Care Home: Gailey Lodge

What the care home does well The premises are clean, warm, well lit and comfortable. People using the service said that staff are kind, patient and provide them with good care. People said that they are supported to be independent. The manager and provider demonstrated a strong committment to making sure that the service provided at Gailey Lodge continues to improve. They work well with the Commission and took immediate action to address some of the concerns identified within this report. What has improved since the last inspection? Since the last inspection, the following requirements have been complied with: all staff have updated their medication training; staffs` competency to administer medication has been assessed; the arrangements for handling medication have improved. Improvements have been made to the premises. For example, the provider has replaced the lift. New flooring, armchairs and televisions have been provided in communal areas. New equipment has been purchased for the kitchen, including a cooker, fridge and microwaves. Some bedroom furniture has been replaced and additional office equipment has been purchased. The quality of food provided, and the choices available to people, have improved following a decision to use alternative suppliers. The systems for managing people`s money and financial affairs have improved. What the care home could do better: People`s care plans and risk assessments need to be improved. This will help to make sure that staff are clear about how to meet people`s needs. Improve safeguarding arrangements within the home. This will help to make sure that staff are clear about how to keep people safe. Continue to make improvements to the premises. This will help to make sure that people are able to benefit from living in a home which is well maintained. Make sure that robust pre-employment checks are carried out and staff records contain evidence of the training they have completed. Make sure that all staff training is up to date. This will help to make sure that only suitable people with appropriate training are employed within the home. Make sure that the home`s fire risk assessment is available at all times and fire safety checks are carried out on a regular basis. This will help to demonstrate that there are appropriate arrangements for protecting people in the event of a fire. Ensure that an effective quality assurance system is in place. This will help to make sure that the home is run in the best interests of the people living there. Devise an annual development plan which clearly sets out what improvements will be made to the home, who these will be carried out by and within what timescales. Key inspection report Care homes for adults (18-65 years) Name: Address: Gailey Lodge 32-33 Victoria Avenue Whitley Bay Tyne & Wear NE26 2AZ     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Elizabeth Gaffney     Date: 2 5 0 3 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 33 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 33 Information about the care home Name of care home: Address: Gailey Lodge 32-33 Victoria Avenue Whitley Bay Tyne & Wear NE26 2AZ 01912970890 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): gaileylodgeltd@aol.com Gailey Lodge Limited Name of registered manager (if applicable) Brigette Stephenson Type of registration: Number of places registered: care home 19 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 physical disability Additional conditions: The maximum number of service users who can be accommodated is: 19 The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Physical disability Code PD, maximum number of places: 19 Date of last inspection Brief description of the care home Gailey Lodge provides personal care accommodation for up to 19 service users mainly with physical disabilities. The building is a large converted Victorian house. The home is located in a busy area of Whitley Bay, within walking distance of the local shops, library, post office churches and leisure facilities. The beach is also a short walk from the home. There is easy access to the town centre and public transport routes. All the bedrooms are single and seven rooms have en-suite facilities. There are two lounge areas and a separate dining room. Service users also have access to a small kitchen Care Homes for Adults (18-65 years) Page 4 of 33 Over 65 0 19 1 7 1 2 2 0 0 9 Brief description of the care home area where they can prepare snacks and drinks. Fees for the home start at 440.00 pounds per week plus an extra 1.5 per cent inflation uplift. Copies of inspection reports are available in the reception area. Care Homes for Adults (18-65 years) Page 5 of 33 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: We have reviewed our practice when making requirements to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations - but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. Before the visit we looked at: * Information we have received since the last key inspection visit carried out on the 11 May 2009; * How the service dealt with any complaints and concerns since the last visit; * Any changes to how the home is run; Care Homes for Adults (18-65 years) Page 6 of 33 * The views of people who use the service, staff and other professionals. An unannounced visit was made on 04 April 2010. During the visit we: * Talked with people who use the service, some of the staff, the manager and provider; * Looked at information about the people who use the service and how well their needs are met; * Looked at other records which must be kept; * Checked that staff have the knowledge, skills and training to meet the needs of the people they care for; * Looked around the building to make sure it was clean, safe and comfortable; * Checked what improvements have been made since the last visit. Care Homes for Adults (18-65 years) Page 7 of 33 What the care home does well: What has improved since the last inspection? What they could do better: Peoples care plans and risk assessments need to be improved. This will help to make sure that staff are clear about how to meet peoples needs. Improve safeguarding arrangements within the home. This will help to make sure that staff are clear about how to keep people safe. Continue to make improvements to the premises. This will help to make sure that people are able to benefit from living in a home which is well maintained. Make sure that robust pre-employment checks are carried out and staff records contain evidence of the training they have completed. Make sure that all staff training is up to date. This will help to make sure that only suitable people with appropriate training are employed within the home. Make sure that the homes fire risk assessment is available at all times and fire safety checks are carried out on a regular basis. This will help to demonstrate that there are appropriate arrangements for protecting people in the event of a fire. Ensure that an effective quality assurance system is in place. This will help to make sure that the home is run in the best interests of the people living there. Devise an annual development plan which clearly sets out what improvements will be made to the home, who these will be carried out by and within what timescales. Care Homes for Adults (18-65 years) Page 8 of 33 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 33 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 33 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The arrangements for assessing peoples needs before they are admitted into the home are good. This means that people can be confident that staff will know how to meet their needs when they move into Gailey Lodge. Evidence: Admissions into the home do not take place until an assessment of peoples needs has been undertaken. The homes manager obtains a copy of any assessment and care plan produced by social services and healthcare professionals. Experienced and qualified staff carry out the homes own in-house pre-admission assessment. Care Homes for Adults (18-65 years) Page 11 of 33 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive personal support which meets their individual needs. However, peoples support plans and risk assessments are confusing and unclear. Because of this, people may not receive good quality care delivered by staff who are clear about how to meet their needs. Evidence: An assessment of each persons needs has been completed and individualised action plans have been put in place. Six monthly reviews as well as an annual placement review are carried out. People spoke highly of the staff that support them and said that their needs are well met. However, some peoples action plans do not contain a clear description of their needs, a statement of desired outcomes or a detailed plan of intervention for staff to follow. People have not signed their action plans to confirm that they have read and understood them. Action plans and risk assessments are not available in easy to read versions. Some peoples actions plan contain unsuitable guidance about how staff should meet their needs. Peoples action plans are not always updated to reflect changes in their needs. Care Homes for Adults (18-65 years) Page 12 of 33 Evidence: Although staff complete risk assessments for each person covering such areas as bathing and accessing the community, they do not always clearly identify current risks or provide a detailed management plan for staff to follow. The registered manager has recognised that peoples support plans and risk assessments require further work and is already taking steps to improve them. Peoples care records do not contain recorded evidence that their capacity to make decisions affecting their daily lives has been assessed using a recognised tool. This may lead to staff being unclear about how people wish their needs to be met. Care Homes for Adults (18-65 years) Page 13 of 33 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The arrangements for supporting people to participate in their local community, maintain important personal relationships and take a good diet, are satisfactory. This helps people to live fulfilling and stimulating lives. Evidence: Staff support people to develop and maintain independent living skills. An assessment of each persons home life and daily living skills has been carried out. People are supported to do their laundry, look after their bedroom, make use of the homes small kitchen area and access local community facilities. People said that they receive the right level of support to occupy their time both within and outside of the home. However, action plans identifying the level of support that each person requires to develop their independent living skills lack detail and specific guidance for staff to follow. Care Homes for Adults (18-65 years) Page 14 of 33 Evidence: People who use the service have the opportunity to develop and maintain important personal and family relationships. Visitors to the home are made to feel welcome and can meet with their relative in private if desired. An assessment of the support that people require with maintaining important relationships has been carried out. Action plans providing staff with guidance on how to support people in this area have not been completed. People are able to easily access menu information. This means that people are able to make choices about what they want to eat. People said that the quality of food served at the home is satisfactory but can vary depending on who is cooking. People said that they would like more choice about what they eat, but confirmed that they always receive enough to eat and drink. People are able to use the small kitchen area to make drinks and snacks. The dining room is a pleasant area and staff were observed taking their lunch with people who use the service. The atmosphere was warm and welcoming. However, a number of concerns were identified. There are food stains on the dining room walls and a small area on one wall needs re-plastering. Some of the dining chairs are unclean and the radiator guard in the dining room is not attached to the wall. Care Homes for Adults (18-65 years) Page 15 of 33 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive the personal and healthcare support they need and the systems for handling and managing medication have improved. However, peoples healthcare support plans, and their daily medication records, need to be further improved and developed. Evidence: People said that staff make sure that their personal and healthcare support needs are met. People said that they are supported to access medical, optical and dental services as and when needed. Each persons life plan assessment contains details of their past medical history as well as information about their current physical and healthcare needs. Support plans have been devised to help make sure that peoples healthcare needs are met. However, annual reviews of peoples action plans contain limited information about how their healthcare needs have been addressed during the previous 12 months. Also, peoples care records contain limited information about their preferences concerning how they want their personal and healthcare needs to be met. Some healthcare plans are generic and have not been devised specifically to meet each persons individual needs and preferences. Care Homes for Adults (18-65 years) Page 16 of 33 Evidence: Staff demonstrated that they are able to meet peoples need for personal support in a person centred manner. People said that staff are flexible, considerate and respect their privacy and dignity. One person said that although staff are often busy, they always have time for you, especially the manager. This person also said that they are supported to be an independent as possible. Improvements have been made to the arrangements for handling medication. The medication room has been re-located to provide easier access and is currently being refurbished. Improvements have been made to the systems for recording the receipt and administration of medicines. However, there are still occasional gaps in peoples medication administration records. Advice has been sought from the local primary care trust about how the home can improve its systems for managing medication and further training is due to be provided in May 2010. The manager has obtained up to date professional guidance on handling medicines. Prescriptions are now delivered to the home which enables staff to check that the right medicines are received into Gailey Lodge. Staff who administer medication have received guidance on how to administer controlled drugs safely. A lockable medicines fridge has been purchased to make sure that medicines requiring cold storage can be stored at the correct temperature. Care Homes for Adults (18-65 years) Page 17 of 33 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager now makes sure appropriate professionals are informed of any safeguarding concerns. However, some staff have not received appropriate training in safeguarding peoples welfare. Also, the homes safeguarding policies and procedures are not up to date. Because of this staff may not take appropriate action to keep people safe. Evidence: There is a complaints procedure to help people to understand how any concerns they might have will be handled. People said that they have been told how to make a complaint. The home and the Commission have been notified of one complaint since the last inspection concerning children being on the premises without adequate supervision and the conduct of staff. Some professionals who visit the home have raised similar concerns. The provider is currently carrying out an investigation regarding this matter. The home has an adult protection policy and procedures to help make sure that staff are clear about how to safeguard the people living at Gailey Lodge. However, these have not been updated to reflect recent changes in safeguarding legislation. Other policies and procedures are being reviewed to protect peoples safety and well-being. Staff have access to a copy of the local authoritys safeguarding protocols. Some of the professionals who have contact with the home have expressed concerns Care Homes for Adults (18-65 years) Page 18 of 33 Evidence: about some staffs awareness of how to keep people safe. Some of the care staff have not completed local authority safeguarding training. Also, the manager has not completed advanced safeguarding training. There have been three safeguarding referrals since the last inspection of the service. These have been handled under the local authoritys safeguarding procedures. Where concerns are identified, the provider takes immediate action to keep people safe from harm. The provider and his manager respond positively to any recommendations made and review the homes practice accordingly. The manager is very good at making sure that the Care Quality Commission is made aware of any concerns arising within the home. Care Homes for Adults (18-65 years) Page 19 of 33 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples quality of life has improved as a result of improvements made to the premises. But, the arrangements for maintaining the premises are not fully satisfactory. This means that people are not able to benefit from living in a home which is safe and well maintained. Evidence: The home is located within the community of Whitley Bay and is in keeping with other properties in the area. The home offers people easy access to local community facilities. Staff make sure that the home is clean, warm, well lit and odour free. It is comfortable and provides a domestic atmosphere. People are supported to personalise their bedrooms and keep them clean. Although not purpose built, the design, layout and security of the premises are suitable for meeting the needs of people with physical disabilities. A new lift has been installed and was being commissioned at the time of the inspection. Records show that the manager and provider worked in conjunction with other professionals to ensure that peoples needs could be safely met during the lift installation. People have access to aids which help to promote their independence. For example, the home has adapted baths which are easier for people with physical disabilities to Care Homes for Adults (18-65 years) Page 20 of 33 Evidence: use. Grab rails are fitted in toilets and bathrooms. The home has a small kitchen area which is used to promote peoples independent living skills. A stair lift was installed to move people between floors whilst the new lift was being fitted. The homes laundry was clean and tidy and looked well organised. People said that they are happy with the service they receive. All equipment was in good working order. However, potentially hazardous materials had been left unsecured. The manager confirmed that the Department of Health infection control self-assessment checklist has not been completed. Some staff have not received infection control training. The provider employs a full time maintenance worker who is responsible for maintaining the building and making repairs. Staff reported that it is difficult to maintain a good standard of decoration and paintwork throughout the building due to damage caused by peoples electric wheelchairs. Concerns about the condition of the building were identified. For example, a wall in the laundry has not been redecorated following building works and the corridors are in a poor decorative condition. There is water damage to the ceiling in the top floor toilet. The manager produced a list of maintenance work to be carried out in March 2010 which covered most of the above concerns. Care Homes for Adults (18-65 years) Page 21 of 33 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The arrangements for recruiting and appointing staff are inadequate. Because of this, people living at the home cannot be confident that the home has carried out appropriate checks to make sure that all staff are suitable. Evidence: Staff are receiving regular supervision and there is recorded evidence of this. Annual appraisals of staffs performance also take place. Arrangements are in place to provide staff with an in-house induction which covers the Skills for Care induction and foundation standards. However, none of the completion statements have been signed to confirm that the training has been successfully completed. Over 50 per cent of the care team have completed a National Vocational Qualification at Level 2 or above. Arrangements are in place to update staffs mandatory training and make sure that new staff receive the training they need to do the job. However, some staff files do not contain documentary evidence that they have completed their mandatory training. Some staffs moving and handling training was out of date. A training and development plan has not been completed for each member of staff. There is no recorded evidence of an overall training plan for the staff team. Staff who returned surveys said that they receive training that is relevant to their role, helps them to understand and meet peoples individual needs, and keeps them up to date Care Homes for Adults (18-65 years) Page 22 of 33 Evidence: with new ways of working. There is documentary evidence that staff have completed some training related to the special needs of people using the service. However, none of the staff have completed training in using physical intervention, person centred planning, the Mental Capacity Act and Deprivation of Liberty Regulations. Also, the home does not have policies and procedures which provide staff with clear guidance about how to implement this legislation. There is evidence in staffs individual files that they have provided written statements regarding their physical and mental health, and whether they have any convictions or cautions. Applicants are required to complete an application form and a Criminal Records Certificate is obtained for each person. However, other aspects of the homes recruitment and selection processes are inadequate. Two written references have not always been obtained for each member of staff. There is no recorded evidence that new staff who commence work with a PoVA First certificate, but without a Criminal Records Certificate, are being properly supervised. Criminal Records Certificates are not being stored in line with guidance issued by the Criminal Records Bureau. There are no records available to confirm that appropriate discussions have been held where applicants for posts disclose that they have a conviction or caution. Records are not being kept of the outcome of selection interviews. Some staff have not supplied a sufficiently detailed employment history. Staff files do not always contain an identification photograph or evidence that their identity has been verified. Care Homes for Adults (18-65 years) Page 23 of 33 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The arrangements for promoting peoples health and safety, and for monitoring the quality of care and facilities provided at the home, are not fully satisfactory. This may mean that the service is not being run in the best interests of the people living there. Evidence: The manager is a qualified social worker and has the experience needed to manage the home. However, she has not yet completed the Leadership and Management Award. Although Mrs Stephenson has completed the required mandatory training, this is not up to date in some areas. Also, documentary evidence of all the training completed by Mrs Stephenson is not available. The arrangements for handling peoples money are satisfactory. The majority of people using the service do not manage their own money. Peoples care records contain financial care plans. However, these are limited and do not provide staff with clear guidance on how to meet peoples needs in this area. Records are kept which show how the home manages peoples money. These are well maintained. The amount of money held on peoples behalf matches the balances detailed on their financial Care Homes for Adults (18-65 years) Page 24 of 33 Evidence: record sheets. Records showed evidence of regular audit. People said that they are satisfied with the way that the home manages their money. People have access to a lockable facility within their bedrooms where they can safely store their money. The home does not have an effective quality assurance system. The provider is not carrying out unannounced visits to monitor the performance of the service. As a consequence, shortfalls in practice are not being promptly identified and addressed. There is evidence that some management audits are carried out. However, these do not cover all areas of the homes day to day performance. The home does not have an annual development plan. Although Mrs Stephenson is aware that improvements need to be made at Gailey Lodge, there is no recorded action plan which states what her priorities are or how any objectives will be achieved. Mrs Stephenson reported that she is in the process of developing a quality audit system and was able to provide evidence of this. Action is taken to promote peoples health and safety. During the last 12 months, safety checks of the homes electrical equipment, gas boilers and fire fighting equipment have been completed. The provider and manager took action to make sure that peoples needs could be properly and safely met whilst work was underway to install a new lift. However, a number of concerns were also identified: although the manager reported that the home has an up to date fire risk assessment, she was unable to locate this document; records of in-house fire instruction and fire drills are inadequate; concerns about the arrangements for managing smoking were identified. The fan in the smoking room was not working effectively and because the automatic closer on the door to this room is broken, smoke was escaping into the corridor; peoples moving and handling risk assessments are inadequate. For example, the assessments do not provide clear guidance about how to carry out moving and handling tasks. Also, one persons moving and handling plan has not been updated to reflect a change in their support needs. Care Homes for Adults (18-65 years) Page 25 of 33 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 26 of 33 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 6 15 Make sure that peoples support plans contain: a clear description of their needs; statements of desired outcomes and a clear plan of intervention. Peoples support plans must be updated to reflect changes in their needs. This will help to make sure that staff are clear about how to meet peoples needs. 30/09/2010 2 24 16 Make sure that: * The laundry walls are covered with an easy clean surface; * The ground floor toilet is re-decorated and the grab rail repainted. The fan should be cleaned and the ceiling and toilet plinth repainted; * The radiator guard is 30/09/2010 Care Homes for Adults (18-65 years) Page 27 of 33 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action securely attached to the wall; * The homes maintenance programme provides for regular re-decoration of bedroom and corridor areas; * All beds are of a good standard; * All radiator guards are kept clean. This means that people can be confident that the building is well maintained and meets their needs. 3 24 13 Make sure that potentially dangerous materials are kept locked away at all times. This will help to promote peoples health and well being. 4 34 19 Ensure that: * A full 03/05/2010 employment history and two written references are obtained for each member of staff; * Each staff members identity has been verified; * Each persons staff file 26/04/2010 Care Homes for Adults (18-65 years) Page 28 of 33 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action contains an identity photograph. This will help to demonstrate that only suitable staff are employed to work in the home 5 34 19 Make sure that appropriate 03/05/2010 supervisory arrangements are put in place for new staff who commence working at the home with a clear PoVA First, but pending receipt of a Criminal Record Certificate. This will help to ensure that only suitable staff are employed at the home. 6 35 19 Ensure that staff complete the required mandatory training. This will help to ensure that staff are able to meet peoples needs in a safe and competent manner. 7 35 19 Ensure that staff files contain documentary evidence of any mandatory training they have completed. This will help to ensure that staff are able to meet peoples needs in a safe and competent manner. 03/05/2010 03/05/2010 Care Homes for Adults (18-65 years) Page 29 of 33 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 8 39 24 Introduce an effective 30/09/2010 quality assurance system to monitor the performance of the home against the National Minimum Standards and Care Home Regulations. This will help people to feel confident that the service is being run in their best interests. 9 39 26 The provider must arrange for monthly unannounced monitoring visits to be carried out which take account of the views of people using the service. A written record must be kept and forwarded to the Care Quality Commission each month. This will help people to feel confident that the service is being run in their best interests. 03/05/2010 10 41 17 Make sure that statutory records are available for inspection purposes at all times. This will help to demonstrate that robust record keeping is in place to protect peoples health and well being. 03/05/2010 11 42 23 Repair the smoking room door closer. 23/04/2010 Care Homes for Adults (18-65 years) Page 30 of 33 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This will help to protect peoples health and wellbeing. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 2 6 6 Carry out an assessment of peoples capacity to make key decisions using a recognised tool. Make sure that peoples risk assessments clearly identify current risks as well as the steps that staff must take to keep them safe. Provide evidence that people have been provided with an opportunity to read and sign their support plans. Peoples support plans should be available in an easy to read version where appropriate. Peoples support plans should: * Provide staff with guidance on how to help people maintain important relationships with family members and friends; * Include clear and detailed guidance on how staff should be supporting people to develop and maintain independent living skills. 3 6 4 12 5 19 Make sure that peoples healthcare support plans clearly identify their preferences in terms of how they want their needs to be met. Make sure that staff complete peoples medication administration records immediately following the administration of their medication. Make sure that the home has a clear policy setting out the circumstances in which children will be allowed to visit the premises. Where appropriate, risk assessments should be 6 20 7 23 Care Homes for Adults (18-65 years) Page 31 of 33 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations carried out to keep people using the service safe. 8 23 Make arrangements for the manager to complete advanced safeguarding training. Ensure that all staff complete basic safeguarding awareness training. Ensure that the homes safeguarding policy and procedures are updated to reflect changes in relevant legislation. Complete the Department of Health self-assessment infection control checklist and devise an action plan. Prepare an individual training and development plan for each member of staff. Devise an overall training plan which identifies what training staff have received and when this next needs updating. Devise an annual development plan which clearly sets out what improvements will be made to the home and within what timescales. Devise an action plan which clearly sets out the managers priorities, how these are to be achieved and within what timescales. Provide people with an opportunity to complete satisfaction surveys. Complete robust moving and handling risk assessments using a recognised format. Consider providing an alternative fan in the smoking room. Make sure that fire doors are not propped open unless this has been agreed with the local fire service. Make sure that clear records are kept which show when each member of staff participates in a fire drill or receives fire instruction. 9 10 11 23 30 32 12 39 13 39 14 15 16 17 18 39 42 42 42 42 Care Homes for Adults (18-65 years) Page 32 of 33 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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