Care Home: Goffs Park Nursing Home

What the care home does well Service users told us and surveys also indicated that they and their relatives feel they are looked after by a caring and friendly staff team. They say they are supported to make decisions about their daily lives and the home is flexible to their needs. The staff team work well together and respect the privacy and dignity of service users. The home does not use agency staff so ensures the continuity of care for the service users accommodated. The home has a nice friendly atmosphere and is clean throughout. Service users are encouraged to have personal possessions in their rooms to make them more homely. The new Registered manager is committed to improving the home and the outcomes for service users, there is a basic quality assurance system in the home and the Provider monitors the home on a regular basis What has improved since the last inspection? Work has started to refurbish the bathrooms and the first one is presently being done. Service users and their relatives are involved more in the planning of care which they sign to say they have agreed. Key nurses have been allocated to service users to provide continuity of care and also provide accountability. The activity program has been expanded and there are more group and one to one activities taking place. CARE HOMES FOR OLDER PEOPLE Goffs Park Nursing Home 39 Goffs Park Road Crawley West Sussex RH11 8AX Lead Inspector Ann Peace Unannounced Inspection 5th June 2008 09:30 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 Goffs Park Nursing Home DS0000024146.V365341.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. Goffs Park Nursing Home DS0000024146.V365341.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Goffs Park Nursing Home Address 39 Goffs Park Road Crawley West Sussex RH11 8AX 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) 01293 524942 01293 539506 www.goffsparknursinghome.co.uk Goffs Park Care Homes Limited Mr Yaqub Mahandi Masih Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Goffs Park Nursing Home DS0000024146.V365341.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with nursing - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP). The maximum number of service users to be accommodated is 37. Date of last inspection 18th July 2007 Brief Description of the Service: Goffs Park is a care home, which is registered for up to 39 people aged 65 years and over. It provides nursing care. The care home is a converted large detached house, situated in a residential area of Crawley, close to the town centre. Accommodation is provided on 3 floors, which can be accessed using a passenger lift. There are 27 single and 4 double rooms. 1 of the double bedrooms on the third floor is being used as a communal lounge, in order to provide additional lounge space for the residents. There is one other medium sized lounge on the ground floor. There are large, well kept grounds which are accessible to service users in suitable weather. Since he last inspection Mr Masih has been registered with the Commission as Registered Manager. Fees are £520 to £650 per week. Goffs Park Nursing Home DS0000024146.V365341.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience GOOD quality outcomes. The purpose of this Key inspection was to assess how well the care home is doing in meeting the Key National Minimum Standards (NMS) and the Care Home Regulations 2001. The findings of this report are based on several different sources of evidence. One inspector undertook the inspection visit on the 5th June 2008, which lasted for approximately 5 hours. The Commission received an Annual Quality Assurance Assessment (AQAA) from the service prior to this. The AQAA provided further evidence of how the home is meeting the Key National Minimum Standards and what improvements the service has identified it could make. The Commission for Social Care Inspection (CSCI) sent ‘Have your say’ feedback forms to people living at Goffs Park and people who are involved with the service prior to this site visit and comments from these forms are reflected in this report. Some comments were: “I am very happy here”. “The home seeks advice and residents needs are met with respect”. “Residents are supported to live the life they choose”. We interviewed 5 people living at Goffs Park, and 2 visiting relatives. We also interviewed 5 staff and the registered manager. We met service users in communal areas and in their bedrooms. We also observed interactions between staff and service users, and were present during the serving of lunch. We observed that service users were comfortable and relaxed in the home and had friendly but professional relationships with the staff who look after them in a caring way. Five sets of care plans were sampled, together with other records including accident reports, complaints records, and staff recruitment and training records. Goffs Park Nursing Home DS0000024146.V365341.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Goffs Park Nursing Home DS0000024146.V365341.R01.S.doc Version 5.2 Page 7 The environment both internally and externally is in need of attention. The décor and general upkeep has been neglected and this detracts from the good nursing care the home offers. One bedroom does not have adequate natural ventilation the widow cannot be opened. There have been repeated requirements for the provider to establish a dining room for service users and we were told during this inspection work was planned as soon as the bathrooms are completed. Mr Lallchand has submitted a plan with given timescales for the work to be finished. The organisation had identified improvements, which it could make in the Annual Quality assurance Assessment (AQAA) that it returned to us. These included: • Improve and extend staff training, including creating a new system for tracking training. • Involve service users and their relatives more in planning care and when reviews are undertaken. • Organise service users, relatives meetings and have more staff meetings. • Plan more activities related to service users identified needs. • Ensure staff are updated in the safeguarding and complaint procedures. • Renovate bathrooms and showers. • Establish a dining area for service users. 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. Goffs Park Nursing Home DS0000024146.V365341.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 Goffs Park Nursing Home DS0000024146.V365341.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): 1,2,3,4,5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are given the information they need to make an informed decision about the home. Each service user has a written contract/statement of terms and conditions with the home. Service users are admitted on the basis of a full assessment and have an up to date plan of care for daily living, prospective service users are able to visit the home for a trial stay. Goffs Park nursing home does not provide Intermediate Care; therefore Standard Six does not apply. EVIDENCE: Goffs Park Nursing Home DS0000024146.V365341.R01.S.doc Version 5.2 Page 10 We saw the Statement of Purpose and Service User Guide which is available in the hallway of the home. This does need updating to reflect the changes to the management of the home. The Statement of Purpose/Service User Guide gives clear information and sets out the objectives and philosophy of the home. The recent CSCI findings are also included and all service users have a copy. People considering moving into a care home and their relatives are encouraged to look around the home and can go into the home for a trial stay. During our visit to Goffs Park Nursing Home we looked at the needs assessments of five people living at the home. They have pre assessments completed and risk assessments and care plans formulated following admission. This shows that admissions to the home only take place if the service is sure they can meet the needs of the service user. All service users have a contract/terms and conditions. The homes own needs assessment is supported by a care management assessment carried out by a Social Services Care Manager when applicable. Goffs Park Nursing home does not provide intermediate care. Goffs Park Nursing Home DS0000024146.V365341.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. Plans of care are in place that set out individual personal and health care needs. Service users benefit from a caring team of staff and service users have access to additional health services to meet their assessed needs. Medication policies and procedures are in place and staff follow safe administration practices. Service users feel that they are treated with respect, their right to privacy is upheld and are assured that at the time of death staff will treat them and their families with care sensitivity and respect. EVIDENCE: Goffs Park Nursing Home DS0000024146.V365341.R01.S.doc Version 5.2 Page 12 Care records are comprehensive and contain all of the information for staff to be able to provide personal and health care for service users. We are told that a new system of key worker groups has been implemented, this means that designated staff will have a group of service users they are responsible for, we are told that this will improve continuity of care. Risk assessments are compiled but need to be in more detail, not just noted as a problem in the care plans. The nutritional risk assessment needs to be updated to bring in line with current good practice and recognised guidelines. All care plans are updated on a regular basis and show what if any changes have occurred and how staff are to deal with them. Mr Masih was advised to seek advice from the dietician who regularly visits the home. Care records were tracked from assessments to care plans and then equipment to see if service users needs were being met and in all cases seen the equipment and care was being provided according to care plans and risk assessments. The social care plans are presently being compiled and we are told that they will contain a précis of the previous lifestyle and routines of service users so that the home can continue where possible these routines, such as bathing/showering routines and social interests. At present an activity record is completed and kept with the care plans. Five service users and two visitors were spoken to during the visit and all said the care was very good and the staff were friendly and caring. They all said and surveys recorded that staff listen to service users and support them. Service users have access to healthcare and remedial services as required. On the day of the visit a physiotherapist contracted by the home was visiting and attends the home on a weekly basis. One General Practitioner wrote, “The home seeks advice and residents needs are met with respect”. “Residents are supported to live the life they choose” and one service user wrote, “I am very happy here”. All five service users spoken to say staff do respect their privacy and dignity surveys also recorded this. Service users who were being nursed in bed and were too poorly to converse looked clean and comfortable and relevant charts were in their rooms which showed that staff were being attentive and meeting their needs. In relation to dying and death, from what was seen on the day of the visit and what we were told, we concluded that staff would treat service users and their family with care sensitivity and respect. Goffs Park Nursing Home DS0000024146.V365341.R01.S.doc Version 5.2 Page 13 Only qualified nurses administer medication and policies and procedures are in place. Medication records are up to date and a random check was made of the controlled drugs kept in the home and these were correct. No service users are able to self medicate at present. Goffs Park Nursing Home DS0000024146.V365341.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): 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. Service users find that the lifestyle they experience in the home matches their expectations and meets their needs. There is an activity programme in the home and service users are supported in maintaining contacts with family and friends and are able to exercise choice and control over their lives within care needs. The majority enjoy the food provided at the home and special diets, likes and dislikes are catered for. EVIDENCE: There is an activity programme available for service users which includes arts and crafts, bingo and exercise to music. Staff also carry out individual activities for those service users who either wish to stay in their rooms or who are unable to take part in-group activities. A local church is very involved in the home and provides activities on a regular basis. A musician also visits the home on a monthly basis. Goffs Park Nursing Home DS0000024146.V365341.R01.S.doc Version 5.2 Page 15 There were photographs available of recent high tea that had been held in the home and service users looked happy to be involved. All service users spoken to expressed satisfaction with what activities were offered, the majority of surveys also said there was enough activities on offer. There are two communal rooms available for service users, one is on the top floor of the home and we are told is not used by service users. The other is on the ground floor and is well used by service users who also eat their meals in there from small individual tables. There is no separate dining area for service users to access and it has been a requirement since 2005 that the Provider provides adequate sitting, recreational and dining space for service users. This has not yet happened although some work has started on refurbishing the bathrooms and we are told that the dining area is next on the list. There is a safe and pleasant rear garden laid to lawn with shrubs, a water feature and plants. We are told that there is also garden furniture and a gazebo for service users to be able to sit out when the weather is good. We noted and were told by service users that daily routines in the home are flexible and they told us that visitors are welcomed into the home and they are able to see their visitors in private. Service users are offered well-balanced home cooked food; there was a mixed response from surveys when asked if they liked the food although the majority said they did. Menus are not routinely displayed in the home and the manager was advised that they should be, he said he would ensure they were available in the future. We saw a copy of the menus which indicated that there are a good variety of meals served and the menu’s change weekly over a 6-week cycle. Service users can have a cooked breakfast if they wish; the main meal of the day is at lunchtime with a supper of mainly soup and sandwiches. Snacks are available at other times and service users confirmed that they are offered snacks. Staff go around to each service user on a daily basis to ask what they would like to eat for each meal and a record is kept of this. On the day of the visit, there was minced beef with runner beans and mashed potatoes for the main meal, followed by fruit and cream or ice cream. A number of service users asked for the alternative to the main meal and had omelettes. The meal was sampled and was tasty. Service users spoken with said they had enjoyed lunch. Goffs Park Nursing Home DS0000024146.V365341.R01.S.doc Version 5.2 Page 16 Goffs Park Nursing Home DS0000024146.V365341.R01.S.doc Version 5.2 Page 17 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. Service user’s and their relatives are confident that their complaints will be listened to, taken seriously and acted upon. Policies and procedures ensure that, as far as is possible the service users who live at Goffs Park Nursing Home are safeguarded. EVIDENCE: A complaints procedure is available to service users and is displayed in the hallway of the home, service users told us that they knew how and who to complain to. The procedure does need to be updated with the correct address of the Commission. Service users also said they felt safe and listened to and able to speak to staff if they had a problem. No complaints have been received by CSCI and there were no recent complaints recorded in the home’s records. Service users are able to vote by post if they wish which two of them confirmed. Staff did confirm training in safeguarding adults and could explain the procedure if a safeguarding issue was identified. Goffs Park Nursing Home DS0000024146.V365341.R01.S.doc Version 5.2 Page 18 Goffs Park Nursing Home DS0000024146.V365341.R01.S.doc Version 5.2 Page 19 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): 19,20,21,22,23,24,25,26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users live in homely clean environment although some areas are in need of upgrading and decoration and previous requirements relating to the environment have not yet been met resulting in a poor outcome rating. Service users do not have access to a suitable dining area. Service users have access to pleasant gardens. EVIDENCE: There have been some improvements to the home since the last inspection but previous requirements have still not been met in relation to upgrading the bathrooms and providing a dining area, although an action plan has been submitted saying the bathrooms will be completed by the end of August 2008 and the dining area by the end of September 2008. Goffs Park Nursing Home DS0000024146.V365341.R01.S.doc Version 5.2 Page 20 We could see that work has started to upgrade the bathrooms but the first one has not yet been finished and there are two more to upgrade. Other areas in the home are in need of repainting and decoration and some outside woodwork is poorly maintained resulting in windows that do not open or that have window restrictors that are not suitable and would not safeguard service users from falls. Two of these were bought to the attention of Mr Masih during the visit and were fixed by the maintenance man while we were in the home. Mr Masih is advised to carry out an audit of each room to identify outstanding work that needs carrying out and to bring this to the attention of the Providers. Service users have personalised their rooms to make them more homely. One service user has a large bedroom which has been made to look like a bedsit with their own furniture, comfortable seating and a fridge, they are very happy with the room but unfortunately there is no opening window in the room so there is no ventilation. Mr Masih told us there are plans to put in a window vent but this may not meet Standard 25.2 which states: “Rooms are individually and naturally ventilated with windows conforming to recognised standards”. Nursing beds are provided but they are old-fashioned metal-framed beds which detract from the homely atmosphere, we were told there are no plans to renew these beds. Systems are in place and records kept to evidence that the checks are maintained to make sure the environment is safe and apart from the windows that needed attention on the day of the visit we could confirm this. All areas of the home are clean and hygienic and staff noted to observe safe infection control procedures. Goffs Park Nursing Home DS0000024146.V365341.R01.S.doc Version 5.2 Page 21 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. Service user’s needs are met by the number and skills mix of staff on duty at Goff’s Park Nursing Home. The home is working towards meeting a staff ratio of 50 trained to NVQ Level two. There is a thorough recruitment process in place and in the majority of cases this is followed. A staff training programme is in place. EVIDENCE: The staff rota seen during the inspection showed that there are enough staff on duty over a 24-hour period to meet the needs of the service users presently accommodated. Service users told us that they thought there is enough staff on duty to meet their needs. To support nursing and care staff, Goffs Park also employs a cook, housekeeping staff and a maintenance man. Goffs Park Nursing Home employs Registered Nurses and we were told and staff confirmed that the home is working to achieve a ratio of fifty per cent of care staff with an NVQ Level two. Goffs Park Nursing Home DS0000024146.V365341.R01.S.doc Version 5.2 Page 22 We could see that training has been arranged by notices on the board and what staff told us. Mr Masih told us that he is working an a training matrix to ensure there is a system in place to track staff training which will be kept with their supervision files. Case tracking showed that the home operates a thorough recruitment process that includes obtaining two written references, a Criminal Records Bureau check and a POVA check prior to staff commencing work. By talking to service users on the day of the visit and by observing staff we concluded that the staff team are well trained, respectful and caring in their approach to service users and that service users do have confidence in the staff. Mr Masih told us that he plans to have more staff meetings in the future. Goffs Park Nursing Home DS0000024146.V365341.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38,Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Mr Masih the Registered Manager manages the home to a good standard for the benefit of service users, however the providers have not yet complied with previous requirements they have now submitted an action plan with given timescales. There is a basic quality assurance system in place to ensure the home is run in the best interests of service users. Service user’s financial interests and health and safety are safeguarded by the homes policies, procedures and record keeping. EVIDENCE: Goffs Park Nursing Home DS0000024146.V365341.R01.S.doc Version 5.2 Page 24 In January 2008 the acting manager Mr Masih was registered with the Commission, he has completed the registered Managers award. Mr Masih manages the home well on a day-to-day basis, however the Providers have not complied with previous requirements related to the upkeep and maintenance of the environment which Mr Masih has no control over. Since the inspection the Providers have submitted an action plan stating that all works will be completed by the end of September 2008. All section of the AQAA were completed and the information gives a reasonable picture of the current situation within the service. The AQAA gives us some limited detail about the areas where they still need to improve. Regular Regulation 26 visits by the provider to the home on a monthly basis are carried out and the reports are available in the home for inspection. There is a basic quality assurance system in the home although this could be expanded; this was discussed with Mr Masih during the inspection. Mr Masih told us that surveys for 2008 are due to be carried out in the near future. He was reminded that the results of this and any action taken should be made available to service users and others who have an interest in the home. Mr Masih told us that the improvements he plans to implement include extending staff training to make it more specific and including creating a new system for tracking training. Also to organise service users, relatives meetings and have more staff meetings. We had a discussion with Mr Masih regarding people who work in the home for short periods of time for example hairdressers and he was reminded that they need an enhanced CRB to be able to work in the home to ensure service users are safeguarded at all times. Service users told us that the manager and the staff do listen to them and act on what they say, they also told us that there is an open atmosphere and they could speak to the manager at any time. Staff told us that feel well supported to carry out their jobs and all said they like working at the home. Service users are able to control their own finances if they are able and wish to. Relatives and solicitors look after the finances for those residents who are unable to do so themselves. The manager does not have control of any service user’s finances but may hold small amounts of money for incidentals, records are kept of this. The AQAA completed by the manager recorded that services and tests are carried out on working equipment, including fire appliances. Goffs Park Nursing Home DS0000024146.V365341.R01.S.doc Version 5.2 Page 25 Health and safety records were seen and are completed appropriately although the general risk assessment for the home does needs updating. Goffs Park Nursing Home DS0000024146.V365341.R01.S.doc Version 5.2 Page 26 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 2 1 3 3 2 2 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Goffs Park Nursing Home DS0000024146.V365341.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP15 Regulation 23(2)(g) Requirement The registered person shall ensure there is adequate sitting, recreational and dining space provided from the resident’s private accommodation. This requirement remains unmet since the inspection of 1/6/05. The timescales given of 31/12/05, 30/9/06, 30/6/07 and 21/12/07 have expired. Timescale for action 30/09/08 3. OP21 23.2 (j) The home needs to provide bathrooms and shower rooms of a standard suitable to meet the needs of the people living at Goffs Park. This requirement remains unmet since the previous timescale of 21/12/07. The provider needs to ensure that sufficient numbers of care staff are achieving the national vocational qualification (NVQ) or equivalent in care at least at level 2 in order to help maintain standards of care provided. This DS0000024146.V365341.R01.S.doc 30/08/08 4. OP28 18.1 (a) 30/06/09 Goffs Park Nursing Home Version 5.2 Page 28 requirement remains unmet since the previous timescale of 21/12/07. OP25 5 23.2 (p) Ventilation suitable for service 30/08/08 users is provided in all parts of the care home which are used by service users. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations It is recommended that Mr Masih carries out an environmental audit for all areas of the home identifying areas that need attention and presents a report of this to the providers. Nutritional screening using a recognised tool should be undertaken on admission and recorded on a periodic basis. 2 OP8 Goffs Park Nursing Home DS0000024146.V365341.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Goffs Park Nursing Home DS0000024146.V365341.R01.S.doc Version 5.2 Page 30 - 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. 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