Inspection on 07/12/06 for Green Gables

This inspection was carried out on 7th 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Green Gables 01/12/08

Green Gables 16/02/06

Green Gables 22/06/05

Green Gables 02/03/05

Green Gables 01/06/04

Green Gables 27/01/04

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

CARE HOME ADULTS 18-65 Green Gables Wingfield Road Alfreton Derbyshire DE55 7AN Lead Inspector Angela Kennedy Key Unannounced Inspection 7th December 2006 09:30 Green Gables DS0000019997.V301554.R01.S.doc Version 5.2 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 DS0000019997.V301554.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 Adults 18-65. 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 DS0000019997.V301554.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Green Gables Address Wingfield Road Alfreton Derbyshire DE55 7AN (01773) 832422 (01773) 522502 linda.barker@lc-uk.org www.leonard-cheshire.org.uk Leonard Cheshire 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) Linda Barker Care Home 28 Category(ies) of Physical disability (28) registration, with number of places Green Gables DS0000019997.V301554.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Plus Two (2) Day Care Places Date of last inspection 16th February 2006 Brief Description of the Service: Green Gables is purpose built and suitably adapted and equipped and provides personal care and support for up to 28 service users with severe physical disabilities who are wheelchair users. It is located on the boundary of the village of Oakerthorpe within fairly short vehicular access to Alfreton town centre. Accommodation comprises of three units all named by service users who live there - Treetops and Fairways are single storey level access accommodation and The Snug, being the original building, is split level and provides both passenger lift and wheelchair access. Each unit has its own dedicated facilities, although there is also a central kitchen/catering facility. All service users are provided with single room accommodation with accessible en suites. The homes stated aims include that of enabling service users to take an active part in the management of the home and promoting their independence and right of choice. Services are designed to meet the physical, social and emotional needs of service users. The Registered Manager is supported by a team of care services staff and also via external management arrangements. Service user’s fees are dependent on the costing and price model that is used at Green Gables, this model assesses each individuals needs and estimates the level of support and skill of staff required in order for needs to be met. Green Gables DS0000019997.V301554.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced key inspection (this means that the service was assessed against all of the key national minimum standards). To assess the quality and detail provided to staff on how to support each individual, three service users were case tracked. This involved looking at each individuals needs assessment, support plans, risk assessments and other records kept relating to the support provided for each individual. The three service users were spoken with to ascertain their views on the support and care provided to them. Two members of the care team were spoken with to assess their understanding of the support and care that was required to meet the service users needs and to gain their views on the training opportunities and support that was given to them. Other documents and practices were looked at throughout the inspection and included; the activities provided, the meals provided, how religious and cultural needs were met, the medication practices, staff recruitment practices, staff training, the quality assurance systems in place and some of the safe working practices in place. What the service does well: Green Gables provides a safe and friendly environment for the people who live there. A positive rapport was noted between the staff team and service users and this was demonstrated in the relaxed and friendly interactions seen. Service users spoke very highly of the service and support they received from the staff and manager. The training provided to staff is of a good standard and specific to the needs of the service users, which demonstrates that service users needs and the support required are provided by a staff team who through on going professional development ensure their competency is maintained. The registered manager provides a good standard of leadership and both staff and service users were very complimentary regarding her ability to manage the service. Green Gables DS0000019997.V301554.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Green Gables DS0000019997.V301554.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Green Gables DS0000019997.V301554.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users needs are assessed before they move into Green Gables to ensure the staff team can meet their needs. EVIDENCE: Needs assessments were in place within the three service user’s files looked at. These assessments provided the sufficient information to ensure all areas of need were addressed prior to each service users moving into Green Gables, this demonstrated that the service ensured they could meet individual needs before admission was agreed. All of the three service users were able to confirm that a needs assessment had been undertaken before they came to live at Green Gables, although not all three service users could remember who had undertaken this assessment. Green Gables DS0000019997.V301554.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Care plans were not up to date and therefore did not ensure that service users needs would be fully met. Service users make decisions about their lives with assistance as needed and are supported to take risks as part of an independent lifestyle. EVIDENCE: Personal support plans and personal profiles were available in all three of the service users files seen, these were detailed and covered all areas of need including; personal care needs and support required, mobility, diet and nutrition, communication, behaviour and medication. However on discussion with one of the service users it was identified that some of the information within their support plan was not accurate as their needs had changed within certain areas and this had not been identified on the written information provided. Green Gables DS0000019997.V301554.R01.S.doc Version 5.2 Page 10 Evidence was in place within the three files seen to demonstrate that each service user had been appointed a key worker and the service user’s had been involved in the development of their support plans. However one service user stated that due to their visual ability they were unable to read their support plans and some of the other documents within their personal files. This was discussed with the registered manager. Personal support plans and assessments such as independent living skills had been reviewed six monthly and in general any changes had been recorded. Information was available within the service users personal files seen to demonstrate how service users had been supported to make individual choices and decisions regarding their lives. One service users discussed how the staff had supported them regarding issues within their personal life and stated that ‘the staff are lovely, very caring and can’t do enough for you’. Assessments were in place within all the service user files seen and these provided good detail of any areas of risk and the actions in place to minimise each risk, this included a personal emergency evacuation plan which identified the risk areas and the level of support each service user required to ensure a safe evacuation was achieved. All of the risk assessments seen had been signed, dated and reviewed as required to reflect any changing needs. Green Gables DS0000019997.V301554.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are part of the local community and engage in appropriate leisure activities, which enriches their lives. Service users rights were respected and the meals provided were varied and nutritious in content. EVIDENCE: The registered manager confirmed that three service users accessed some form of day opportunity services during the weekdays. One service user attended a community centre and two other service users attended day centres. The registered manager stated that activities were provided both in house and within the community. The registered manager discussed plans that were ongoing to request a pedestrian crossing on the main road outside of Green Gables, to enable Green Gables DS0000019997.V301554.R01.S.doc Version 5.2 Page 12 service users to safely cross the road. It was confirmed that all of the service users needed varying levels of support when out in the community but stated that the provision of a safe crossing would greatly assist them in accessing the local community. On the day of inspection several different activities were being undertaken within small groups. One group of service users were seen undertaking craftwork and one service user confirmed that they were making Christmas cards. Several pieces of craftwork that had been previously created were seen in and around building. Other in house activities included music and movement, reading groups, numeracy and literacy and gardening and independent living skills, such as cooking. A mobile library service also visited Green Gables. Activities that were accessed outside of the service included computer courses, visits to parks, shopping trips, cinemas and holidays both within the U.K and abroad. The registered manager confirmed that three service users had recently returned from a holiday in Lanzarote, and some of the service users had also been to Tenerife and Blackpool this year. Service users that were spoken to discussed the different activities that they took part in both within Green Gables and within the community. All of the service users spoken with felt that there was plenty of activities to take part in and were very complimentary regarding the staff support provided to enable them to participate in different activities. The service users spoken with also confirmed that if they chose not to participate in any activities the staff would respect their wishes. Family and friendship links were maintained and encouraged by the staff team. Service users spoken with confirmed that they were able to receive their visitors whenever they chose to and said they were able to speak with friends and family within their private accommodation or within the communal areas, as they preferred. There were no visitors available to speak with on the day of inspection. Service users were able to develop and maintain intimate personal relationships with people of their choice and discussions took place with one service user regarding this. The service user confirmed that staff had been very supportive regarding their needs in this area. Discussions with the registered manager confirmed that this service user had been supported by the staff team and external agencies to ensure their choices and rights were respected. Green Gables DS0000019997.V301554.R01.S.doc Version 5.2 Page 13 The registered manager confirmed that door keys were available for each service users private accommodation but stated that most service users chose not to use them. The service users spoken with confirmed this. However it is recommended that service users, who are able and who chose not to keep the door keys to their private accommodation sign a written declaration to this effect. Within Green Gables there are three separate units and each unit has its own domestic style kitchen. There is also a main kitchen that is staffed by one cook and one kitchen assistant. The staff team within each individual unit prepares breakfasts, the cook prepares the lunch and the kitchen assistant prepares the tea. The only exception to this was on Saturdays when no kitchen staff was available. This was discussed with the registered manager and it was confirmed that these additional hours are at present being advertised and in the meantime Saturday meals were being prepared on a Friday and left for the staff team to cook on Saturdays or alternatively take away meals were purchased. Service users spoken with were very complimentary regarding the meals and made comments such as “ the meals are absolutely brilliant” and “ I don’t eat a lot but the quality of meals and choices available are very good”. The menus were looked at and provided choices at each meal; vegetarian alternatives were also available at each meal. Fresh fruit, vegetables and salad were available on the menu each day. Green Gables DS0000019997.V301554.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users received personal support according to their assessed needs and choice, which ensured that their physical and emotional health needs were met. The homes practices for dealing with medicines ensured service users safety could be maintained. EVIDENCE: Service users spoken with confirmed that they were able to choose their preferred times for going to bed and getting up and said that if they chose to have a lie in they would be able to take their breakfast when they got up. On the day of inspection two service users were observed taking a late breakfast and they confirmed that this had been their choice. Green Gables DS0000019997.V301554.R01.S.doc Version 5.2 Page 15 Assessments were in place for individual moving and handling procedures and these assessments clearly instructed staff on the number of staff support required and on the moving and handling procedure. Health care needs were addressed within all of the service users files seen and evidence was in place to demonstrate that they were well met. This included access to primary care services and included assessments, information and records provided by doctors, physiotherapists, speech and language therapists and occupational therapists. The medication practices at Green Gables were assessed and medication assessments that looked at the competency of staff administering medication were in place. Procedures were also in place providing instruction on the administration of medicines and the procedure to follow in the event of a medication administration error; these procedures were detailed and provided clear instructions for staff. The medication administration records and storage for medication were looked at and found to be satisfactory. One service user, who was able, chose to self-administer their medication and a risk assessment was in place that demonstrated their capacity to do so. This demonstrates that the service endeavours to maintain safe working practices in medication administration. Green Gables DS0000019997.V301554.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users felt their views were listened to and acted on and the arrangements in place for safeguarding service users ensured that they were protected from abuse. EVIDENCE: All three service users spoken with were confident that any concerns they had would be listened to and dealt with by the registered manager and all confirmed that if they had any concerns they would discuss these with the registered manager or their key worker. A copy of the complaints procedure was available within the service users personal files seen. Three complaints had been made to Green Gables since the last inspection; these were discussed with the registered manager. The correct procedures had been followed in addressing these issues. Concerns have been raised with the Commission by one parent regarding the levels and skill mix of staff on duty and the impact they felt this was having on the service users. These issues had been brought to the attention of Green Gables in order for them to be addressed. These concerns were discussed with the registered manager and it was confirmed that staffing levels had much improved since this concern had been raised and although there was some minor deficit still remaining in staffing levels this was being addressed. Green Gables DS0000019997.V301554.R01.S.doc Version 5.2 Page 17 The registered manager confirmed that no safeguarding adults referrals or investigations had taken place since the last inspection. The files of two care staff were seen and both had evidence in place to demonstrate that they had undertaken training in safeguarding adults. The training matrix seen also demonstrated that all care staff had undertaken this training and undertook a refresher course every two years. The practices in place for the safe keeping and recording of service user monies was looked at and found to be satisfactory. All financial transactions were recorded and two signatures were in place for each transaction, one signature being that of the service user if they were able to provide this. The monies checked corresponded with the figures recorded. Green Gables DS0000019997.V301554.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. Service users live in a well-maintained, comfortable and safe environment. EVIDENCE: A tour of the building was undertaken. All three units within Green Gables were seen. The décor within Treetops and Fairways was of a good standard and provided a comfortable and modern environment for the service users that lived there, this included en suite facilities within private accommodation. The décor in The Snug was in need of redecoration and it was noted that paintwork was chipped on one of the bathroom doors and the kitchen area was in need of modernisation. Green Gables DS0000019997.V301554.R01.S.doc Version 5.2 Page 19 One of the service users spoken with stated that she would like to see The Snug modernised and it was confirmed by the registered manager that plans had been put in place to redecorate The Snug within the next budget. The private accommodation of one service user was seen and had been personalised to demonstrate individual choice, preferences and tastes. Some of the bathrooms were seen and provided adequate space to meet the assessed needs of the service users and sufficient personal privacy. The laundry facilities were seen and the equipment in place satisfactorily met disinfection standards. Green Gables DS0000019997.V301554.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users are supported by a competent, trained and qualified staff team. The recruitment practices in place require further development to ensure service users are fully protected. EVIDENCE: Two members of the care team were spoken with and both demonstrated a good understanding regarding the needs of the service users. Both staff had achieved a National Vocational Qualification (NVQ) at level 2 in care. Training records demonstrated that over 50 of the care staff team were trained to NVQ 2 in care or equivalent. The registered manager stated that the care staffing levels during the day within each unit were, one unit manager that undertook managerial responsibility over the three units, plus: Treetops – three staff on duty in the morning and three staff on duty in the afternoon. Green Gables DS0000019997.V301554.R01.S.doc Version 5.2 Page 21 Fairways- two staff on duty in the morning and two staff on duty in the afternoon The Snug- three staff on duty in the morning and two staff on duty in the afternoon with an additional member of staff working from 5pm to 9pm. At night three night staff were on duty to manage the three units, the registered manager stated that she felt these numbers were satisfactory as very few service users required support throughout the night. The staffing rotas for duties from the 8th to 29th October were looked at and demonstrated that on several occasions during this period staffing levels had been running low within both The Snug and Treetops. The registered manager confirmed that a full staffing complement had recently been reached, but unfortunately two members of staff had since left. Therefore the service is now looking to recruit 30 care staff hours a week and the registered manager stated that agency staff will be used to cover this deficit until these posts are filled. Discussions took place regarding the catering hours vacant and the registered manager confirmed that an additional 14 hours was to be appointed to cover the weekend catering requirements and until an appointment has been made the catering arrangements in place will remain (please see standard 17 for further details). The recruitment practices within three staff files were looked and in general were good. All staff had satisfactory criminal records bureau checks in place and the required identification documents. Two staff files had two satisfactory references in place, however the third staff file looked only contained one reference. There was evidence in place to demonstrate that attempts had been made to chase up the second reference however there was no evidence to demonstrate that this had been achieved and this member of staff had been in employment since March 2006. The employment application forms seen within the three staff files had not been amended in print, to state that a full employment history was required and that a satisfactory written explanation of any gaps in employment be provided. However there was evidence to demonstrate within a recently employed staff’s file that this information had been obtained. The registered manager confirmed that new application forms had been amended to request this information. Terms and conditions of employment and satisfactory health declarations were in place within all three staff files seen. Green Gables DS0000019997.V301554.R01.S.doc Version 5.2 Page 22 A training matrix was in place that demonstrated that the service provides on going training to all staff. Within the three staff files looked at there was evidence that training had taken place on a regular and ongoing basis and included induction training, fire safety, first aid, food hygiene, moving and handling, medicine administration, safeguarding adults, infection control, disability equality and whistleblowing. Two of the staff, whose files were looked at, were spoken with and both staff said that the training provided was very good and confirmed that training was ongoing and covered all mandatory training and training that was specific to the needs of the service users. Green Gables DS0000019997.V301554.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users benefit from a well run home and their views and opinions influence the running of their home. The safe working practices in place protected Service users health and safety. EVIDENCE: The registered manager has been in post at Green Gables for the last 21 months although for 7 months she was seconded away from the service and has recently returned in post as the manager. The registered manager has achieved an NVQ 4 and the Registered Managers Award and previous to her present post worked within the NHS as a senior nurse manager. Green Gables DS0000019997.V301554.R01.S.doc Version 5.2 Page 24 Both staff and service users spoke very highly of the registered manager’s ability to run the service and all stated that she was very supportive and had an open door policy for both staff and service users, should they wish to discuss any issues or concerns. Service users satisfaction questionnaires had been sent out in January 06 and the information obtained within these questionnaires had been collated and fed back to service users. The registered manager stated that relatives or independent advocates were used to support any service users who required assistance in completing their questionnaires. Service user meetings were held each month and these were chaired by one of the service users. Service users spoken with stated that their opinions and views were listened to and considered and confirmed that they had been asked to complete questionnaires regarding their opinions of the service and support provided at Green Gables. The registered manager stated that full service audits were undertaken every two years by the provider to assess the standard and quality of the service. Every other year the registered manager was asked by the provider to undertake a self-assessment service audit. The provider also undertook monthly monitoring checks of the service and this involved discussion with service users and staff. Key performance indicators were used to assess different areas within the service, such as staff sickness, staff turnover, staff training and qualifications, service user satisfaction and financial performance. It was stated by the registered manager that since the last inspection to areas of improvement were; over 50 of the staff team now hold an NVQ 2 in care and staff sickness has been reduced from 15 to 2 These ongoing monitoring systems indicated that the service strives to review and develop its practices and standards of care to enhance the lives of the people living at Green Gables. Some of the safe working practices at Green Gables was assessed this included the fire safety systems in place, evidence was in place to demonstrate that a fire inspection had been undertaken in May 06 and no requirements had been made following this inspection. Information provided demonstrated that service certificates were in place for the electrical wiring systems, gas installation, the lift and moving and handling equipment. Green Gables DS0000019997.V301554.R01.S.doc Version 5.2 Page 25 Green Gables DS0000019997.V301554.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Green Gables DS0000019997.V301554.R01.S.doc Version 5.2 Page 27 NO Are there any outstanding requirements from the last inspection? 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 YA6 Regulation 15, 17 (3) (a) Requirement Personal support plans must be kept up to date to reflect the assessed changing needs of service users. Two written references must be obtained for all staff employed. Timescale for action 31/03/07 2. YA34 19 (b) Schedule 2 (3) 01/02/07 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 YA6 Good Practice Recommendations Information contained within service users personal files should be made available in a format that can be read and understood by the service user. A written declaration that has been signed by the service user (who is able) should be in place for all service users who do not wish to retain the door key to their private accommodation. Redecoration of ‘the snug’ should be undertaken. A full complement of staff should be maintained to ensure DS0000019997.V301554.R01.S.doc Version 5.2 Page 28 2. YA16 3. 4. YA24 YA33 Green Gables service users needs can be met. Green Gables DS0000019997.V301554.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. 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