Care Home: Gorseway House

What the care home does well The house has a very welcoming atmosphere. The general environment is very impressive with the old ballroom now being a lounge area. The surrounding gardens are well maintained and give residents a pleasant outlook and a safe environment to take walks. The activities programme is very inclusive and residents from the warden controlled flats visit the home regularly to participate in these. The inspector observed a social atmosphere in the lounge during the afternoon among the ladies of the house. Residents are encouraged to maintain their maximum independence with staff assisting them to mobilise where possible and offering them choices over many aspects of their daily lives. Comments from residents include `I would recommend this home to anybody`. `I knew the home before I chose to come to live in it`. `The food is sometimes good` `I usually get what I ask for. It may not be what I really need`. `There is a good range of activities`. Comments from relatives were generally very positive: `Me and my family are happy with the care my father receives`. `Visitors are made welcome` `The home provides an attractive environment`. The home provides imaginative menus`. The staff comments received were that they were very happy with their employ and feel well supported within their roles. `I think the best thing is the team work and the time we are able to spend with the people we care for`. `The standard of care we provide in the home is excellent. All aspects of care are catered for and our residents are very happy`. What has improved since the last inspection? The home is developing a new quality assurance system and this will enable the manager to constantly monitor the standards in the home. The personal documentation for the residents has been reviewed and reappraised. The files provide very comprehensive documentation of all aspects of care. What the care home could do better: The management of the medication could be reviewed. The storage cupboard was packed with medicines that were no longer in use and needed to be recorded and destroyed as per policy. The stock control and ordering of `as needed medication` and dressings needs to be monitored as overstocking was evident on the day of the inspection visit. The carpets that are heavily stained need to be replaced as these were spoiling the overall effect of the home. CARE HOMES FOR OLDER PEOPLE Gorseway House 354 Seafront Hayling Island Hampshire PO11 0BA Lead Inspector Jan Everitt Unannounced Inspection 25th April 2007 09:00 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 Gorseway House DS0000011518.V331893.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. Gorseway House DS0000011518.V331893.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gorseway House Address 354 Seafront Hayling Island Hampshire PO11 0BA 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) (023) 92 466412 (023) 92 469222 enquiries@gorseway.co.uk Gorseway Care Limited Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28), Terminally ill (6), Terminally ill over 65 of places years of age (28) Gorseway House DS0000011518.V331893.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. All service users must be at least 60 years of age. Date of last inspection Brief Description of the Service: Gorseway House is a care home with nursing for people over the age of 60 years. The Home is situated in the Gorseway complex, which is adjacent to Hayling Island beach and amenities. The main meals are in the main prepared and cooked in Gorseway Lodge, also a nursing home, which is on the same site as Gorseway House. Both homes are set in landscaped grounds, which are well maintained and able to be accessed by all the residents including wheelchair users. The home has a bed that is funded by the local PCT into which GPs can refer patients. The home has a strict criterion for referrals to the GP bed, to ensure that residents occupying the bed are within the conditions of registration of the Home. Fees: £530 - £795 The respite bed costs for nursing care are £810 and for residential care £670. Extra costs are incurred by the resident for hair, chiropody, papers, magazines, toiletries and private phones. Gorseway House DS0000011518.V331893.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit inspection to Gorseway House, which was unannounced, took place over a one-day period on the 25th April 2007 and was attended by one inspector who was assisted by the newly appointed manager Mrs. Grey. The visit to Gorseway House formed part of the process of the inspection of the service to measure the service against the key national minimum standards. The focus of this visit was to support the information gathered prior to the visit. The judgements made in this report were made from information gathered prior to the visit; pre-inspection information submitted to the commission by the manager, information from the previous report, the service history correspondence and contact sheets appertaining to the service were also taken into consideration. A number of comment survey cards were sent to relatives prior to the visit of which three were returned. They were generally very positive about the care and services in the home. Eight of the service users’ surveys were returned to the CSCI. The inspector also received four care worker surveys. Further evidence was gathered on the day of the site visit. The inspector toured the home and spoke to staff and residents who gave their views on the service. Residents in general stated that they enjoyed living at the home and liked the staff. Care and other records and documentation identified in the report were viewed. What the service does well: The house has a very welcoming atmosphere. The general environment is very impressive with the old ballroom now being a lounge area. The surrounding gardens are well maintained and give residents a pleasant outlook and a safe environment to take walks. The activities programme is very inclusive and residents from the warden controlled flats visit the home regularly to participate in these. The inspector observed a social atmosphere in the lounge during the afternoon among the ladies of the house. Residents are encouraged to maintain their maximum independence with staff assisting them to mobilise where possible and offering them choices over many aspects of their daily lives. Comments from residents include Gorseway House DS0000011518.V331893.R01.S.doc Version 5.2 Page 6 ‘I would recommend this home to anybody’. ‘I knew the home before I chose to come to live in it’. ‘The food is sometimes good’ ‘I usually get what I ask for. It may not be what I really need’. ‘There is a good range of activities’. Comments from relatives were generally very positive: ‘Me and my family are happy with the care my father receives’. ‘Visitors are made welcome’ ‘The home provides an attractive environment’. The home provides imaginative menus’. The staff comments received were that they were very happy with their employ and feel well supported within their roles. ‘I think the best thing is the team work and the time we are able to spend with the people we care for’. ‘The standard of care we provide in the home is excellent. All aspects of care are catered for and our residents are very happy’. What has improved since the last inspection? What they could do better: The management of the medication could be reviewed. The storage cupboard was packed with medicines that were no longer in use and needed to be recorded and destroyed as per policy. The stock control and ordering of ‘as needed medication’ and dressings needs to be monitored as overstocking was evident on the day of the inspection visit. The carpets that are heavily stained need to be replaced as these were spoiling the overall effect of the home. Gorseway House DS0000011518.V331893.R01.S.doc Version 5.2 Page 7 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. Gorseway House DS0000011518.V331893.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 Gorseway House DS0000011518.V331893.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): Standard 3 - Standard 6 is not applicable to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples’ needs and care are assessed prior to their going to the home to live. EVIDENCE: The home has appointed a new manager. She told the inspector that she personally goes to assess all persons that have been referred for a placement in the home. The inspector viewed the pre-admission assessment document, which was comprehensive and covered all aspects of a person’s care needs. The manager also reported that she gains information from clinical areas and communicates with clinicians and social workers, which enables her to gather a Gorseway House DS0000011518.V331893.R01.S.doc Version 5.2 Page 10 comprehensive over view of the potential resident’s care needs. The manager confirmed that in most instances relatives are present at the assessment if the person is unable to advocate for him or herself. This assessment forms the basis for the care plans that will be written to provide guidance for the staff when providing care in the home. Comments received from residents about their admission to the home would indicate that for many of them the arrangements for their residency had been undertaken by close family and in general they were very satisfied with their placement. Gorseway House DS0000011518.V331893.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care planning and communication systems in the home ensure that the health and care needs of the residents are met in a way that respects their privacy and dignity. EVIDENCE: The inspector viewed a sample of three residents care records. The newly appointed manager has undertaken a comprehensive audit of all care plans and these were found to be well documented and the information in the files contained the information that would be needed to allow staff to be able to deliver care to the residents in an individual and consistent way. Details in the records included: Gorseway House DS0000011518.V331893.R01.S.doc Version 5.2 Page 12 • • • • Risk assessments for mobility, Nutrition, Tissue viability Records of visits by other health professionals. Care plans detailed the specific health care needs of the resident and any identified risks. The manager told the inspector that the home is served by two GP practices and that she communicates readily with the primary health team to give advice on tissue viability, continence and other clinical issues if opinions are requested. There was evidence that all the assessments had been regularly reviewed and re-assessed to reflect the changing needs of the residents and to ensure that the needs of the residents are met at all times. The inspector observed that care plans had been signed by the residents if they were able and chose to do so. The home has a trained nurse who co-ordinates the management of all medication from ordering to disposal. The systems for co-ordinating this were discussed with her and the inspector viewed the medication records that were found to be in order and recorded appropriately. The inspector viewed the policies and procedures for the home with regard to all aspects of medication administration, storage and disposal, which is undertaken by a waste disposal contractor. The inspector did observe that there was a large amount of medicines for disposal that were waiting to be recorded and disposed of. The inspector also observed that the cupboards were over stocked with a variety of ‘as needed medicines’ and prescribed dressings. This was discussed with the nurse and the manager as to whether the present systems were being managed appropriately. Other policies and procedures include guidance for staff on the crushing and covert administration of drugs. Other guidelines available for staff include drug interactions with food and drinks. At the time of this visit there were no residents choosing to self-medicate but the manager reported that the respite care residents are encouraged to continue managing their own medication following a risk assessment as to the safety of them doing so. The inspector observed part of a medicine round and the nurse was following the home’s procedures for the safe administration of medicines. There was only one room being used as a double and a married couple occupied that. The gentleman told the inspector that he was waiting to be Gorseway House DS0000011518.V331893.R01.S.doc Version 5.2 Page 13 transferred to the other care home on site to obtain a better room. His wife told the inspector that she was happy in this room and the staff were ‘very kind.’ The nurse in attendance at the time was observed to be patient and allowed the residents time to take their medicines and whilst she was in attendance there was good communication and interaction between her and the residents. Residents spoken to during the inspection said that staff were always respectful and acknowledged their right to dignity and privacy at all times. Whilst touring the building staff were observed to be courteous to service users when they were communicating and assisting them in their daily tasks. A comment on the care worker survey stated that the ethos of the home ‘helps residents to retain their privacy and dignity’. Gorseway House DS0000011518.V331893.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. The management of the social activities creates a positive, varied and interesting life for the residents, which meets their expectations for living in the home The arrangements for meals ensures that the residents have a nourishing and well balanced meals that are taken in surroundings of their choice. EVIDENCE: Information is gathered about the potential resident’s social history and their hobbies and recreational preferences at the pre-admission assessment meeting. This together with other information gained during the admission assessment, assists the assessing nurse to create a social profile of that resident. Gorseway House DS0000011518.V331893.R01.S.doc Version 5.2 Page 15 The social activities programme is arranged between Gorseway House, Gorseway Lodge and the warden-controlled flats owned by Gorseway Care that are within the grounds of the two nursing homes. The programme provides opportunities for the residents to visit local shopping centres as well as attend activities within the home. The residents from the flats come into the home and attend coffee mornings and other activities. The home could demonstrate an activities programme for five days of the week. The activities include two visits a week from an occupational therapist and include an exercise programme, reminiscence therapy and quizzes. Many of the activities are based at the Lodge as the residents are more dependant and the residents from the House are taken to the Lodge when this occurs. There is also a Day Care Centre on site that respite care residents are able to attend during their stay. The home has a lay preacher that attends regularly and the Christian church holds occasional services and is at present liaising with the manager to increase these to monthly services at the request of the residents. The manager reported that the local community is organising for one church to be specifically attached to the home and the vicar responsible would attend the home. The manager herself organises some of the church services. The residents surveys completed informed the inspector that those completed were of the Christian faith and that the home was not accommodating any other faiths at the time of this visit. The manager told the inspector that the home would accommodate and provide for all faiths if requested. The visitors’ book evidenced that there are regular visitors to the home each day. Residents are able to come and go as they wish. One resident informed the manager that she was going out into the grounds for a walk around and another had also taken the opportunity of enjoying the surrounding gardens in the fine weather. The home has open visiting and has the provision of a visitor’s room, designated to visitors who wish to stay over night, or have privacy with the resident they are visiting. The assessment documents residents’ preferred ways of undertaking their activities of daily living. The menus demonstrated choices of food at every mealtime and the head of housekeeping speaks to all new residents to ascertain their dietary likes and dislikes. Gorseway House DS0000011518.V331893.R01.S.doc Version 5.2 Page 16 Residents are given choices of where they wish eat their meals and the inspector observed that some prefer to stay in their rooms. Residents spoken with confirmed that this was the case. The manager told the inspector that all residents were of white origin and some residents found it difficult to communicate and accept care from the staff that are from an ethnic background. Service users spoken with reported that staff were very kind and helpful, were generally available when they needed them and were familiar with their needs. The pre-inspection information included a four-week menu plan and this demonstrated a varied nutritious menu with choices. The food is cooked at the Lodge and transported over in an insulated trolley. The inspector observed the lunchtime meal being served and eaten. There were mixed reviews about this particular menu. Although most residents made positive remarks about the food in general, some said the meal was dry and needed a sauce or gravy. The inspector supported this view, on observation of the residents having difficulty in eating quite a dry menu. This was discussed with the chef on duty who said he would acknowledge what was being said and ensure that this was highlighted at the main kitchen for the future. Residents’ surveys returned to the inspector indicated that there was a mixed view on the food with some saying they always liked the food, and other stating sometimes or usually. The head of housekeeping has recently spoken to all residents and undertaken a quality assurance survey and a report written, which was seen by the inspector, who observed that the menus have been reviewed as a result of this and will be reviewed in the proceeding three months. The inspector spoke to residents and asked their views on the food and generally there was a positive response but one gentleman, who chose to eat his meals in his room, said that the food was not hot enough when it arrived. The care plans evidenced nutritional risk assessments for residents and care plans written to manage any identified at risk. The inspector spoke to the chef who reported that he and other kitchen staff have the relevant Food Handling and Hygiene certificates. He reported that special diets are catered for and the home has a number of residents with diabetes. He said that although the catering staff have some knowledge of special diets, and the head chef has undertaken training on diets, the remainder of the staff anticipate they will attend a more extensive course appertaining to special diets. Gorseway House DS0000011518.V331893.R01.S.doc Version 5.2 Page 17 Gorseway House DS0000011518.V331893.R01.S.doc Version 5.2 Page 18 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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures are in place to ensure that all complaints are acknowledged and handled objectively. The vulnerable adults procedure ensures that any allegation of abuse will be addressed appropriately EVIDENCE: The home has a detailed complaints procedure that is available in the home’s Statement of Purpose. No complaints about the home have been received by CSCI since the last inspection. The manager maintains a record of any complaints on the electronic database. Residents spoken to confirmed that their concerns are always taken seriously and acted upon. Surveys received from residents indicated that they would talk either to their relatives or to the manager if they wished to complain. Robust policies and procedures for the reporting of allegations of abuse within the home are in place. Staff members spoken with and surveys received from staff confirmed that they are aware of the procedure for reporting abuse and that they receive regular training for the awareness and reporting of abuse within the care home setting. Gorseway House DS0000011518.V331893.R01.S.doc Version 5.2 Page 19 The training matrix identified that abuse awareness training is on the agenda for this coming year. This training also forms part of the Skills for Care foundation programme and the NVQ level 2 training. Gorseway House DS0000011518.V331893.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The ongoing review of services provided in the home ensures that all residents are enabled to live in a clean, safe and generally comfortable environment. EVIDENCE: The inspector toured the home with the manager and visited every room and spoke to residents that were in their rooms. The house is an old building which has retained many of its original features and as a consequence the maintenance manager describes it as a ‘never ending maintenance project’. He told the inspector that the rooms are decorated when they become vacant and that the day-to-day maintenance is documented in the maintenance records which is left on the desk for staff to document any snags that need attending to. Gorseway House DS0000011518.V331893.R01.S.doc Version 5.2 Page 21 The site has a team of maintenance people and a gardener who maintains the pleasant surrounding gardens. The inspector did observe on the tour of the building that there were areas of the home in need of redecoration and refurbishment. The inspector observed that the majority of carpets in bedrooms were badly stained and in need of cleaning or replacing. The manager acknowledged this and reported that she had toured the home when she was appointed and identified the areas that needed repairs, redecoration and the carpets that needed replacing. The funding for this work has yet to be agreed by the organisation. The inspector observed that most of the rooms had pleasant views with some having double aspect windows that allowed views over the sea. Residents had made their rooms very homely and individual and some had chosen to bring their own pieces of furniture with them. The house was in the process of having a ‘spring clean’. The previous two domestics had left the home’s employ and the manager had identified that the standard of cleanliness throughout the home had dropped. The head of housekeeping had organised a rota and extra hours given to the existing staff to undertake a deep clean of the house and this was in progress during this visit. The service users surveys and the relative surveys identified a high level of satisfaction with the cleanliness of the home but one relative did identify that carpets were in need of replacing. The training matrix identified that staff attended infection control training in the previous year. The inspector observed hand-washing facilities throughout the home and alcohol hand wipes. Staff have gloves and aprons available to enable them to follow procedures for infection control. The home has a waste disposal contract which covers clinical waste and the disposal of medication. Gorseway House DS0000011518.V331893.R01.S.doc Version 5.2 Page 22 Gorseway House DS0000011518.V331893.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers of staff on duty at any one time appear to be sufficient to meet the needs of the residents. The home provides training for staff to enable them to be competent to do their job. Staff are recruited through a robust recruitment process. EVIDENCE: The pre-inspection documents included staff rotas that demonstrated that all shifts throughout a twenty-four hour period were covered by the recommended numbers and skill mix of staff, ensuring that staff were available to provide and maintain a high standard of care for all the residents in the home. The home has a separate housekeeping staff along with a separate laundry and kitchen staff and the managers of these departments maintain rotas as they cover both homes on the site. The pre-inspection document stated that 60 of the care work force has achieved the NVQ level 2 qualification. The remainder of the care staff were Gorseway House DS0000011518.V331893.R01.S.doc Version 5.2 Page 24 commencing this training. This was being funded and supplied by a training provider organisation ‘Train to Gain’ who were present in the home the day of the visit to talk to staff and assess their training needs. The inspector viewed the training programme for the coming year and this demonstrated a variety of appropriate training to support staff to undertaken their duties and provide a high standard of care in the home. The inspector also identified the mandatory training records for staff and recommended to the manager that she enter this on a training matrix to enable her to easily identify staff that have not attended training. Moving and Handling training is provided for all staff in one day. The present manager has to attend the ‘train the trainer’s’ course and until then the home is buying in this training. Staff spoken to confirmed that there is a comprehensive programme of training available to all the staff. The training programme has included: • • • • • • • • • Bowel care Tissue viability Abuse Motor Neurone Disease Palliative Care Male Catheterisation Liverpool Care Pathway Diabetes Care Nutrition The inspector viewed a sample of personnel recruitment files. These records are maintained in the administration office on site. The process of recruitment was discussed and the adverts for staff vacancies are displayed in the local papers and from which the manager reports, the home receives a good response from. The records viewed were all found to be in order with evidence that an application form had been completed, references obtained and proof of personal identity was recorded. Evidence that appropriate checks with the Criminal Records Bureau (CRB) and the Protection of Vulnerable Adult Register (POVA) was shown to the inspector. The manager interviews all prospective new members of staff and a record of the interview is kept. All trained staff are required to produce evidence of their current PIN with the Nursing and Midwifery Council. This is validated by the manager for the home prior to commencement of employment. Gorseway House DS0000011518.V331893.R01.S.doc Version 5.2 Page 25 Gorseway House DS0000011518.V331893.R01.S.doc Version 5.2 Page 26 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. The manager of the home is suitably qualified and ensures that the home is well run and that the needs of the residents are met Monitoring of practices within the home safeguards the health, safety and welfare of residents, staff and visitors to the home. EVIDENCE: The newly appointed manager has been in post since February 07. She is a registered general nurse and is a qualified district nurse. She has a Gorseway House DS0000011518.V331893.R01.S.doc Version 5.2 Page 27 considerable number of years experience working with elderly people and was one of the registered nurses employed at the Lodge previous to this appointment. She therefore, brings to the job a great deal of clinical experience. She is in the process of being registered with the CSCI and is anticipating undertaking her Registered Managers Award in September 07. At the time of this visit the manager was in the process of introducing her own systems for working and the home was in a period of change and development. Staff spoken to feel supported by her and the inspector observed good interaction and communication between herself, staff and residents. The organisation is in the process of reviewing the quality assurance system. The manager told the inspector that the management are developing a new system of quality control in line with the format and information required to be recorded on the Annual Quality Assurance Assessment (AQAA) document that all homes will present to the CSCI annually. She does at present do internal quality control along with the head of house keeping. She has audited all care plans and made recommendations to ensure that the quality of information is accurate and reflects current needs of the residents. The manager from the Lodge visits the home monthly to undertake a visit and reports on her findings, copies of the reports are in the home. Standard 35 was not assessed, as the home is not responsible for any residents’ monies. The inspector viewed a sample of the policies and procedures for the home and some have been identified as needing to be reviewed. The manager reported that she is reviewing all policies and procedures within the coming months. Records showed that equipment and systems in use in the home are regularly maintained and serviced. The fire safety records confirmed that staff receive regular fire safety training and that all fire safety equipment is regularly checked and maintained. Gorseway House DS0000011518.V331893.R01.S.doc Version 5.2 Page 28 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X x 3 X X 3 Gorseway House DS0000011518.V331893.R01.S.doc Version 5.2 Page 29 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 OP9 Regulation 13 Requirement All medication that is no longer needed or in use must be recorded and disposed of within a reasonable timescale to ensure that all medication can be traced and accounted for. Identified areas of the home in need of repair and refurbishment, with particular reference to the heavily stained carpets throughout the home, must be replaced or thoroughly cleaned to ensure service users are living in clean pleasant surroundings. Timescale for action 31/05/07 2 OP19 23 31/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Gorseway House DS0000011518.V331893.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Gorseway House DS0000011518.V331893.R01.S.doc Version 5.2 Page 31 - 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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