Inspection on 16/08/07 for Gables (The)

This inspection was carried out on 16th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Gables (The) 06/12/08

Gables (The) 06/12/07

Gables (The) 30/01/07

Gables (The) 05/10/05

Gables (The) 06/05/05

Gables (The) 28/09/04

Gables (The) 22/06/04

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

CARE HOMES FOR OLDER PEOPLE Gables (The) The Gables Pembroke Road Woking Surrey GU22 7DY Lead Inspector Susan McBriarty Unannounced Inspection 16th and 29th August 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 Gables (The) DS0000013649.V346013.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. Gables (The) DS0000013649.V346013.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gables (The) Address The Gables Pembroke Road Woking Surrey GU22 7DY 01483 828792 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) Mrs Deoranee Boodia Mr Jugmohan Boodia Mrs Deoranee Boodia Care Home 16 Category(ies) of Learning disability over 65 years of age (14), registration, with number Mental disorder, excluding learning disability or of places dementia (2) Gables (The) DS0000013649.V346013.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age range of persons accommodated will be: 2 aged 45 to 64 years. 30th January 2007 Date of last inspection Brief Description of the Service: The Gables is a family owned and managed residential care home providing personal care for up to 16 Older People with learning difficulties or mental health needs. The home is a large detached house in a residential part of Woking, and is accessible to the main motorways and public transport. The facilities include large communal rooms, single bedrooms and an activities room. Car parking is provided to the front of the house. Residents have access to the garden at the rear of the home. The fees for the home range from £329 to £750 per week. Gables (The) DS0000013649.V346013.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 09:00 am on the 16th August 2007 and was in the service for seven hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owner or manager, and any information that CSCI has received about the service since the last inspection. A further visit was carried out on the 29th August 2007 from 9:30 to 12:15pm as information gathered by the commission on the 16th August 2007 had been lost through problems with IT equipment. What the service does well: What has improved since the last inspection? During the visit of the 16th August none of the fire doors had been wedged open meeting the requirement made during the inspection of the 27th January 2007. The laundry room floor had been replaced and was of a material easily cleaned assisting in reducing the risk of cross infection. Evidence was available to confirm that appliances in the home had received maintenance as required. Gables (The) DS0000013649.V346013.R01.S.doc Version 5.2 Page 6 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. Gables (The) DS0000013649.V346013.R01.S.doc Version 5.2 Page 7 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 Gables (The) DS0000013649.V346013.R01.S.doc Version 5.2 Page 8 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 was assessed. Standard six does not apply. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Further work is needed to make sure any new admission to the home is carried out in line with the home’s policy and procedure confirming the home only admits people whose needs they are able to meet. EVIDENCE: A resident had recently been admitted to the home, the manager confirmed to the commission she had not carried out a written assessment before the person moved in and the care plan had been written ‘about a week’ after arriving at the home. Please also see the Personal and Healthcare section of this report. Some information was available in the file from the local authority and previous placement that identified the needs of the new resident. The home was advised that it was good practice to carry out their own written assessment to make sure they could meet the needs of any prospective Gables (The) DS0000013649.V346013.R01.S.doc Version 5.2 Page 9 resident and make sure members of staff knew what to do until the initial care plan had been completed. The AQAA received by the commission from the home said that a full process of assessment was carried out via a care manager for suitability. The AQAA also sets out what areas were assessed prior to admission including dietary preferences, social interests, hobbies, religious and cultural needs, mental health and cognition and oral health. This was not confirmed during this visit. The referral and admission procedure of the home was last reviewed on the 27th June 2007. A requirement is made for the home to review their admission procedure to make sure the home follows the procedure they have laid out. Gables (The) DS0000013649.V346013.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10 were assessed. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvement is needed to make sure the people who use the service are supported and protected by clear, accurate care plans and risk assessments. Some work was needed to improve the ordering of medication. EVIDENCE: Feedback from four people including residents and relatives said the home always met their personal and health care needs. The commission were informed all the residents received the medication they needed and visits from a doctor when necessary. A local authority funded all the people living at the home. The manager said nutritional screening as required from the inspection of 23rd January 2007 had not taken place. The commission were told the General Practitioner (GP) and District Nurse had told the home this was not necessary and would only be carried out if necessary. The manager had not informed the commission of the outcome of this requirement until this inspection. The Gables (The) DS0000013649.V346013.R01.S.doc Version 5.2 Page 11 assessment process as noted under Choice of Home takes into account dietary preferences only. The commission sampled two of the five resident files including a recent admission. The manager said the care plan for the recently admitted resident had not been completed until ‘about a week after’ admission. The care plan did not make clear how members of staff were to assist or support the new resident. For example, issues about not taking medication noted staff were to call for medical assistance if this happened and not whether other options might be available to encourage the person to take their medication. One care plan identified the action to be taken by the home to make sure a health matter was monitored every day, this had not occurred. The manager confirmed the home did not have the equipment to carry out the monitoring. During the second visit to the home the manager said she had spoken with the local District Nurse who confirmed occasional monitoring was adequate and on those occasions when agreed with the resident. The equipment needed to carry out the monitoring was seen by the commission during the second visit. The manager was aware the information on the care plan needed to be updated to show this change. The care plans would benefit from further development to include more detailed information about the residents likes and dislikes and how these would be met. The risk assessments viewed did not clearly set out what the risk was and what members of staff had to do to reduce the risk. Other information and dates had been added to the risk assessments and it was unclear if the previous information remained valid. The AQAA received by the commission said risk assessments were reviewed every three months this was not confirmed by the documents seen. The requirement made following the inspection of the 27th January 2007 for risk assessments to be reviewed regularly had not been met. A requirement is made for the home to review and revise the care plans and risk assessments to ensure they provide clear accurate information about the people who use the service, their needs and how those needs must be met. A separate record held on the files had been kept for use by the doctors visiting the home, these had been signed and dated and included information about the outcome of their visit. The commission sampled medication given by the home and found that on one occasion a resident was not given the medication they needed during the morning. The manager said this was because the medication was not delivered until later in the day. In discussion with the manager the home was aware of how much medication the resident had and how long it would last Gables (The) DS0000013649.V346013.R01.S.doc Version 5.2 Page 12 and had enough time to make sure a delivery was made before the resident ran out. It is recommended the home ensure arrangements are such the home does not run out of medication for any current or future resident. A Nomad (boxed doses of medication) is used, the name and a description of the medication to be given was on the back of the box to assist members of staff to check the correct medication is provided. Signatures of staff trained to give medication were at the front of the medication record file; the manager said one member of staff on the list had left the service. A policy and procedure for giving medication was in place. We advised the manager to keep the list up to date as this would confirm the home kept accurate records and people who use the service were protected by the practice of the home when giving medication. Gables (The) DS0000013649.V346013.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 and 15 were assessed. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The lifestyle experienced at the home met the expectations of the people who use the service and satisfied their social, cultural, recreational and religious needs enabling residents to maintain family relationships and exercise choice and control over their lives. Meals are provided at suitable times and the food was varied. EVIDENCE: Feedback from the surveys received and from people who use the service given to the commission during the visit confirmed activities were provided either by the home or other external services, for example attendance at a day centre. The activities provided by the home included games, books and playing cards. One person said they could do an activity at any time they asked. The feedback received by the commission also said residents sometimes went out for meals, to the cinema or went shopping. Transport is not provided by the home. A local lay preacher also attended the home to provide Christian services. All the surveys received said most of the residents held a Christian faith. Where possible contact was maintained with family members. Gables (The) DS0000013649.V346013.R01.S.doc Version 5.2 Page 14 A separate dining area was provided and residents were able to take their meals together if they wished. Lunch was observed during the visit and was served hot and well presented. Feedback from the people who use the service said that meals were liked and no concerns were raised about the food provided. The home was aware of residents who were on diets related to their health, for example diabetes. Gables (The) DS0000013649.V346013.R01.S.doc Version 5.2 Page 15 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): Standard 16 and 18 were assessed. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who use the service can be confident their views are listened to and acted upon. Further work is needed to make sure residents and members of staff are supported and protected by the policy and practice of the home regarding safeguarding matters and the use of restraint. EVIDENCE: A complaints policy and procedure was in place and included timescales and the new address of the commission. The surveys received and feedback from people who use the service during the inspection confirmed they knew whom they would talk to if they were unhappy or wanted to make a complaint. The AQAA said the home had not received any complaints within the last twelve months. The home had a copy of the local authority multi-agency procedures in the office. The home’s policy and procedure for safeguarding adults (adult protection) and whistle blowing were looked at. The safeguarding policy states the manager would carry out an investigation into any allegation, this action did not support the local authority procedures. The whistle blowing policy did not make the link between allegations of abuse and the safeguarding procedure. This will make sure the management and members of staff working at the home know what to do if an allegation of abuse is made. Gables (The) DS0000013649.V346013.R01.S.doc Version 5.2 Page 16 The information about training was looked at, not all members of staff had received training about safeguarding adults most had received training in 2005. Please also see the Staffing section of this report. The home had not made or received any safeguarding (adult protection) referrals in the last twelve months and none had been made or received by the commission. A requirement is made for the safeguarding policy and procedure to be revised to support the local authority multi-agency procedures and for the whistle blowing policy to contain a statement making the link to safeguarding matters. This will ensure members of staff and residents are protected by the practice of the home. The policy and procedure for dealing with aggression was also viewed. The policy states that restraint may be used in certain circumstances. None of the members of staff working at the home had received training to carry out a restraint. A requirement is made for the policy and procedure to be reviewed and if considered by the home as necessary members of staff must receive accredited training to carry out safe restraints. This will make sure residents and members of staff are kept safe by the policy and practice of the home when dealing with aggression. Gables (The) DS0000013649.V346013.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 were assessed. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some improvement was needed to make sure the home was kept safe for the residents. The home was comfortable and kept clean. EVIDENCE: A tour of the home took place and most of the bedrooms were seen and all of the communal areas. The fencing at the rear of the home had not been attended to and was collapsing; the manager said the fence was not the property of the home. A recommendation is made for the home to make the area safe for the people who use the service by taking appropriate action to ensure residents cannot approach the area until such times as the fence is repaired or replaced. The extension was not is use by residents the manager was using the vacant bedrooms for storage, part of the hall in the same extension was also being Gables (The) DS0000013649.V346013.R01.S.doc Version 5.2 Page 18 used for storage. A requirement is made for the items to be risk assessed in case of fire or other risks to be identified by the home in order to make sure residents are safe. The laundry floor had been replaced and was clean as required during the inspection of the 23rd January 2007. The requirement had been met. None of the liquid soap containers held any soap. The manager told the commission the containers leaked and had been replaced with bottles of liquid soap. Most of the areas seen did have a bottle of liquid soap provided; all toilets and bathrooms had communal towels in use. A requirement is made for this to be risk assessed against the possibility of cross infection taking into account the needs of the residents. No doors were wedged open inappropriately during this visit. The manager did not confirm consultation with a fire safety officer had taken place as required from the inspection of 23rd January 2007. A requirement is made for the home to confirm in writing the date of the last visit carried out by a fire safety officer and tell the commission about any recommendations made. Feedback from people who use the service said the home was always kept clean and fresh and was cleaned daily by the staff working at the home. Gables (The) DS0000013649.V346013.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 and 30 were assessed. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some work was needed to ensure information about staffing levels on duty is recorded accurately. Improvement is needed to make sure the people who use the service are provided with care and support by robust recruitment procedures and trained competent members of staff. EVIDENCE: Staffing rotas for June, July and August 2007 were requested from the home prior to the visit and were received on the 10th August 2007. The AQAA received stated the home ‘adhered to Standards 27.2 to 27.7 of The National Minimum Standards. Standard 27.1 states the staffing numbers and skill mix of the home are appropriate to the needs of the service users, this Standard was not set out as adhered by the home. In the section on ‘what we do well’ the home said ‘members of staff are skill mixed-qualified/unqualified’ the AQAA did not confirm the home considered numbers of staff to be adequate to the needs of the residents. The rotas received confirmed the owners/manager lived on the premises and covered all of the sleep-in night duties, no waking night members of staff were provided. One of the owners also carried out a ‘check round’ at 9pm and 12pm on a regular basis. One other member of staff worked from 8pm to 11pm between four and five nights a week on those occasions a check round was carried out at 9pm and 12pm finishing work some time after midnight. Gables (The) DS0000013649.V346013.R01.S.doc Version 5.2 Page 20 Most days viewed between June and August 2007 on the rota show two on duty each morning up to 1pm or 2pm and one in the afternoon to 8pm continuing with one member of staff until 11pm with up to three on during a change in shift or a morning shift to assist five residents. Concerns had been raised with the commission about staffing levels at the home and a telephone call was made at 9:45pm on the 28th August 2007 by the commission. A member of staff was on duty and was able to inform the commission of the changes to the rota and the reason for the change. On the day of the second visit changes had been made to staffing, these had not been recorded on the staff rota. A recommendation is made to ensure any changes to staffing are recorded on the rota and accurately reflect who is on duty and when. This will make sure adequate staffing numbers are shown as being available throughout the day. The AQAA received said more than 50 of the members of staff working at the home were nurse qualified. The AQAA also documented that training and support for members of staff was offered to ‘maintain and fulfil the aims of the home and meet the needs of the service users’. Improvement in the last twelve months noted that members of staff had attended training although no details were given of what training had been attended. Detailed information was taken about training provided to each member of staff working at the home. The information showed not all staff had received training about mental health needs or learning disabilities and other mandatory training was out of date including manual handling. Induction training where provided was confirmed by the use of a tick list, one member of staff had received formal induction training. During the second visit to the home the manager said she had already contacted a training provider and they were arranging a visit to the home to discuss and plan dates for the training required. A requirement is made for the home to provide the commission with details of the training planned including mental health, learning disabilities and mandatory training. The information to include which member of staff including the management of the home will be attending what training including the date. This was the third inspection where concerns were raised by the commission including the 23rd January 2007 and 5th May 2006 that members of staff were found to be working at the home without either a PoVA first check or a Criminal Records Bureau (CRB) check. A PoVA check makes sure the person applying for a job had not been placed on a list advising they must not be allowed to work with vulnerable people. The AQAA received made no mention of the recruitment policy and procedure followed by the home to ensure safe and robust recruitment practice and Standard 28 of The National Minimum Gables (The) DS0000013649.V346013.R01.S.doc Version 5.2 Page 21 Standards for Older People had not been mentioned as being adhered to in the section on ‘what we do well’. During this visit it was found that a long-standing member of staff did not have a CRB check. The manager contacted the agency that carries out the CRB and PoVA first checks and confirmed that no application had been made. The manager said she could not understand how this matter was overlooked. An immediate requirement was made to make sure that no member of staff worked at the home or began working at the home without a satisfactory PoVA first check or a satisfactory CRB check. This will make sure the people using the service are supported and protected by the recruitment practice of the home. At the time of the second visit the manager had written to the commission confirming the action taken to make application for a CRB and confirmed the person was not working at the home until such times as a satisfactory CRB was received. The employment application form used by the home would benefit from making clear that a full employment history is required, the form asks for an employment history and a reason for any gaps. Feedback received by the commission from people who use the service said members of staff were kind and listened to what they said. Gables (The) DS0000013649.V346013.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35 and 38 were assessed. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvement is needed to make sure the home is run in the best interests of the people who use the service to make sure their health, safety and welfare are promoted and protected by the practice of the home. EVIDENCE: The AQAA received by the commission said the manager of the home was nurse qualified and had been running the home for twenty two (22) years and said she took ‘reasonable and practical responsibility of the health, safety and welfare of the service users and staffs’. In addition under ‘what we have improved’ the manager said ‘ we have worked with legislations and recommendations from our modernising CSCI’. This was not confirmed during this visit by the commission. Gables (The) DS0000013649.V346013.R01.S.doc Version 5.2 Page 23 A requirement has been made in the Staffing section of this report that includes the manager with regard to making sure all members of staff working at the home have the training they need. Please see Staffing section for detail. Matters raised in this report, particularly about non-compliance with requirements made by the commission, risk assessing and recruitment practices, do not confirm that the practice of the home promotes and protects the people who use the service. As stated in the AQAA received the home had drafted a policy and procedure for carrying out a quality assurance audit as part of the requirement made following the commission’s visit on 23rd January 2007. The manager confirmed that no other action had been taken to find out what the experience was of the people who use the service or the views of their relatives. A further requirement is made to make sure the views of the residents, their relatives or others involved in their care and support is sought and the outcomes made known. The commission sampled the finances of two of the people living at the home one was correct and one was found to have more money than had been identified by the record held. The manager said other payments had not yet been taken out and she had not had the time to sort the matter out. The manager was advised to make sure that any expenditure and income were recorded immediately to make sure the records were kept up to date and accurate. This will make sure that residents’ finances are protected by the practice of the home. Evidence was seen of safety checks having been completed including gas safety and electricity tests. Documents were not available to show that legionella testing had been carried out as required on the 23rd January 2007. The manager said a water test had been sent within the last two weeks. The manager made a telephone call to the agency carrying out the tests and informed the commission the test was negative and a certificate to confirm was being sent to the home. The manager told the commission that she had not had time since the inspection of the 23rd January 2007 to undertake the risk assessments about chemical hazardous to health (COSHH) as had been required. A further requirement is made for the home to complete the risk assessments to make sure the people using the service are safe. The home provides for people who have mental health needs or a learning disability and this must be taken into account when carrying out the risk assessments. This will make sure that members of staff know what to do in the event of an incident and if additional support would be needed if the incident involved a resident. Gables (The) DS0000013649.V346013.R01.S.doc Version 5.2 Page 24 A recommendation was made on the 23rd January 2007 for the home to record the review dates of the policies and procedures used by the home. Some of the policies and procedures seen had been dated and others had not been. The recommendation for the home to provide a visitors book for people to sign in and out of the home was not looked at during this visit. The manager said both these matters were being dealt with. Gables (The) DS0000013649.V346013.R01.S.doc Version 5.2 Page 25 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 1 Gables (The) DS0000013649.V346013.R01.S.doc Version 5.2 Page 26 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 OP3 Regulation 14 Requirement The policy and procedure for admitting new residents must be reviewed to make sure the home is able to meet the procedures given and for the home to follow those procedures consistently. This will make sure the home does not admit someone whose needs cannot be met. Care plans and risk assessments must be reviewed and revised to make sure all the details needed are accurate and detailed. This will make sure members of staff know the care and support needed and how the care and support must be provided. The Registered Person must ensure all risk assessments are reviewed on a regular basis. This will make sure members of staff are aware of and know what to do to reduce known risks to the people who use the service. Timescale from the 27th January 2007 not met. Gables (The) DS0000013649.V346013.R01.S.doc Version 5.2 Page 27 Timescale for action 28/09/07 2. OP7 OP8 15,13(4) (c) 28/09/07 3. OP7 13 (4) (c) 28/09/07 4. OP18 13(6)(7) (8) The policy and procedure for safeguarding (adult protection) must be revised to make sure it supports the local authority multi-agency guidelines. The whistle blowing policy must have a statement added to identify the link to adult protection. The dealing with aggression/restraint policy and procedure must be reviewed to make sure the home is able to safely provide such restraint if needed or make a decision about alternative options. 31/10/07 5. OP19 OP26 13(4)(c), 23(2)(b) (o) This will make sure the people who use the service are supported and protected by the policy and practice of the home regarding safeguarding matters. 28/09/07 A risk assessment must be completed about the first floor hallway being used for storage to reduce any potential hazard to residents. A risk assessment must be carried out and any action necessary taken to reduce the risk of cross infection from the use of communal towels taking into account the needs of the residents. To notify in writing to the commission the last date of a visit to the home by the fire safety officer and any recommendations made during the visit. This will ensure that any potential hazards identified by the home receive attention and Gables (The) DS0000013649.V346013.R01.S.doc Version 5.2 Page 28 6. OP29 19 (1) (a) (b) residents are protected by the practice of the home. The Registered Person must ensure that POVA first checks and Criminal Records Bureau clearances are undertaken on all staff before they commence duties in the home. This will make sure residents are supported and protected by robust recruitment procedures. Timescale from the inspections of the 5th May 2006 and 27th January 2007 not met. 16/08/07 7. OP28 OP29 18(1)(a) (c)(i)(ii) Mandatory and specialist training must be provided to all members of staff including the management of the home. The training must include the following: Mental health, learning disabilities, formal induction programme for new staff, manual handling, food hygiene, fire safety, administration of medication, health and safety and risk assessment, adult protection and restraint (if restraint policy remains in place) and qualifying training. The commission must be informed in writing of the dates for training and the training to be provided and to whom. 12/10/07 8. OP33 24 This will make sure people who use the service are supported by trained competent members of staff. The Registered Person must 31/10/07 undertake quality assurance on a regular basis to ascertain the views of residents, relatives and DS0000013649.V346013.R01.S.doc Version 5.2 Page 29 Gables (The) 9. OP38 13 (4) (c) other associated professionals to ensure the home is run in the best interests of residents. Timescale from the inspection of 27th January 2007 not met. The Registered Person must ensure that the risk assessments in regard to the Control of Substances Hazardous to Health (COSHH) are updated and reviewed on a regular basis. This will make sure residents and members of staff are protected by the policy and practice of the home. Timescale from the inspection of 27th January 2007 not met. 28/09/07 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. 2. 3. 4. Refer to Standard OP9 Good Practice Recommendations It is recommended the home order medication in a timely fashion to make sure residents have the medication they have been prescribed. It is recommended the home take action to ensure a risk assessments is completed regarding the broken fencing at the rear of the home. It is recommended all the recruitment files are thoroughly reviewed to make sure all the information required is available. It is recommended an accurate duty roster be kept by the home. This will ensure the home provides adequate staffing cover throughout the day to meet the needs of the residents. OP19 OP29 OP27 Gables (The) DS0000013649.V346013.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Oxford Office Burgner House, 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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 Gables (The) DS0000013649.V346013.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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