (AQAA). The annual quality assurance assessment is a new process that is being used for all regulated services from April 2007. 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 individuals were reviewed. The registration certificate for the home was reviewed at this inspection and the information contained within it was found to be accurate. 16 Comment cards were received prior to the inspection, 5 of these were from relatives of those who live at the home, 8 were from individual’s who live at the home, the other comment cards were from visiting health/social care professional who visits individuals at the home. Comments made were reviewed during the visit and these, maintaining individual’s confidentiality, were shared with the registered manager and have been incorporated within this inspection report. What the service does well: The home has a clear, detailed statement of purpose in place; this provides sound and detailed information about the services and facilities that able to be provided at the home. The home has a structured admission process based on the homes ability to meet the assessed needs of residents. Good standards of care and service continue at the home. These are well recorded within individuals care plans and risk assessments. Those spoken with during the visit said they were happy and enjoyed life at the home. The staff team at The Gloucester are caring and have developed good relationships with residents at the home; they have a sound understanding of The Gloucester DS0000061774.V337988.R01.S.doc Version 5.2 Page 6 the needs of residents. There is a low staff turnover and residents can therefore be confident that they will receive support from people they know. It was clearly evident that the manager and the staff team are committed to ensuring that all of the needs of individuals at the home are met, this is done through consultation and observation and previous knowledge and an understanding of individuals. Further comments made during the site visit were; ‘The staff are great, very attentive and kind’, ‘it was the best move I ever made coming into the home’ and finally from a visiting relative at the home; ‘I have never seen mum so well and she is very happy and settled here, nothing is too much trouble for the staff’. What has improved since the last inspection? What they could do better: The Gloucester DS0000061774.V337988.R01.S.doc Version 5.2 Page 7 In order that residents can be assured that staff have the knowledge and skill in able to perform their duties in a safe manner it is required that the four staff identified during this visit receive manual handling training and those who had training in this are over a year ago must also undertake refresher training in this area. In order that residents can feel confident that the manager has the knowledge and skills in order to perform her duties in line with the National Minimum Standards and Care Homes Regulations it is required that the manager must register and complete a National Vocational Qualification at Level 4 in management. In order to ensure that the home is safe and is appropriate for the needs of residents is it required that fire detector self closure to be fitted to the kitchen door, furthermore the home must notify the Commission any proposals for change of use within the environment and include the impact that this could have for residents and how this will be minimised. Residents would be better assured of security at the home if medication is stored securely and also when the home have forward formal notification to the Commission of the outcomes of a staff investigation. Residents would be assured that staff are appropriately supervised if the home developed a supervision proforma for consistent formal recording of these meetings 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. The Gloucester DS0000061774.V337988.R01.S.doc Version 5.2 Page 8 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.V337988.R01.S.doc Version 5.2 Page 9 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, 3, 4, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager takes a lot of care when admitting residents to The Gloucester in order to ensure that the home are able to meet the assessed needs of the individual. Clear information is provided about the services and facilities available at the home. EVIDENCE: A requirement was made at the last site visit to the home, which was undertaken in October 2006, that the homes statement of purpose must be updated in order to ensure that management and staffing information is correct. The inspector saw that this documents had been reviewed in May 2007 and upon examination this document was found to contain all of the required information in order that residents and prospective residents have access to clear information about the facilities and services that are able to be provided at the home. The Gloucester DS0000061774.V337988.R01.S.doc Version 5.2 Page 10 Information within this document also included the admission process for the home, how individuals can raise concerns if they are not happy with the service they received, notice periods and how individuals would be supported at the home and outlines rights of residents to be treated equally and to be treated with respect and dignity. A number of admission records were examined and these included copies of the home’s assessment and where an individual was known to the local authority a copy of their assessment. The Pre Admission assessment included information about the physical and health needs of the individual and also provided a way of establishing the dependency level of the individual. Included in the assessment is information about the social needs, personal history and daily routines, interests of the perspective resident, personal safety and risk. Information in files showed that individuals admission into the home is tailored to their needs and wishes, individuals have an opportunity to visit the home prior to admission, to spend the day at the home and to have an overnight stay if they wish. All individuals into the home do so on a one months trial basis in order to ensure that their needs can be met at the home and that the placement is suitable for them. There were no residents in the home at the time of the inspection admitted solely for intermediate care. The Gloucester DS0000061774.V337988.R01.S.doc Version 5.2 Page 11 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, 10, 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are well supported with their needs by staff. Care plans reflect residents’ current personal care and health needs. Generally the practices for storage and administration of medication are safe, however some improvements are needed in respect of security of medication. EVIDENCE: Four individuals care records were reviewed at this inspection and it was found that the plans in place had been generated from a care management assessment. Information contained within care records included: an individual’s profile containing information about health care support services involved, next of kin, family contact details and medical history. Each resident also had completed risk assessments, records of health professionals visiting, daily records of individuals routines and a care plan. The Gloucester DS0000061774.V337988.R01.S.doc Version 5.2 Page 12 The care plan identified the areas in which the individual required support, how staff intervention and support would be provided, the support and the situation is in turn evaluated and dated. When examining the care plans it was evident that the home had spent time with residents discussing their wishes and choices and incorporating these within individuals care plans. Thorough examination of care documentation evidenced that residents are well supported with their health care requirements in order to access services. There were records of when individuals have been visited by dentist, optician’s district nurses and general practitioners. A comment card received from a resident prior to the site visit had written ‘The home always contacts my doctor when needed’, this was further confirmed by residents and their relatives who were spoken with during this visit to the home. Procedure for medication administration, handling, records and storage were assessed. The home had policy and guidelines on medication. A local pharmacy provides medication using a monthly monitored dosage system. A check of the blister packs indicated that medication had been administered as recorded. The pharmacy supply printed medicines administration record sheets each month. Records of administration of medicines were clear. Records are kept of medicines received into the home. Waste medication is recorded and disposed of via the supplying pharmacy. It was noted that the home have a metal trolley for storage of most medication, and this was attached securely to the wall, however some surplus stock held medication is held else ware and it was noted that this facility was not always kept locked, it is required that all medication is kept safe and secure Three comment cards were received from health professionals prior to this site visit, both recorded that the home communicates clearly and works in partnership with them, that there is always a senior member of staff to confer with and that any specialist advice is incorporated into the service users plan of care. All commented that they are satisfied with the overall care provided to residents living at the home. All of the residents are allocated a key worker; staff spoken with had a clear understanding of their role and responsibilities. It was noted that information was in place to demonstrate that resident’s wishes concerning terminal care and arrangements after death have been discussed. The Gloucester DS0000061774.V337988.R01.S.doc Version 5.2 Page 13 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, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for meeting the social and recreational needs of residents are good and there are opportunities for residents to maintain links with family, friends and the local community. The home’s practice and routines are flexible and enable residents to exercise choice and have control over their lives. The home provides meals, which are balanced and meet the dietary needs of individuals in the home. EVIDENCE: Discussion with the manager, staff members and evidence from the visitors’ book showed that the residents maintain good contact with families and representatives. The level of contact varies for each resident living at the home, some receive regular visitors and go out with family, and others do not. One comment card received from a relative prior to this visit to the home said that their relative had memory problems, however the home supports this individual to send cards to family on special occasions and the was ‘very much appreciated’. The Gloucester DS0000061774.V337988.R01.S.doc Version 5.2 Page 14 A senior staff member said he home would contact individual’s next of kin should they need to be they need to be informed of issues, which affect the well being of an individual living at the home. All comment cards received from relatives prior to the visit to the home confirmed this. At a brief walk around the building residents were seen spending time in their bedrooms and the communal lounges. Daily records of care showed that residents are able to choose when to get up and retire, what to eat/drink and how they were to be assisted with aspects of their life. As the inspector arrived at the home just after eight in the morning one of the residents was having their breakfast in the lounge, they said they prefer to have their meals alone in the lounge and the staff ensure they are able to do this. The inspector observed residents having their meal at lunchtime. The meal was relaxed and residents were given the meals based on the choices they made after consultation on the meals available to them. Of the comment cards received from residents prior to the inspection one said they felt meals could be improved, five others said that meals were ‘much better choice’, ‘quality of food has improved’, residents said that the food was ‘ 100 better than before’, another said ‘I love the food, there is always plenty’, others confirmed that if they were hungry or thirsty in between meals staff would provide something. Two residents said that the toast takes a long time to cook, this was raised with the manger who said that this would be dealt with promptly and a new toaster would be purchased the next day. Prior to this site visit 8 comment cards were received from residents who live at the home and information contained within these, and feedback also received from relatives of those who live at the home included; ‘making it seem as much like a home as possible’, ‘care without imposing too many rules’, ‘the staff provide a family atmosphere’ During this visit there were a number of visitors to the home and residents were taken out for lunch, another resident visits the pub on a daily basis and is supported by staff to cross the road safely. Comments received from residents and relatives prior to the visit included: ‘I wish there were more activities to occupy our time, we mostly sit and watch TV’. A relative also said that the home could improve upon more activities for residents and if residents were taken out more. The deputy manager showed the inspector a proforma to show that all residents had been asked on an individual basis (residents confirmed this) what activities, interests and hobbies they would like, as a result of these consultations the home have devised a rota to include those activities such as painting, film shows, music and trivial quizzes and bingo. In the homes AQAA documents received prior to the site visit the manager had recorded that the home are considering employing an activities coordinator. This would benefit residents and would provide additional opportunities for residents to be supported with activities on a one to one basis rather than group activities; this area will be further reviewed at the next site visit. The Gloucester DS0000061774.V337988.R01.S.doc Version 5.2 Page 15 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, 17, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are enabled to complain and are confident that their complaint will be listened to. Practices at the Home ensure protection of residents from harm and abuse. EVIDENCE: The Home has appropriate procedures in place for management of complaints. This document contains information about the Commission for Social Care Inspection to enable individuals to contact the Commission if they were not satisfied with the outcome of their complaint to the home. There is a copy of the South Gloucestershire Council policy on The Protection of Vulnerable Adults from Abuse at the Home to ensure that the Home is aware of the protocol to be followed if incidences of abuse occur. Staff spoken to showed an awareness of the policies and procedures in place to protect vulnerable adults. The home also has a clear whistle blowing policy in place. Staff have undertaken training in protection of vulnerable adults. Records of recently employed staff members were viewed and contained personal information and record of identity. Other information seen included two satisfactory references, record of previous employment, and satisfactory Criminal Record Bureau disclosures. The Gloucester DS0000061774.V337988.R01.S.doc Version 5.2 Page 16 A requirement made at the last site visit was that all complaints must be fully recorded. A review of the homes logbook for recording complaints found that this requirement had been met and all issues had been dealt with effectively and to the satisfaction of those involved. In a comment card received prior to the site visit a resident confirmed that ‘I complain to the staff’, residents spoken with said that if they had any worries or problems they would speak with the manager. No issues or concerns were raised to the inspector during this site visit. The Gloucester DS0000061774.V337988.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 25, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a Home that is safe and the quality of furnishings are of a high standard and suitable for the needs of residents. EVIDENCE: The Gloucester is located in Filton on the main A38 road, which leads directly to Bristol City Centre, within walking distance to the home there are three churches, a community centre, a library and pubs and shops. The home is situated on a main bus route and is within a short distance of the M4 and M5 motorways. The home is well maintained and has a homely feel; there is a pleasant dining room and two comfortable lounges for residents use, there is also a decked area and pleasant garden for residents to enjoy at the rear of the house. The Gloucester DS0000061774.V337988.R01.S.doc Version 5.2 Page 18 There were a number of requirements made at the last site visit undertaken to the home and these are outlined below: • • • • • Carpet in identified room to be replaced. Attention must be given to repair or replace the kitchen floor. 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. A review of all of these areas found that the requirements had been met, the carpet had been replaced, the kitchen flooring had been repaired, the bedroom and bathroom had been redecorated and the doors in the landing areas of the house has been painted and finished off. It was obvious that there has been some investment into the fabric of this home, the front lounge has just been redecorated and on the day of this visit a painter was on site decorating the dining area, he further confirmed that he would be shortly commencing work on the stairs and landing areas. The manager and handyperson also said that all of these areas would be recarpeted when the work had been finished. Both residents and visitors to the home said that they were ‘most impressed’ with the décor and ‘our home looks so much brighter and fresher now’. The home shows a good standard of housekeeping and no offensive odours are apparent. The kitchen was seen to be clean and tidy and well organised, the home is to be commended for obtaining four stars in a food hygiene award issued by South Gloucestershire Council Environmental Health services in January 2007. It was noted that the kitchen door was being wedged open, this is a dangerous practice and must stop, is it required that fire detector self closure to be fitted to the kitchen door. Some discussion took place with the manger about proposals for the future with the environment, this may include moving the office to the garage and moving the laundry area, it has been required that the home must notify the Commission any proposals for change of use within the environment and include the impact that this could have for residents and how this will be overcome or minimised. Bathroom and toilet facilities are available for residents use on all floors of the home. The Gloucester DS0000061774.V337988.R01.S.doc Version 5.2 Page 19 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, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had sufficient staff on duty and staff are qualified to provide good level of care. Residents have confidence in the staff that care for them. All staff are clear regarding their role in what is expected of them. Recruitment practices safeguard the residents. EVIDENCE: The inspector arrived at the home just after eight in the morning, there were two care assistants, a senior care a cook and the gardener/handyperson on duty, the registered manager arrived at the home at nine. Duty rotas for the past month were reviewed these found that there are consistently the required numbers of staff needed in line with the needs of the residents. It was found that cover between eight and nine in the morning was not clear on the rota, the manager said that she would rectify this. A requirement was made at the last site visit that was undertaken in October 2006 was that the manager should ensure that the home’s induction-training matches National Skills for Care standards in order to ensure that residents benefit from consistent and good safe working practices. This had been outstanding since May 2005. A review of three of the most recently appointed staff members confirmed that their induction was in line with the National Skills for Care standards. A staff member told the inspector about their The Gloucester DS0000061774.V337988.R01.S.doc Version 5.2 Page 20 induction and showed her their portfolio, the information within this file showed that the induction is produced in a format similar to National Vocational model it outlines the support and areas to be covered within a six month period and covers areas such as supervision, health and safety, adult protection and personal development and identification of training needs. Another staff member spoken with confirmed that they had received fire safety instruction on their first day and had been given essential information in order to support residents and to work in a safe way. Another requirement, which was made at the site visit undertaken in October 2006, was that care staff must receive formal recorded supervision. Supervision notes seen in staff files evidenced that staff members were being well supported and were being given clear guidance and instruction from the manager in order to achieve their full potential and furthermore had been given clear information about the expectations of their role and the support they can receive from management and their peers. It was recommended that the home develop a supervision proforma in order that sessions are structured and of a consistent approach. A review of staff files at the last site visit found that not all staff had full employment documents in place and a requirement was made that all staff must have a statement of their terms and conditions of employment. The recruitment and selection documents for three recently appointed staff members were reviewed at this site visit; these staff files evidenced that full and robust practices are adhered to at the home to ensure that those appointed have the qualities and skills to work within this care environment. Appropriate adult protection checks are taken to ensure the protection and safety of residents. A review of staff files and the homes training matrix showed that staff have undertaken training in core areas such as protection of vulnerable adults, first aid, fire safety, medication competency and basic food hygiene. It was noted that four staff members had not received any training in manual handling and furthermore that there were a number of staff who had been training in 2005. In order that residents can be assured that staff have the knowledge and skill and are able to perform their duties in a safe manner it is required that the four staff identified receive manual handling and those who require it must also undertake annual refresher training in this area. Comments received in written feedback from residents who live at the home prior to the site visit included; ‘The care assistants really do care and try and see things from our point of view’. Staff spoken with stated they felt supported and confirmed that the manager operated an ‘open door’ policy that is they felt able to approach her with any queries The Gloucester DS0000061774.V337988.R01.S.doc Version 5.2 Page 21 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, 32, 33, 35, 36, 37, 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Home benefits from good leadership and management, this would be improved if the manager had an appropriate qualification which is in line with the requirements of the post. The practices within the home have offered protection to the health and safety of residents. The home is run in the best interests of the service users. The home is well managed ensuring that individual’s interests and rights are promoted and protected by a knowledgeable and committed staff team. The Gloucester DS0000061774.V337988.R01.S.doc Version 5.2 Page 22 EVIDENCE: The Manager of the home is Karen Headington; Karen has undergone a ‘fit persons’ interview with the Commission and is registered. Prior to taking up the manager’s post Karen was the deputy manager and has extensive experience within the care field, however she does not hold a management qualification and this is a necessity for this role. It is required that the manager must register to undertake a National Vocational Qualification at Level 4 in management. The Registered manager, the deputy manager and their team were positive and motivated throughout the inspection process. There was evidence that the manager and her team were committed to maintaining good levels service provided at The Gloucester and also to improving services. Comments received from relatives of individuals who live at the home had recorded: ‘The manager Karen is always willing to talk over any queries we may have’, ‘ The home treats my relative with courtesy and a pleasant attitude’ ‘This home runs extremely well and I am quite happy with the way they run it’, ‘There has been a vast improvement over the past 18 months, my relative is very happy at the home and enjoys the interaction with staff members’ There was evidence that the home ensures so far as is reasonably practicable. the health and safety of resident’s staff and visitors. The home has robust policies and procedures in relation to aspect of health and safety. The fire logbook was viewed and was well maintained. The home was completing the appropriate checks on the fire equipments and recording of training and testing of equipments were satisfactory. Staff have attended fire drills to ensure that they have clear knowledge of action to be taken in the event of fire emergency The home notified the Commission of an incident in which a staff member, following an investigation, has been subsequently dismissed. The home responded promptly and appropriately to the incident in order to ensure the safety of residents, it is required that the home forward to the Commission formal notification of the outcomes of the staff investigation. Accident reports were viewed during the inspection, information crossed referenced with care records and were well written. The home displays a current certificate of Employer’s Liability Insurance. Staff spoken with confirmed that they felt supported and able to approach the manager and the registered providers should they wish to discuss day-to-day running of the home. One staff member said ‘It’s really nice here. I like working here’. The Gloucester DS0000061774.V337988.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 3 2 3 The Gloucester DS0000061774.V337988.R01.S.doc Version 5.2 Page 24 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 OP30 Regulation 13(5) Requirement All staff must receive manual handling instruction and those identified must receive an annual update. The manager must register to undertake a National Vocational Qualification at Level 4 in management. A fire detector self closure to be fitted to the kitchen door. The home must notify the Commission any proposals for change of use within the environment and include the impact that this could have for residents. Medication must be stored securely. The home must forward formal notification of the outcomes of a staff investigation. Timescale for action 24/12/07 2. OP31 9 (2) b 24/11/07 3. 4. OP19 OP19 23(4) 37 24/08/07 24/10/07 5. 6. OP9 OP37 37(g) 13(2) 24/07/07 24/08/07 The Gloucester DS0000061774.V337988.R01.S.doc Version 5.2 Page 25 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 OP32 Good Practice Recommendations The home to develop a supervision pro forma for consistent formal recording of these meetings. The Gloucester DS0000061774.V337988.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!