Inspection on 27/12/06 for Five Gables Care Home

This inspection was carried out on 27th December 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Five Gables Care Home 10/12/08

Five Gables Care Home 26/01/06

Five Gables Care Home 26/09/05

Five Gables Care Home 10/03/05

Five Gables Care Home 22/02/05

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Five Gables Care Home 113 Victoria Road Kirkby In Ashfield Mansfield Nottinghamshire NG17 8AQ Lead Inspector Jayne Hilton Key Unannounced Inspection 27th December 2006 10:15 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 Five Gables Care Home DS0000008677.V323821.R02.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. Five Gables Care Home DS0000008677.V323821.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Five Gables Care Home Address 113 Victoria Road Kirkby In Ashfield Mansfield Nottinghamshire NG17 8AQ 01623 752 512 01623 751838 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) Mr Alan Peter Pearce Mrs Lesley Pearce Lesley Pearce Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Five Gables Care Home DS0000008677.V323821.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. No one falling within category OP may be admitted into Five Gables Residential Care Home where there are 16 persons of category OP already accommodated within this home To be able to admit the named person of category DE(E) named in variation application number V34288 dated 09.08.06 No more than 16 persons can be accommodated within Five Gables Residential Care Home 26th January 2006 Date of last inspection Brief Description of the Service: Five Gables provides residential care for up to sixteen service users and is discreetly positioned close to the town centre of Kirkby-in-Ashfield. There is ample on road parking and some spaces available to park in the home’s own car park. The gardens are private, well kept and have a pleasant water-fall feature, with many areas to chose from to sit out when the weather permits. Accommodation is provided over the ground and first floor, with the choice of a passenger lift and period style staircase. Information was provided by the manager on 27-12-06 on the range of fees charged; these are £314, service users pay extra for newspapers, hairdressing and chiropody. Five Gables Care Home DS0000008677.V323821.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection took place over 5 and a half daytime hours. The main method of inspection used was called ‘case tracking.’ This involves selecting three residents and looking at the quality of the care they receive by talking to them, examining their care files and discussing how support is offered to them by staff members. Judgements in this report are made from including observation and reading residents’ records and documents. Two of the residents who were “case tracked” were able to help by giving an opinion about the care provided. One was not available on the day. Relatives were observed visiting the home but due to the busy festive time of year and the focus of the inspection, comments from one relative only was obtained. Two members of staff, the manager and the responsible person, were spoken with as part of this inspection, documents were read and medication inspected to form an opinion about the quality of the care provided to residents. A tour of the premises and several records were assessed also. Four service user /relative comments were obtained at the inspection sealed in envelopes. The Registered Provider returned a pre inspection questionnaire in June 2006 and information reported in this document was randomly sampled and included within the report. What the service does well: A Service user commented: “Five Gables is the next best place than home” Five Gables Care Home DS0000008677.V323821.R02.S.doc Version 5.2 Page 6 Service users find the lifestyle experiences in the home matches their expectations and preferences and they can maintain contact with family friends and the community as they wish. Service users are helped to exercise choice and control over their lives and receive a wholesome appealing balanced diet in pleasing surroundings. Service users live in a home, which is run and managed by a person who is fit to be in charge and which is run in the best interests of service users and the health, safety and welfare of service users and staff are generally promoted and protected. Perspective service users have the information they need to make an informed choice about where to live and each service user has a contract and assessment of needs in place. Service users say that their health care and personal care needs are being fully met and they feel they are treated with respect and their right to privacy is upheld. Service users and their relatives are confident that their complaints will be listened to taken seriously and acted upon and are protected from abuse. A clean, well-maintained environment is provided that suits the needs of service users and their needs are met by the number and skill mix of staff and are in safe hands. Service users are supported and protected by the homes recruitment policy and procedures. What has improved since the last inspection? The complaints procedure has been amended. Some improvement had been made in relation to supervision and training records for staff. Some areas of medication management had been improved. Five Gables Care Home DS0000008677.V323821.R02.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. Five Gables Care Home DS0000008677.V323821.R02.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 Five Gables Care Home DS0000008677.V323821.R02.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, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Perspective service users have the information they need to make an informed choice about where to live and each service user has a contract and assessment of needs in place. A review of the documentation used and the system in place for assessment and care planning is recommended to ensure service users needs are fully met. The home does not provide an intermediate care service. EVIDENCE: There was a Statement of Purpose and Service User Guide displayed in the home. The manager reported that she intended to update this in the near future. The manager was advised that the Commmison For Social Care must be notified of any changes to these documents as required by regulation. Five Gables Care Home DS0000008677.V323821.R02.S.doc Version 5.2 Page 10 Contracts were seen and extended community care assessments where applicable. Service users spoken with were unsure whether they had seen the Service User Guide or a previous inspection report. It is recommended that service users or their representatives are asked to sign as receipt of the service users guide and that they have been informed how they can access a copy of the inspection reports for the home. The inspection report was located in the entrance near to the visitors book. Comments received by service users and relatives indicated that they were given a tour of the home prior to admission. One relative said they liked it that the manager was not pushy and gave lots of advice and information before they agreed for their family member to stay at the home. The assessment documents for three service users were examined. The assessment does not include foot care and this is recommended to ensure that service users needs are fully met. The diversity needs of service users can be identified within the current documentation but focus on religious and expressing sexuality needs. The assessment documentation should be further developed to include equality and diversity needs of service users. The use of the assessment is not consistent and care plans had not always been put into place for all identified needs of service users. The manager reported that they tend to use the assessment as a care plan and the standex system used indicates that this should be the case, however there is not sufficient room on the assessment documentation for detail for staff on how the identified needs of service users will be met. Any history of falls is recorded on the assessment documentation but weight is not always being recorded upon admission. One service users manual handling risk assessment was not completed despite the assessement document identifying poor mobilty. Care should be taken to ensure all assessments and care plans are dated and signed. Five Gables Care Home DS0000008677.V323821.R02.S.doc Version 5.2 Page 11 The system in place should be reviewed and improved to ensure care plans and risk assessments are in place for all assessed needs of service users, that these are appropriatly evaluated and reviewed and that service users or their representative have agreed them. Five Gables Care Home DS0000008677.V323821.R02.S.doc Version 5.2 Page 12 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 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users say that their health care and personal care needs are being fully met, however the system in place to document how this is happening requires improvement. Medication management needs to be improved in some areas. Service users feel they are treated with respect and their right to privacy is upheld. EVIDENCE: As stated care plans were not in place for all identified need of service users. Basic information was included within the assessment document, but this did not instruct staff how to meet the needs of service users. All staff need to have a consistent approach in relation to behavioural needs and have a clear understanding about how this is to be managed. Five Gables Care Home DS0000008677.V323821.R02.S.doc Version 5.2 Page 13 Information about pressure relieving equipment was documented and there was evidence of manual handling assessments for some residents but not all. One service user had a medical condition, which indicated that weight monitoring was needed to evaluate health and well being. Weight records were in place but again lacked consistency of frequency and whether taken on admission. Where service users refuse to be weighed this should be documented and weight records should be used in the evaluation of service users nutritional needs and well - being. The use of risk assessments was not consistent and not all care files indicated the date of admission. Risk assessments should be in place for alcohol use with medication. As the preparation and cooking of meals is encouraged as is the freedom to prepare between meal snacks and drinks, appropriate risk assessments should be in place to support those that choose to undertake this. There was some evidence of service user involvement within the assessment and care plan documentation but signatures of the service users or their representatives were not always obtained, that said a service user and relative spoken with said the manager spoke with them regularly about their care plans and had signed their agreement. Reviews of care plans were in place but not undertaken monthly. Again space for appropriate evaluation and review was limiting within the documentation used. The manager reported that she agreed that the paperwork could be better but that time is focused on direct care practice. Service users and relatives highly praised the manager and staff, and said the care and support received was excellent. However documentation is required by regulation and therefore improvement in this area must be made to evidence the service delivered. The system in place should be reviewed and improved to ensure care plans and risk assessments are in place for all assessed needs of service users, that these are appropriatly evaluated and reviewed and that service users or their represntative have agreed them. Five Gables Care Home DS0000008677.V323821.R02.S.doc Version 5.2 Page 14 The system in place for the management of medication was examined. The procedures for receipt and returns was satisfactory. Training for staff is provided in house. All staff should receive acreddited training. The system in place for responsibility/holding of keys for medication stores needs to be in place as the current system is not safe. Keys for medication storage should also be kept separate to all other keys used in the home. The storage temperatures of medication is not being monitored and this should be implemented. There were some gaps noted on medication administration records without any explanation of the reason for this. A requirement to improve medication management is therefore made. Eye drops were stored in lockable box in the fridge and were not date labelled when opened. The registered provider should consider the provision of a suitable medicine fridge for medication requiring cool storage or secure the lockable box within the fridge. Although basic medication policies and procedures are in place there was no policy in place for drug errors. This must be in place and include information of notifying the Commission for Social Care should this occur. A medicines round was not observed but the staff member explained to the inspector the procedures in place, which was assessed as satisfcatory. Staff spoken with and practice observed confirmed that service users privacy and dignity is respected. Service users and relatives spoken with confirmed that staff treated them with respect and maintained their privacy and dignity at all times. Five Gables Care Home DS0000008677.V323821.R02.S.doc Version 5.2 Page 15 Five Gables Care Home DS0000008677.V323821.R02.S.doc Version 5.2 Page 16 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 excellent. This judgement has been made using available evidence including a visit to this service. Service users find the lifestyle experiences in the home matches their expectations and preferences and they can maintain contact with family friends and the community as they wish. Service users are helped to exercise choice and control over their lives and receive a wholesome appealing balanced diet in pleasing surroundings. EVIDENCE: A programme of activities is provided including flower arranging, entertainers, singers, magician, comedian, bingo, cards beetle, coffee mornings, barbeques, fashion shows, local friendship club shopping trips and trips out to places of interest, stately homes, parks seaside destinations craft and garden centres. Comments from service users included, many activities/regular activities are provided but one service user thought there could be more activities. Five Gables Care Home DS0000008677.V323821.R02.S.doc Version 5.2 Page 17 A fellowship group is held once a month. Service users interests are recorded in the assessment documentation. Relatives said they are made very welcome and there was evidence of contact with local community and trips out. Visitors an visit at any reasonable time and the visitors book was clearly completed. Service users confirmed thay made choices within their daily lifestyles and routines such as going to bed , getting up, participation in activities, to stay in their room etc. Comments from service users included: “If the meal of the day is not my liking then I am offered an alternative the staff are very accommodating”, “Staff are friendly and kind which makes a big difference to feeling at home” A sample of menus were provided by the manager and seen displayed in the home on the day of the inspection. Menus are devised over four weeks and appeared nutritious and varied. Although two choices are not offered on the menu the manager and service users confirmed that alternatives are served for personal preferences. A wide range of breakfast options are offered, a choice of five cereals, toast and choice of preserves, cooked breakfast and fruit juice. A cooked meal is provided at lunch time with a sweet and at teatime, a variety of sandwiches and side salad, jellies, ice cream and cakes. Service users spoken with confirmed that the food was nice and that drinks of tea/coffee/ water or juice are provided frequently as requested. One service user suggetsed that more fish be provided on the menu. Food stocks were satisfactory. The manager stated in the Pre Inspection questionnaire, that they believe that personal choice and flexibility should be incorporated at all times and menu plans are for suggestion only and with this in mind they try to encourage all of the residents to be involved in menu planning and from this are able to develop personal, cultural, ethnic and special dietary needs. Five Gables Care Home DS0000008677.V323821.R02.S.doc Version 5.2 Page 18 Meal times are flexible to accommodate activities and participation and preparation in the menu and cooking of meals is encouraged as is the freedom to prepare between meal snacks and drinks. Five Gables Care Home DS0000008677.V323821.R02.S.doc Version 5.2 Page 19 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. Service users and their relatives are confident that their complaints will be listened to taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: The complaints policy was seen and meets requirements. Service users, staff and relatives were confident that any complaints would be referred to the manager and these would be dealt with appropriately. Two complaints were recorded that had been made to the home since the last inspection, another had been made through the Commission for Social Care Inspection, and all had been fully investigated and resolved where possible. Staff spoken with were clear that they would report any concerns about the way service users were treated and what constituted abuse. They were not however fully able to discuss the whistle blowing policy and therefore it is recommended that this be discussed with them. There was evidence that staff has undertaken training in abuse awareness but the manager has not yet attended training in the use of the Nottinghamshire Five Gables Care Home DS0000008677.V323821.R02.S.doc Version 5.2 Page 20 Committee for the Protection Of Vulnerable Adults policy and procedure. This was recommended at the previous inspection. Service users said they felt safe in the home. Five Gables Care Home DS0000008677.V323821.R02.S.doc Version 5.2 Page 21 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): 19,22, 24, 25, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A clean, well-maintained environment is provided that suits the needs of service users. Some recommendations are made for some identified areas for improvement/further maintenance of standards. EVIDENCE: The home was found clean, well maintained and comfortable with assorted seating in a choice of sitting areas. All internal areas were accessible to wheelchair users. Service users spoken with were satisfied with the environment and said they felt comfortable in the home. Five Gables Care Home DS0000008677.V323821.R02.S.doc Version 5.2 Page 22 Radiator covers were provided and a sample test of the water outlet temperatures were taken and found to be satisfcatory. Window restrictors are provided on the first floor but not on the ground floor. It is recommended that restrictors are fitted to ground floor windows to ensure safety and security of the service users. Three bedrooms were examined all were personalised, clean and service users confirmed they were comfortable. Lockable facilities are provided as appropriate and service users hold keys should they wish to. A small leaded pane of glass was cracked in a service users room, the safety of this should be monotored until the pane can be replaced. The kitchen is in need of refurbishment which was identified at a visit from the Environmental Health Officer at a visit in June 2006 and some recommendations were made, some of which had been met or were in hand. The registered person/manager stated that there are plans to undertake a kitchen refurbishment but did not have a date for the commencement of this. The Fire Officer also visited in June 2006 and the registered provider informed the inspector that no requirements were made as everything was satisfcatory. As there was no fire risk assesment available for inspection, it is recommended that the registered provider ask the Fire Officer for confirmation in writing that the systems examined were satisfcatory. CCTV cameras are in use on the main entrance and exterior of building. Some handrails/raised seats around toilets were not securely fixed and may present a hazard if they tip on use. It is recommended that the home is assessed by an appropriate proffesional to ensure that the aids and adaptations in place are suitable for the current service users in residence. One bathroom had been fitted with new flooring but had started to ripple over the Christmas period. The manager stated that the supplier had been notified to rectify the problem and that service users would be asssisted until the flooring was fitted appropriatly. A lift is provided to access the first floor. Five Gables Care Home DS0000008677.V323821.R02.S.doc Version 5.2 Page 23 In the staff toilet there were no paper towels provided, there was a bar of hard soap as well as liquid soap. For infection control purposes papertowels should be in use and hard soap bars disposed of. [ i.e. the provision of liquid handsoaps only in communal areas] Towels should not be openly stored in toilet/bathrooms or communal areas as these may present a risk of cross infection also. The heating boiler had been working intermittently over the last two days, the manager reported that it had been very hot on the previous day and cool on the day of the inspection. The provider was experiencing difficulty getting parts but said he would notify the Commission for Social Care Inspection and arrange suppliment heating if the problem continued. Five Gables Care Home DS0000008677.V323821.R02.S.doc Version 5.2 Page 24 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users needs are met by the number and skill mix of staff and are in safe hands. Staff are not competent in first aid, diabetes and dementia care and training in these topics must be provided to ensure the needs of service users are fully met. Service users are supported and protected by the homes recruitment policy and procedures but the home does not meet the regulations in documentation held on file for staff employed. EVIDENCE: The duty rota was examined two care staff are provided on each day shift and two at night, additional hours are provided as needed. Training records and the Pre inspection questionnaire indicate that 60 of staff have achieved National Vocational Qualifications at Level 2 or above. Training records evidenced mandatory training provision for staff apart from first aid. Staff confirmed a good level of training in induction, food hygiene, fire safety, health and safety, manual handling, infection control and abuse awareness. Five Gables Care Home DS0000008677.V323821.R02.S.doc Version 5.2 Page 25 It was identified from speaking with care staff that knowledge about some areas of service users needs was limited and therefore it is recommended that care staff should have training provided in diabetes, challenging behaviour and dementia care. Staff should also receive training in equality and diversity. Four personal staff files were examined and although references and Criminal Records checks and Protection of Vulnerable Adults checks were clearly undertaken, one staff member had obtained two references from the same company and therefore another reference should be sought. One had a missing photograph. Five Gables Care Home DS0000008677.V323821.R02.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, 36, 37, and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a home, which is run and managed by a person who is fit to be in charge and which is run in the best interests of service users. The health, safety and welfare of service users and staff are generally promoted and protected. EVIDENCE: The manager is one of the providers and was currently undertaking National Vocational Qualification level 4 in management. The manager is registered with the Commission For Social Care Inspection. Five Gables Care Home DS0000008677.V323821.R02.S.doc Version 5.2 Page 27 The manager agrees that improvement to the documentation is needed to evidence the good service delivery provided. Record keeping other than what is reported in the report is otherwise satisfactory and notifications under the Requirements of Regulation 37 are sent to the Commission For Social Care Inspection. Service users and relatives reported that the manager is approachable and the staff and relatives reported that there are good relationships between both parties. The manager reported that generally no monies were held on behalf of any service user. The manager explained that charges for chiropody are included in the care fees and residents or their families pay the hairdresser direct. However through examination of service users finance records/receipts, there was evidence that at times that cash was held in the home on behalf of some service users and the system for receipts was not well organised. It is recommended that the registered provider review the system and ensure that impovements and appropriate records are kept. A safe is provided. The manager reported that there were no valuables kept in the safe on service users behalf. Improvement to the financial records held on behalf of cash transactions for service users would ensure protection to service users and staff. Quality assurance consultative committee meetings are held, the committee is made up of relatives and service users and they carry out regulation 26 requirements and arrange service user surveys. Service users are interviewed six months after admission by the consultative committee. Minutes were seen for these and for resident meetings and staff meetings. The manager was keen to self monitor the home and ensures the service users are consulted. The manager and relatives spoken with reported that there is a good relationship between relatives and management and the manager plans to monitor the relatives committee and make any required changes as appropriate. Five Gables Care Home DS0000008677.V323821.R02.S.doc Version 5.2 Page 28 Formal supervision is in place records were seen of sessions held. Staff confirmed that they have one to one time with the manager to discuss their performance and devlopment. Supervision should however take place at least six times a year. A random check was undertaken on health and safety records and maintenance records to confirm dates given in the pre inspection questionnaire. The five-year electrical circuit test and annual gas safety certificate were satisfactory. There were no issues identified in relation to water outlet testing and prevention of legionella. Care should be taken to ensure ‘use by dates’ on foodstuffs are noted. Where service users choose to keep alcohol in the communal areas, this should be risk assessed to ensure the safety of everyone. Five Gables Care Home DS0000008677.V323821.R02.S.doc Version 5.2 Page 29 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 2 X 3 3 2 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 4 X 2 3 2 3 Five Gables Care Home DS0000008677.V323821.R02.S.doc Version 5.2 Page 30 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 OP7 Regulation 14,15 Timescale for action Ensure care plans are devised for 27/03/07 all identified care needs of service users, which inform staff of how those needs will be met and that they are kept up to date and agreed by service users or their representatives. A requirement set at the previous inspection for care planning Timescale 28/02/06 is not met and therefore outstanding. Requirement 2. OP9 13 The registered person shall make 27/03/07 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. In relation to the issues identified within the report. 3. OP19 23 Ensure the flooring in the identified bathroom is re fitted DS0000008677.V323821.R02.S.doc 27/02/07 Page 31 Five Gables Care Home Version 5.2 4. OP29 19 5 OP30 18 Ensure staff personal records contain the required documentation as specified in schedule 2 and 4 Ensure all staff are fully competent to undertake their duties in relation to the provision of training in first aid, dementia, diabetes and challenging behaviour. 27/03/07 27/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations Obtain signatures from service users or their representative that they have been issued with a service user guide and information how they can access inspection reports Develop the equality and diversity agenda within the home and particularly in the assessment documentation and care plans Include foot care within the assessment and care plan documentation Ensure weight records are used in conjunction with healthcare evaluation and that weights are measured monthly. The registered manager should obtain training in the use of the Nottinghamshire Committee for the Protection of Vulnerable Adults policy and procedure. See www.nottsadultprotection.org for training information. Provide restrictors to the ground floor windows for security reasons. Re-furbish the kitchen. Consult with the fire authority in relation to fire risk assessment discussion. Provide evidence that the home has been appropriately assessed for aids and adaptations by a suitably qualified person and that the equipment in place is suitable. Address the infection control issues identified in the report DS0000008677.V323821.R02.S.doc Version 5.2 Page 32 2 3. 4 5 OP3 OP3 OP8 OP18 6. 7. 8 9 10. OP19 OP19 OP19 OP22 OP26 Five Gables Care Home 11. 12. 13 OP30 OP35 OP38 Provide training for staff in equality and diversity Review the current systems for receipting cash received for hairdressing and the organisation of receipts as discussed at the inspection. Ensure risk assessments are undertaken for alcohol kept in the home. Five Gables Care Home DS0000008677.V323821.R02.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Five Gables Care Home DS0000008677.V323821.R02.S.doc Version 5.2 Page 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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