Inspection on 22/08/06 for Green Gables

This inspection was carried out on 22nd August 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Green Gables 16/08/07

Green Gables 27/09/05

Green Gables 11/04/05

Green Gables 18/10/04

Green Gables 24/05/04

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

CARE HOMES FOR OLDER PEOPLE Green Gables Green Gables 2 Woodside Road Low Moor Bradford West Yorkshire BD12 0TX Lead Inspector Sue Dunn Key Unannounced Inspection 22nd August 2006 10:00 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 Green Gables DS0000001280.V307452.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. Green Gables DS0000001280.V307452.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Green Gables Address Green Gables 2 Woodside Road Low Moor Bradford West Yorkshire BD12 0TX 01274 676231 F-P1274 676231 greengablesch@aol.com 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) R & N Partners Mr Ian Helstrip Care Home 11 Category(ies) of Dementia (2), Old age, not falling within any registration, with number other category (10), Physical disability (1) of places Green Gables DS0000001280.V307452.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th September 2005 Brief Description of the Service: Green Gables is situated in the Low Moor area of Bradford on a bus route into the city. The stone built detached house, standing in a large garden with a small area for off road parking, is indistinguishable from other houses in the area. Several local shops and a bookmaker are within walking distance of the home. All but one of the rooms is shared and none have en suite facilities. One of the shared rooms is on the ground- floor; a stair lift provides access to the first floor rooms. Decorations and furniture give a homely feel and people are encouraged to bring some small personal possessions into the home. Two care staff are on duty at all times during the day with one waking and one sleeping person on at night. A cook is employed 7 days a week and tries to include residents’ choices into the weekly menu. Green Gables DS0000001280.V307452.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the inspection was to ensure the home was operating and being managed for the benefit and well being of the residents. One inspector undertook the inspection, which was unannounced. The inspection started at 12.05 pm and finished at 5.30pm A pre inspection questionnaire sent to the manager had been completed at the time of the inspection and was used to support judgements made during the inspection visit. Comment cards with pre paid envelopes had previously been left in the home inviting people to express their views about the service. None had been returned since the last inspection. The report is based on information received from the home since the last inspection in September 05, observation and conversation with residents, staff and relatives, examination of 3 care files (case tracking of one) and an inspection of the premises. Information not received before the visit and unavailable during the visit has been requested to be sent to the CSCI. What the service does well: Relatives spoken with said the home had been chosen for its small size and ‘homely’ atmosphere which they felt would have been lost in a large purpose built building. Staff and service users have the opportunity to develop close relationships due to the small number of both and staff were observed to be caring and have a good rapport with service users. The people in the home have the opportunity to keep in regular contact with staff and service users in the company’s other home in the Bradford area. The manager either provides or organises transport for this. The menu provides good ‘home cooking,’ which fills the home with mouthwatering smells. A relative said that the staff ‘go out of their way’ to accommodate the tastes of people who do not want the set menu. Green Gables DS0000001280.V307452.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The Statement of Purpose must be a document that all staff understand and work to as this is not just for inspection purposes but should be guiding the way the home operates. The information in needs assessments must be accurate and as far as possible give information about more than just physical care needs. Improvements could be made by including more background information about peoples’ past lives in the care files. This would enable staff to direct activities and conversation towards individual interests and skills. It must be possible to follow through the outcome of recorded information. The medication procedures must be safe. Staff must be able to put into practice the training they have received and understand the medication they are giving. The manager is advised to contact the local Health Trust for information about their recently introduced risk assessment for pressure ulcers. The care files should include peoples’ wishes about their end of life care. Fire exits in the home are accessed via a link door between two bedrooms and through the bathroom, which means these doors cannot be locked. The manager has been asked to look at ways in which this breach to privacy may be overcome without compromising fire safety. Adult Protection training must be effective. The approach to this was vague even from staff who, after prompting, ‘thought’ they had done some training. The following work is required to the building: - external windows need re painting, pane of glass to be replaced, decorative repair in one bedroom. bedroom door closure to be adjusted to close fully, fire exits to be kept clear at all times, shower cubicle to be kept in a usable condition, the bath side to be replaced, the carpet in the hallway to be replaced/repaired, the laundry floor to be kept clean. There was no evidence to show if an assessment of risk had been carried out on the gate at the top of the staircase, which is a restriction for all service users. This was recommended at the last inspection. Service users must have freedom of access to a telephone. Green Gables DS0000001280.V307452.R01.S.doc Version 5.2 Page 7 The home should have dedicated staff for cleaning to release more time for care staff to spend with service users. The manager must ensure that staff are clear about the training they receive and be prepared to monitor the way this underpins care practices. There must be clear accountability for the management of the home in the manager’s absence and staff left in charge of the home must have the knowledge and information required to fully discharge their responsibilities. There must be a programme of formal staff supervision, which gives each member of staff a minimum of 6 supervisions a year. 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. Green Gables DS0000001280.V307452.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 Green Gables DS0000001280.V307452.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 and 5 Quality in this outcome area is adequate. This judgement is based on all the available evidence which included inspection of care plans, discussion with service users, staff and relatives. The rating could be improved if the Statement of Purpose were used as a document to guide the way the home operates. The pre admission assessment forms were good but these must be completed fully and the information must accurately reflect peoples’ needs to ensure care needs are not overlooked. EVIDENCE: Staff were unsure about the homes Statement of Purpose or its content though a copy of this was in the entrance area close to the visitors book. This is intended to be the basis upon which the home operates therefore all staff should be familiar with the document and its contents. Green Gables DS0000001280.V307452.R01.S.doc Version 5.2 Page 10 Pre admission assessments for more recently admitted service users were checked. These were dated on the day of admission but the proprietor thought the date was when the information had been typed onto the form. He acknowledged this needed to be made clear. The layout of the form was good. Care needs were identified and showed where assistance would be needed. This provided a basis for a care plan to meet physical care needs. There was evidence to show the service users had been involved in the care planning process but it was disappointing to find no social background information to give guidance on social, emotional and spiritual needs. The information in one assessment was found to be inaccurate which had led to a person who had always worn spectacles not having had any spectacles since admission. Discussion with relatives could have sorted this problem quickly. Green Gables DS0000001280.V307452.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is adequate. The judgement is based on all the available evidence including examination of three care files, (one of which was case tracked), speaking to relatives, observing and speaking to service users and observing practices and speaking to care staff. Improvements could be made by including more background information about peoples’ past lives in the care files. It must be possible to follow through the outcome of recorded information. The medication procedures must be safe and staff must put into practice the training they have received. Care files must include information about end of life care. EVIDENCE: Care files were securely held in a locked cupboard which staff had access to. It was evident that some staff did not see the relevance of recording information they received about peoples past lives as a few minutes conversation provided useful background information which was not seen in the file. Care files included a photograph and the number of the room occupied. The content of care plans varied. One care plan gave some specific guidance for staff, an example being how staff should support a person who had difficulty sleeping. Green Gables DS0000001280.V307452.R01.S.doc Version 5.2 Page 12 A plan to reduce falls was linked to a risk assessment A care plan to encourage social interaction mentioned an interest and daily notes showed this was carried through. There was no record however of what action had been taken in response to a loss of weight. Waterlow tissue viability checks had been completed but to make these more effective they should include an explanation of the resulting score. The manager is advised to contact the local PCT who have developed a new system for assessing the risk of pressure sores. Another care plan only covered personal hygiene and social interaction. There was no care plan regarding the management of the person’s diabetes (though there was evidence elsewhere in file to say the person had diabetes) and it was not recorded on a nutritional screening form, which was found in the file. The district nurse had visited the person to check blood sugars but there were no further entries in the file to state the outcome of the visit and nothing to advise staff on the frequency blood sugars were to be checked or any behaviour, which may indicate changes to blood sugar levels. There was evidence staff had taken action to call an ambulance when the service user was unwell. However, the proprietor was asked to investigate the circumstances leading up to this event and inform CSCI. One of the care staff said staff had distanced learning medication training. She explained the medication procedures. This involved a senior carer checking the medication when it arrived at the home then transferring it to a dosset box for each service user. The person who administers the medication then transfers the daily dose into a pot, which is taken to the service user. ‘Secondary dispensing’ does not meet the guidance of the British Royal Pharmaceutical Society, as it is open to error. The member of staff giving the medication was unsure about the purpose of some of the medication and was unaware that a copy of the guidance was in the medication trolley with other medication reference books. None of the service users self medicates. Care files did not indicate service users wishes for the care they would like to receive towards the end of their life. As bedrooms are shared it would be difficult to maintain dignity and privacy for people who may wish to remain in the home to die. Green Gables DS0000001280.V307452.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area was adequate. The judgement is based on all the available evidence, which included discussion with relatives and staff, examination of care plans and observation. Staff attempted to generate enthusiasm in activities but with little background information it was difficult to tailor these to each service user’s preferences. Quality of life was more varied for articulate, active service users. Daily life could be improved with a more broad and imaginative approach based on each person’s background information. EVIDENCE: Overall care files gave little information about personal interests. A memory book, a good idea if used correctly, was only seen in one of the files examined and had not been completed. Care staff said they tried to generate activities around the household and personal care tasks. They said people liked to play dominoes and there were some board games. In the afternoon a care worker was playing sing-along music at high volume and encouraging people to dance. Two mobile service users moved into the dining room one saying ‘I think this music goes on too long’. Green Gables DS0000001280.V307452.R01.S.doc Version 5.2 Page 14 The TV in the small lounge had recently been replaced but the picture and sound was poor as it kept switching from mono to stereo mode. There was no evidence of books magazines or newspapers around the home though one person was said to have been a very keen reader (not seen in the care plan). Daily notes showed that word puzzle games had been provided for one person. Manicures and hairdressing between the hairdresser’s visits are seen as an opportunity for staff to spend 1:1 time with people. Families and friends visit regularly and said the home was chosen for its small intimate atmosphere. However, there is little space for entertaining visitors in private. The Statement of Purpose spoke of trips and outings. The last organised outing was to Blackpool ‘sometime before February’. It is acknowledged that when outings have been arranged in the past people drop out at the last minute. One person said the access bus or manager provides transport to another home every Friday to visit a friend. The two course main meal is at lunchtime followed by a light cooked tea. Alternatives can be provided as observed and heard from a relative. A large bowl of fruit on display in the dining room would have been better had it been real. Service users were satisfied with the ‘home cooked’ style of meals. Green Gables DS0000001280.V307452.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement is based on all the available evidence including the pre inspection questionnaire, examination of documentation and discussion with staff There were concerns about the quality of adult protection training as staff were unclear about adult abuse issues or how to apply the adult protection procedures. One of the daily records raised cause for concern and was brought to the attention of the proprietor for further investigation. There had been no outcome from this at the time of writing. EVIDENCE: The complaints procedure was in a prominent place in the entrance hall where visitors sign in. There had been no complaints since the last inspection A care worker spoken with said she had not had Adult Protection training. She had a vague idea that she would speak to a senior member of staff if she had concerns but was not aware of the procedures or an adult protection manual, which the inspector was told at the time of the last inspection all staff would receive. Another care worker, when prompted could remember having some Abuse training. The proprietor was asked to investigate a written entry in one service user’s care file regarding care practice, which might be considered abusive. Green Gables DS0000001280.V307452.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25 and 26 Quality in this outcome area is adequate. The judgement is based on all the available evidence, which included discussion with service users and relatives and a tour of the premises. The home provides a pleasant environment for people who want the benefits of a small home but would not meet current standards for the existing number of service users were it to be re registered. The home is clean and free from unpleasant odours. Some maintenance and redecoration work had been carried out. Further work was noted including fire safety issues. EVIDENCE: The home has a pleasant domestic atmosphere but is not able to offer the privacy of single rooms. The ground floor room, which accommodates two people, would not meet the new standards, as it is below size and the ratio of single to shared rooms is higher than stated in new standards. There is only one bathroom for 11 service users (the ratio is 1:8). The bedrooms on the first floor are reached by stair lift. Service users wishing to use their rooms during the day have to rely on staff to assist them, therefore appear to snooze in the Green Gables DS0000001280.V307452.R01.S.doc Version 5.2 Page 17 lounge chairs. A small number of personal items were seen in the bedrooms, all of which had been fitted with suitable locks for privacy and security. Privacy continues to be compromised in two bedrooms, which are a through route to the upstairs fire exit and the bathroom, which has another fire exit door. The proprietor and manager are aware of this. A part time gardener kept the garden neat and tidy but there was no planting to provide visual interest for people who may wish to sit out. It was evident from the manager’s pre inspection information and observation that some rooms had been redecorated and looked fresh and clean. The bay window in one of the bedrooms, where there had been damage from a roof leak, had been redecorated and the staff w/c had been repainted. The home’s maintenance programme was not available for inspection in the absence of the manager and a number of maintenance issues were noted as follows: Metal window frames at the front of the house were showing signs of corrosion and there was a pane of glass missing from one of the secondary glazed windows at the rear. The door of room 6 did not meet fire safety requirements, as it was not fully closing, and the wallpaper over a cupboard in one room was peeling from the wall. The bath side had been partially removed (due to ‘problems with the plumbing’) and looked unsightly. The shower cubicle in the bathroom was being used for storage therefore did not offer an alternative choice for bathing and a vacuum cleaner and carpet shampooing machine were stored in front of the fire exit blocking the door. The senior care worker removed the machines immediately. The carpet in the hallway between the kitchen and main lounge is stretched and wrinkled threatening to become trip hazard if left unattended. In the laundry there was a build up of debris on floor, which could become source of cross infection. The home’s telephone is in the hall and is the only phone available for service users to use. Staff indicated that service users have to seek the manager’s permission to use this phone which does not offer privacy if required. Green Gables DS0000001280.V307452.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 30 Quality in this outcome area is adequate. This judgement is based on all the available evidence, which included information from the pre inspection questionnaire, discussion with relatives and service users and staff, observation of staff practices and conversation with the proprietor. Staffing levels were satisfactory but influenced by the absence of dedicated cleaner which affected the time staff had to spend with service users. The staff were caring and seen to have a good rapport with service users. Details of staff training had not been included in the information sent by the manager and staff were unsure about the training they had received. Service users and relatives were happy with the service. EVIDENCE: The manager was on leave on the day of the inspection visit. The two care staff had not previously experienced an inspection and were nervous but did what they could to assist. They were on the early shift with the cook caring for 10 service users, which was a satisfactory ratio for care. The cook finished after lunch leaving two staff on the late shift. The home does not employ a dedicated cleaner therefore care staff do the cleaning, laundry and prepare and serve the evening meals. On the day of the visit a service user who needed help with eating remained on her bed until after everyone else had eaten before she could be assisted There was evidence to show that two staff had done medication training. Green Gables DS0000001280.V307452.R01.S.doc Version 5.2 Page 19 A care worker who started earlier in the year could not recall having had any formal induction training but confirmed she had a CRB check before starting work and had fire lecture the previous week. She described her appraisal and said senior staff tell the manager how she has been doing. She was not aware of having had supervision. Staff were seen to be very kind and conversational with residents but should be more discrete when asking people if they wanted the toilet. One person was seen to wipe a service user’s mouth with her finger rather than getting a tissue. Green Gables DS0000001280.V307452.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 36, 37 and 38 Quality in this outcome area was adequate. The judgement is based on all the available evidence, which included information from the pre inspection questionnaire, Examination of records, discussion with staff, relatives and service users and conversation with the proprietor. The day- to- day management of each shift in the absence of the manager was not clear and could have serious implications in a crisis. Staff left in charge of the home were not clear about their responsibilities for other than basic care practices therefore not aware of the whereabouts of records or how policies and procedures impacted on the whole home. There were doubts about effectiveness of the programme of staff supervision. Green Gables DS0000001280.V307452.R01.S.doc Version 5.2 Page 21 EVIDENCE: The pre inspection questionnaire which was received before the inspection visit had not been fully completed by the manager therefore some information was not available in the manager’s absence. It was not clear at the start of the inspection who had lead responsibility for the shift, as neither of the care staff was sure. The care worker who had worked in the home longest eventually assisted with the inspection and notified the proprietor. The staff were not sure where the fire safety records could be found but thought the ‘supervisor’ did fire tests in the manager’s absence. The proprietor confirmed this. A member of staff spoken with was unsure about whether or not she had supervision confusing this with an appraisal. Staff recruitment and training records and Health and Safety check records could not be accessed. The proprietor was asked to forward copies of these to the CSCI. The manager does not hold any money on behalf of service users. A relative wanting to pay fees was concerned that this would have to wait until the manager’s return. The proprietor was given feedback about the inspection and asked to forward copies of the following records to the inspector: Staff training records and training plan, 2 recent rotas, Health and Safety check records, Details of the fees charged, evidence of the dates of CRB checks, Details of the home’s Quality assurance programme, Details of the GP’s and other health professionals who visit the home Contact details for relatives. Green Gables DS0000001280.V307452.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 3 2 x 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 x x x 2 2 2 Green Gables DS0000001280.V307452.R01.S.doc Version 5.2 Page 23 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 OP4 OP3 Regulation Reg 14 Requirement Information in the assessments of need must be accurate and provide sufficient background information for all needs to be assessed. Information about care provided must be in sufficient detail to show the outcomes Medication procedures must be safe and in accordance with British Royal Pharmaceutical Society Guidelines The manager must look at ways in which privacy can be maintained in those bedrooms with linking doors Care plans must include information about end of life care Care plans must include a social and recreational plan for all service users based on their interests and abilities All staff must have effective training to enable them to fully understand adult protection and the policies and procedures The following work must be undertaken: - external windows need re painting, pane of glass DS0000001280.V307452.R01.S.doc Timescale for action 30/10/06 2 3 OP7 OP9 Reg 15 Reg 13 30/10/06 30/10/06 4 OP10 OP23 OP11 OP12 Reg 23 14/01/07 5 6 Reg 12 Reg 15 Reg 16 Reg 18 31/12/06 31/12/06 7 OP18 31/03/07 8 OP19 Reg 23 31/03/07 Green Gables Version 5.2 Page 24 9 OP21 Reg 12 Reg 23 Reg 18 10 OP30 11 OP32 Reg 18 12 13 OP36 OP37 Reg 18 Reg 17 14 OP38 Reg 23 to be replaced, decorative repair in one bedroom, bedroom door closure to be adjusted to close fully, fire exits to be kept clear at all times, shower cubicle to be kept in a usable condition, the bath side to be replaced, the carpet in the hallway to be replaced/repaired, the laundry floor to be kept clean. Staff must be mindful of privacy and dignity when assisting service users with their intimate personal care. Staff must be able to demonstrate that the training they have had makes them competent to carry out the responsibilities of their work The manager must ensure that staff are clear about who has lead responsibility for the home on each shift in his absence and is sufficiently knowledgeable to be aware of all the policies and procedures associated with the safe management of the home Staff must have a minimum of 6 formal supervisions a year Records must be accurate and staff familiar with the policies and procedures which guide the day to day running of the home All staff must be aware of their own and others responsibility for Health and safety in the home and know where safety check records are held 30/10/06 31/03/07 30/10/06 31/03/07 31/12/06 31/10/06 Green Gables DS0000001280.V307452.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 3. Refer to Standard OP1 OP8 OP9 OP19 Good Practice Recommendations The Statement of Purpose should be a working document which all staff are familiar with It is recommended that the manager seeks information about the local procedures for assessing the risk of pressure ulcers It is suggested staff keep an information file of all the medication in current use to enable them to explain to service users what the medication is for. A risk assessment should be done for the gate on the stairway. Green Gables DS0000001280.V307452.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 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 Green Gables DS0000001280.V307452.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!