Care Home: Gibsons Lodge

What the care home does well At this and at the last inspection, staff who work in the home were welcoming to visitors. The minimum standards require at least 50% of care staff to have a NVQ2. At this home this has been exceeded with all care staff having a NVQ2 and some are also doing a NVQ3 or NVQ4. This creates a well qualified staff group. There has been a lot of investment recently in improving the environment for the residents and further improvements are occurring. See the section `what has improved since the last inspection` for details. What has improved since the last inspection? There has been a lot of investment recently in improving the environment for the residents and further improvements are occurring. The communal lounges have been recarpeted and redecorated, bedrooms have been redecorated and the residents` choice of colour and furniture has been implemented. All the hallways have been {or are being} fitted with new carpet. Art work has been displayed on the walls in communal areas to make the home more homely. There are service user guides in all rooms. There is a new clinical room to better organise medication. There is a new orientation board with the date, day, meals and events on it to help people who need this orientate themselves better. Newspapers and magazines are now available in the lounges. There is a new walk in shower to help the residents be more independent with personal care, and staff photographs are displayed to help residents identify staff more easily. Details on people`s life history has been reviewed and updated to make sure that they are treated and respected as individuals. Care plans now evidence the involvement of the person or their representative and are reviewed regularly. This will make sure that all needs are identified. Care plans now detail how to intervene when a person`s behaviour is challenging. This will help protect the residents. There is now a clear record of medications received into the home. This makes sure that medicines are easily audited. The Statement of Purpose and Service User Guide are spell and grammar checked. This should make them easier to read. Staff have ascertained what is to be done in the event of a person`s death if there is no next of kin. This will ensure a resident`s wishes in this area are known and implemented. Ventilator fans are now cleaned on a routine basis and high dusting is undertaken routinely. This supports effective infection control. Toiletries that are kept for individual use are now returned to the person`s room after use. This supports effective infection control and dignity. What the care home could do better: General social, cultural, and religious needs, and cultural and religious dietary needs need be recorded in care plans. This is needed so that these needs can be well known by staff and therefore acted apon. The outcome for all reviews should be recorded, even when there is no change. This will improve monitoring, as the manager can then tell the difference between a review not occurring and where there has been a review but no change in needs. Care plans and daily records should use appropriate language, so as to protect the dignity of people who live in the home. {For example, where a person has a religious need, changing the word `problem` to `need` in care plans would provide more dignity as it shouldn`t be recorded as a `problem` if someone wants to go to church.} The restraints policy must cover physical restraint and include recording procedures. This is needed to ensure staff are clear about only restraining a resident as a last resort to protect them or other residents, and ensure that staff know safe restraint practices. Information on a person`s sexuality should be incorporated into the care plan when staff have receive training on how to approach this subject. This will ensure that these needs are known. The suspected asbestos in the ground floor cupboard must be professionally assessed for the level of risk and appropriate action taken. This is needed to protect residents` and staff`s health. A resident`s specific nursing guidelines should not be displayed in the resident`s bedroom on wardrobe doors. This does not promote privacy and dignity. An induction within the first six weeks followed by foundation training within the first six months must be completed for all new staff and this must be to National Training Organisation specifications and targets. This is needed to ensure a well inducted staff team. An annual development plan should be created to record the results of the quality assurance system and provide a document that will allow residents to measure improvements in quality for themselves. CARE HOMES FOR OLDER PEOPLE Gibsons Lodge Gibson`s Lodge Nursing Home Gibson`s Hill London SW16 3ES Lead Inspector Barry Khabbazi Key Unannounced Inspection 09:00 21st July 2008 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 Gibsons Lodge DS0000019026.V367532.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. Gibsons Lodge DS0000019026.V367532.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gibsons Lodge Address Gibson`s Lodge Nursing Home Gibson`s Hill London SW16 3ES 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) 020 8670 4098 020 8670 4261 primecare@hotmail.co.uk Gibson`s Lodge Limited A new manager is applying to be registered. Care Home 46 Category(ies) of Dementia - over 65 years of age (14), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (8), Old age, not falling within any other category (24) Gibsons Lodge DS0000019026.V367532.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A maximum of 14 service users in the DE(E) category. Six specified service users in the Dementia - over 65 (DE(E)) category who are in excess of the 14 DE(E) service users that the home is registered for may reside at the home. As and when any of these service users are no longer in receipt of services from this home, the places will revert back to the Old age (OP) category. Six specified service users in the Dementia - over 65 (DE(E)) category who are in excess of the 14 DE(E) service users that the home is registered for OP service users, including the six specified service users referred to in condition no. 2. In order to cater for the needs of the service users, staffing levels must be maintained at the following levels: One of the qualified staff on each shift must be RMN qualified. The number of carers on each shift must be increased by one, thereby giving seven carers on each day shift and four on duty overnight. 17th January 2008 3. 4. Date of last inspection Brief Description of the Service: Gibson Lodge is a 46-bed care home with nursing set in a quiet residential area, yet well placed for access to local transport links. The home caters for up to 14 elderly residents with dementia, and 32 elderly infirm clients. Accommodation is provided in a mix of single and double rooms. There are several communal areas, and a very attractive, large garden. The stated aim of the home is to provide the residents with a secure, relaxed and homely environment in which their care, well-being and comfort are of prime importance. Information about services are detailed in a Service User Guide, which is made available to current and potential Service Users. Additional information can be found in the Statement of Purpose. The current weekly fees (as provided at the time of this inspection) range from £524 - £750. Gibsons Lodge DS0000019026.V367532.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The overall quality rating of the service is 2 star. This means the people who use this service generally experience good outcomes. This inspection was unannounced. At this inspection the new manager was interviewed and policies, care plans, and the building were also examined. We spoke to people who use the service who called themselves ‘residents’. Comments from the residents on this occasion included: ‘they make sure I’m Ok here’, ‘the food’s not bad’, and ‘ I like her’ {pointing to the new manager}. All the key Standards identified throughout this report were re-assessed at this inspection. This inspection also focussed on following up on previous requirements and recommendations, and any new issues arising. Due to the gap between the registered manager leaving and a new manager starting, the manager’s self assessment {AQAA} was not available at the time of this inspection to support this report. By the time of this inspection, all previous actions required by us had been implemented and there had been a significant improvement in the environment. Please see the section ‘ what has improved since the last inspection’ for details. What the service does well: At this and at the last inspection, staff who work in the home were welcoming to visitors. The minimum standards require at least 50 of care staff to have a NVQ2. At this home this has been exceeded with all care staff having a NVQ2 and some are also doing a NVQ3 or NVQ4. This creates a well qualified staff group. There has been a lot of investment recently in improving the environment for the residents and further improvements are occurring. See the section ‘what has improved since the last inspection’ for details. Gibsons Lodge DS0000019026.V367532.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? There has been a lot of investment recently in improving the environment for the residents and further improvements are occurring. The communal lounges have been recarpeted and redecorated, bedrooms have been redecorated and the residents’ choice of colour and furniture has been implemented. All the hallways have been {or are being} fitted with new carpet. Art work has been displayed on the walls in communal areas to make the home more homely. There are service user guides in all rooms. There is a new clinical room to better organise medication. There is a new orientation board with the date, day, meals and events on it to help people who need this orientate themselves better. Newspapers and magazines are now available in the lounges. There is a new walk in shower to help the residents be more independent with personal care, and staff photographs are displayed to help residents identify staff more easily. Details on people’s life history has been reviewed and updated to make sure that they are treated and respected as individuals. Care plans now evidence the involvement of the person or their representative and are reviewed regularly. This will make sure that all needs are identified. Care plans now detail how to intervene when a person’s behaviour is challenging. This will help protect the residents. There is now a clear record of medications received into the home. This makes sure that medicines are easily audited. The Statement of Purpose and Service User Guide are spell and grammar checked. This should make them easier to read. Staff have ascertained what is to be done in the event of a person’s death if there is no next of kin. This will ensure a resident’s wishes in this area are known and implemented. Ventilator fans are now cleaned on a routine basis and high dusting is undertaken routinely. This supports effective infection control. Toiletries that are kept for individual use are now returned to the person’s room after use. This supports effective infection control and dignity. Gibsons Lodge DS0000019026.V367532.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Gibsons Lodge DS0000019026.V367532.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 Gibsons Lodge DS0000019026.V367532.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): Standards 1, 3, and 6: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service User guide do inform people about the details of the service provided. Prospective residents’ needs are assessed before they start at the home to ensure that all needs are known by the staff. This home does not provide intermediate care with a view to return to the community and Standard 6 is therefore not applicable. Gibsons Lodge DS0000019026.V367532.R01.S.doc Version 5.2 Page 10 EVIDENCE: The home does have a Statement of Purpose and Service User guide which does inform people about the details of the service provided. These documents are now also in all residents’ rooms. The last inspection report contained the following recommendation: It is recommended that the Statement of Purpose and Service User Guide are spell and grammar checked. This has now occurred and this recommendation is now met. The files of newly admitted residents were examined and these contained all the required pre-admission assessments. This home does not provide intermediate care with a view to return to the community and Standard 6 is therefore not applicable. Gibsons Lodge DS0000019026.V367532.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): Standards 7, 8, 9, and, 10. People who use this service experience adequate quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. Plans of care record health needs but need to be more holistic and record social care needs to ensure these needs are known and met. Residents are protected by the home’s health monitoring procedures. Residents are protected by the home’s medication procedures. Residents are generally treated with respect and their privacy is maintained although improvements in this area can be made. Gibsons Lodge DS0000019026.V367532.R01.S.doc Version 5.2 Page 12 EVIDENCE: Comments from residents included ‘They make sure I’m Ok here’. The last inspection report contained the following three requirements: 1, Details on people’s life history need to be reviewed and updated to make sure that they are treated and respected as individuals. 2, Care plans must evidence the involvement of the person or their representative and be reviewed regularly. This will make sure that all needs are identified. 3, Care plans detailing how to intervene when a person’s behaviour is challenging, must include specific interventions for staff to use, and whether these interventions have been appropriate. All these three requirements were assessed as met at this inspection. The last inspection report contained the following three recommendations: 1, It is recommended that staff ascertain what is to be done in the event of a person’s death if there is no next of kin. This had occur by the time of this inspection and this recommendation is now met. 2, It is recommended that information on a person’s sexuality is incorporated into the care plan when staff have received training on how to approach this subject. This had not occurred by the time of this inspection and the recommendation therefore remains in place. 3, It is recommended that care plans and daily records use appropriate language, so as to protect the dignity of people who live in the home. Although the care plans had improved in this regard, more consideration of language is needed. For example, where a person has a religious need, changing the word ‘problem’ to ‘need’ in care plans would provide more dignity as it shouldn’t be recorded as a ‘problem’ if someone wants to go to church. This recommendation remains in place. Care plans examined had been much improved but tended to focus on medical and health needs only. For example one resident had cultural food needs that were known to the manager but not recorded in care plans. All a resident’s needs are required to be recorded in care plans and this includes social, cultural, and religious needs. The following new requirement is now set to address this: General social needs, cultural, and religious needs, and cultural and religious dietary needs must be recorded in care plans. Gibsons Lodge DS0000019026.V367532.R01.S.doc Version 5.2 Page 13 Reviews were occurring with the desired frequency but where no change in need was concluded there was no record of the review. This makes it difficult for the manager to fully monitor the occurrence of all reviews. The following recommendation is now set to address this: The outcome for all reviews should be recorded, even when there is no change. The last inspection report contained the following requirement: There must be a clear record of medications received into the home. This will make sure that medicines are easily audited. This had occurred by the time of this inspection and this requirement is now met. Residents are registered with a local GP practice and have access to other NHS facilities as necessary such as a dentist, optician, chiropodist. Other healthcare professionals attend when required. Evidence was seen of regular monitoring of residents’ health. A record of all appointments and check ups are kept. The manager demonstrated knowledge of the health status of individual residents. All staff who administer medication have had approved medication training. Medication profiles and clear medication administration record sheets were seen in records sampled. Medication and the M.A.R sheets are kept. Residents were seen to be treated with respect and personal care was carried out in a manner that promoted the residents’ privacy. Although residents are generally treated with respect and their privacy is maintained, improvements in this area can be made. In some bedrooms the residents’ nursing and care needs were recorded on a piece of paper and stuck to the outside doors of wardrobes. This does not promote dignity and privacy. The following new recommendation is now set to address this: A resident’s specific nursing guidelines should not be displayed in the resident’s bedroom on wardrobe doors. Gibsons Lodge DS0000019026.V367532.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards: 12,13,14,and,15. People who use this service experience good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. Activities in the home are occurring and these are now better linked to the residents’ choices and preferences. Residents are supported in maintaining appropriate relationships, so that their social lives are maximised within chosen boundaries. Residents are supported to exercise choice and control over their lives. The food provided is sufficient in quantity, and choices of food are now better recorded, and support at mealtimes is now more sensitive. EVIDENCE: The routines of daily living and activities are made as flexible as possible, for example there is no set bed time or getting up time. Gibsons Lodge DS0000019026.V367532.R01.S.doc Version 5.2 Page 15 There was an activities list displayed in the hallway, with selection of morning and afternoon activities six days a week Activities included group and open to one activities. Events and birthdays are also celebrated. There is an activities coordinator and care staff will are also involved more in the provision of activities The residents are encouraged to receive visitors at all times and visitors were seen to be made welcome. Community interaction includes the local town centre’s resources and shops. Residents at this service are supported to attend church or other religious venues should they wish to do so. The home is run in a manner that promotes choice and independence and this was confirmed through comments from people who used this service, policies, and observation. Residents can take meals, and particularly snacks, at times and places to suit them and have a choice of meals and alternatives. Residents can bring in their own possessions and furniture if they wish and this was observed in their rooms, which had been individualised. The home menus are based on the likes and dislikes of the people who use this service. These were examined and appeared nutritious and varied. Meals can be taken separately to the main dining room if wanted. Additional drinks and snacks are available at any time. Residents were seen to be offered the choice of soft drinks to have with and after their meal. People were offered a cup of tea when the meal had finished. The mealtime was unhurried and residents were not rushed to finish their meals. Staff provided assistance discretely and sensitively where necessary and all seemed to eat well. One resident said ‘ I like the meals’ and another said ‘ well they’re OK’. The residents also commented positively about the meals at the last inspection. Gibsons Lodge DS0000019026.V367532.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18: People who use this service experience good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. Complaints are managed well which should ensure that concerns are listened to and acted apon. The home’s policies and procedures help protect residents from abuse and help staff if they need to tell someone about any bad care practice they may see. EVIDENCE: The home has not received any complaints since the last inspection. The complaints procedure was clear and contained all the elements required including details of how to contact the Commission. The home has a copy of the local Adult Protection procedure. The home has Gifts Policy that precludes staff from being involved in the making or being the beneficiary of residents wills, a Whistle Blowing Policy, an Abuse Policy and a a restraint policy. The restraints policy however, did not cover physical restraint and include recording procedures. The following requirement is now set to address this : The restraints policy must cover physical restraint and include recording procedures. As it was assessed that this shortfall is currently not having a negative effect on outcomes for the residents, the outcome for the group of standards will remain ‘good’. Gibsons Lodge DS0000019026.V367532.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): Standards: 19, 20, and 26: People who use this service experience good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. The home is in good condition externally and internally, and is now well decorated in a homely fashion and well maintained. This creates a pleasant environment that promotes the dignity and emotional well-being of people who use this service. Residents have safe access to indoor communal areas and work is currently occurring to provide safe access to outdoor communal areas. The home is particularly hygienic and clean, homely and comfortable; this environment therefore promotes a pleasant environment, the residents’ health, and emotional well-being. Gibsons Lodge DS0000019026.V367532.R01.S.doc Version 5.2 Page 18 EVIDENCE: Good practice was identified in improving the environment. There has been a lot of investment recently in improving the environment for the residents and further improvements are occurring. The communal lounges have been recarpeted and redecorated, and bedrooms have been redecorated and the residents choice of colour and furniture has been implemented. All the hallways have been {or are being fitted} with new carpet. Art work has been displayed on the walls in communal areas to make the home more homely, there is a new walk in shower to help the residents be more independent with personal care, and staff photographs are displayed to help residents identify staff more easily. A suspected asbestos product was identified in the ground floor cupboard and shown to the manager and maintenance person. This is not a problem unless it is disturbed and it should therefore be professionally assessed for the level of risk and appropriate action taken. The following requirement is now set to facilitate this: The suspected asbestos in the ground floor cupboard must be professionally assessed for the level of risk and appropriate action taken. Residents have safe access to indoor communal areas and work is currently occurring to provide safe access to outdoor communal areas. The following recommendation is set to support these improvements to access: The home should continue with the current works to the garden path that will ensure better access to all communal areas. The last inspection report contained the following requirement: It is recommended that ventilator fans are cleaned on a routine basis and high dusting is undertaken routinely to make sure there are effective infection control procedures in place. This has now occurred and this recommendation is therefore met. The last inspection report also contained the following requirement: It is recommended that toiletries are kept for individual use and returned to the person’s room after use. This has now occurred and this recommendation is therefore met. At this inspection the home was clean and hygienic. Gibsons Lodge DS0000019026.V367532.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): Standards 27, 28, 29, and 30. People who use this service experience good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. Staff numbers are of sufficient quantity to meet the residents’ needs and provide consistency. People who use this service are supported by a staff group where 50 or more have the required qualifications. Achieving this raises the quality of staff, their knowledge and their practices. {This will need to be re-checked when new placements are made and new staff begin work.} The staff recruitment policies and vetting procedures helps protect the people who use this service from undesirable staff. {This will need to be re-checked when new placements are made and new staff begin work.} Induction and foundation training to National Training Organisation’s specifications is now in place EVIDENCE: Comments from residents included: ‘they make sure I’m ok here’, and ‘I like her’ {pointing to the new manager}. Gibsons Lodge DS0000019026.V367532.R01.S.doc Version 5.2 Page 20 The last inspection report recorded that the duty rota and observation on the days of the site visits indicated that there are adequate numbers of staff to meet needs. This was also the case at this inspection. The minimum standards require at least 50 of care staff to have a NVQ2. At this home this has been exceeded with all care staff having a NVQ2 and some are also doing a NVQ3 or NVQ4. This creates a well qualified staff group. This standard is therefore exceeded. All elements of Schedule 2 {staff files} were available for inspection. Staff recruitment documents were examined for new staff and these included CRB checks, references and proof of identification. No shortfalls were identified in the staff recruitment process. The induction process was examined and it was found that it did not meet the required standard in content and length. The induction process must be to National Training Organisation specifications and targets. The following requirement is now set to address this: An induction within the first six weeks followed by foundation training within the first six months must be completed for all new staff and this must be to National Training Organisation specifications and targets. It is to be noted however that no negative outcomes for the residents were identified at present from this shortfall. The exceeded NVQ numbers and levels are probably currently compensating for the lack of an intensive induction. The general overall rating for this group of standards will therefore remain good. Gibsons Lodge DS0000019026.V367532.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): Standards 31, 33, 35, and 38. People who use this service experience Good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. Residents benefit from a home that is managed by a person with appropriate qualifications and experience. There is a quality assurance system that involves the residents, although an annual development plan needs to be developed to provide feedback to them, and to allow them to be involved in improvements and measure improvements in the home for themselves. Residents’ financial interests are guarded. The home generally promotes the health and safety of the residents, so that practices and the environment do not place their health and safety at risk. Gibsons Lodge DS0000019026.V367532.R01.S.doc Version 5.2 Page 22 EVIDENCE: The current registered manager has the required qualifications, is suitably experienced to manage the home and is currently in the application process to become the registered manager of the home. The manager was seen to treat residents and visitors with respect and understanding and both residents and relatives appeared happy to see her. The manager has also raised standards at this home, particularly with environmental and access improvements. Please see the environment section or the ‘what has improved since the last inspection’ sections of this report for details. There is a quality assurance system that involves the residents, although an annual development plan needs to be developed to provide feedback to them, and to allow them to be involved in improvements and measure improvements in the home for themselves. This could be done by collating all the quality assurance information {from complaints, provider visits and plans, resident questioners, etc} into one document {an annual development plan} this document could then be presented to residents and relatives to inform them of quality plans and allow them to monitor progress by presenting an updated version annually. The following recommendation is now set to address this: An annual development plan should be created and presented to residents and relatives to inform them of quality plans and allow them to monitor progress by presenting an updated version annually. Procedures are in place to protect service users’ money and no anomalies were identified at this or the last inspection. Infection Control, and Handling and Disposal of Clinical Waste policies are all also included in staff induction. All of the health and safety policies and procedures required were seen to be present. Moving and Handling, Fire Safety, First Aid, Food Hygiene, Infection Control, and Handling and Disposal of Clinical Waste policies are all also included in staff induction. The testing of systems required were also present and inspected. These included fire fighting equipment testing, fire warning testing, Portable Appliance Testing, 5-year wiring testing gas testing, and bacterial analysis and testing of the water supply. Gibsons Lodge DS0000019026.V367532.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 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 3 x x x x x 3 STAFFING Standard No Score 27 3 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 x 3 x x 3 Gibsons Lodge DS0000019026.V367532.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 OP7 Regulation 12 (4) (b) Requirement General social, cultural, and religious needs, and cultural and religious dietary needs must be recorded in care plans. The restraints policy must cover physical restraint and include recording procedures. The suspected asbestos in the ground floor cupboard must be professionally assessed for the level of risk and appropriate action taken. An induction within the first six weeks followed by foundation training within the first six months must be completed for all new staff and this must be to National Training Organisation specifications and targets. Timescale for action 30/12/08 2. 3. OP18 OP20 13 (6) (7) (8) 12 13(3) (4) 30/09/08 30/09/08 4. OP30 18(1)c 30/12/08 Gibsons Lodge DS0000019026.V367532.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. 2. Refer to Standard OP7 OP7 Good Practice Recommendations The outcome for all reviews should be recorded, even when there is no change. It is recommended that information on a person’s sexuality is incorporated into the care plan when staff have received training on how to approach this subject. {this recommendation remains from the last inspection} It is recommended that care plans and daily records use appropriate language, so as to protect the dignity of people who live in the home. {For example, where a person has a religious need, changing the word ‘problem’ to ‘need’ in care plans would provide more dignity as it shouldn’t be recorded as a ‘problem’ if someone wants to go to church.} 4. OP10 A resident’s specific nursing guidelines should not be displayed in the resident’s bedroom on wardrobe doors. This does not promote privacy and dignity. The home should continue with the current works to the garden path that will ensure better access to all communal areas. An annual development plan should be created and presented to residents and relatives to inform them of quality plans and allow them to monitor progress by presenting an updated version annually. 3. OP7 5. OP20 6. OP33 Gibsons Lodge DS0000019026.V367532.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. 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