Inspection on 03/05/06 for Grey Gables

This inspection was carried out on 3rd May 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Grey Gables 11/08/09

Grey Gables 17/09/08

Grey Gables 01/11/07

Grey Gables 03/05/07

Grey Gables 23/11/06

Grey Gables 09/12/05

Grey Gables 07/06/05

Grey Gables 05/10/04

Grey Gables 29/06/04

Grey Gables 26/01/04

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

CARE HOMES FOR OLDER PEOPLE Grey Gables 39 Fox Hollies Road Acocks Green Birmingham West Midlands B27 7TH Lead Inspector Brenda O`Neill Unannounced Inspection 3rd May 2006 08:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Grey Gables DS0000016772.V288573.R01.S.doc Version 5.1 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. Grey Gables DS0000016772.V288573.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Grey Gables Address 39 Fox Hollies Road Acocks Green Birmingham West Midlands B27 7TH 0121 706 1684 0121 706 2025 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) www.greygables.org.uk Grey Gables Committee Mrs Annemarie Hosty Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Grey Gables DS0000016772.V288573.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home provide evidence that external support to the management of the home has been provided for the next three months, by 30 April 2006. 9th December 2005 Date of last inspection Brief Description of the Service: Grey Gables is a care home, which is registered to accommodate up to 40 residents. It is close to public transport links. It is set in a large, extended property. The home is owned and run by an unincorporated registered charity, Grey Gables Trust, and representatives of the committee visit the home regularly. The home has a selection of sitting rooms and dining rooms and although residents may choose where they spend their time, residents are grouped in units according to their level of dependency. The home had one double bedroom and the rest were single rooms the vast majority have en suite facilities. The home has ample assisted bathing facilities including one assisted shower. There are parking spaces at the front of the building and to the rear is a large, accessible and well-maintained garden. The homes main entrance has steps but there is a separate access point for service users with mobility difficulties. The home has two passenger lifts that ensure all areas of the home are accessible. Fees charged at the home range from £405 to £455 per week. Grey Gables DS0000016772.V288573.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out this unannounced inspection over one and a half days in May 2006. During the inspection a tour of the premises was carried, the inspectors joined the residents for lunch, four resident and four staff files were sampled as well as other care and health and safety records. The inspectors spoke with the manager, deputy manager, four staff members and eight of the residents. What the service does well: What has improved since the last inspection? Residents had all been issued with a service user guide and this included all the necessary information about the home. The home had employed a member of staff who was responsible for organising activities for the residents and the activities being offered were quite varied. Grey Gables DS0000016772.V288573.R01.S.doc Version 5.1 Page 6 There were ongoing improvements in the building to make the home safer and more comfortable for the residents. Since the last inspection several new carpets had been fitted, residents were able to control the heating in their bedrooms, new furniture had been purchased for one of the dining rooms and redecoration of the corridors had started. The manager of the home had been registered with the commission since the last inspection. Staff were being deployed to specific units in the home and this appeared to have resolved the issue raised by residents at the previous inspection that they could not summon help quickly enough. Staff turnover at the home had reduced since January 2006, which should be better for the continuity of care of the residents. What they could do better: All residents needed to have comprehensive care plans in place that detailed how all their identified needs in relation to health and welfare were to be met by staff. The manager needed to ensure that risk assessments were in place for all the residents’ identified risks and included full details of how the risks were to be minimised. This would ensure consistency by staff when managing risk and also that the residents were as safe as possible. Some minor improvements were needed to the system for administering medication to ensure it was entirely safe. There needed to be further consultation with the residents about the amount and variety of activities offered, as the programme did not meet the expectations of all the residents. To ensure the protection of the residents all staff needed to receive training in adult protection issues and all the required checks needed to be carried out on employees prior to them commencing their employment. To ensure new staff were equipped with all the necessary skills and knowledge to fulfil their roles the manager needed to ensure they undertook appropriate induction training. There was no evidence that the responsible individual was making any unannounced visits to the home to oversee the management/conduct of the home. It is a requirement that these visits takes place and that the responsible individual inspects the environment, samples administration and speaks to the residents and then prepares a report on the outcome of the visit. Grey Gables DS0000016772.V288573.R01.S.doc Version 5.1 Page 7 Improvements were needed in relation to health and safety of the general environment to ensure the residents were not put at risk. The manager needed to produce a timed programme of refurbishment and redecoration that took into account all the issues highlighted during the course of the inspection and forward a copy to the CSCI. 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. Grey Gables DS0000016772.V288573.R01.S.doc Version 5.1 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 Grey Gables DS0000016772.V288573.R01.S.doc Version 5.1 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. There was information available for prospective residents to enable them to make an informed choice about where they live. Prospective residents’ needs were assessed prior to admission to the home to ensure they could be met. There needed to be a process of review of need for regular respite care users to ensure any new needs were identified and could be met. EVIDENCE: There was a service user guide available at the home and all residents had received a copy. Apart from some minor amendments all the required information was included in the guide. The residents files sampled included evidence that where applicable social workers had been involved in the admission process and had drawn up the initial care plans for the residents. The home had a comprehensive assessment document that covered all the required areas and that was used by senior staff to determine if the home could meet the needs of an individual. Assessments Grey Gables DS0000016772.V288573.R01.S.doc Version 5.1 Page 10 for residents who were receiving regular respite care were not checked to ensure their capabilities had not deteriorated. Grey Gables DS0000016772.V288573.R01.S.doc Version 5.1 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Improvements were needed to the care plans to ensure they included details of how all the individual needs of the residents were to be met. Risk assessments needed to be in place for all identified risks and include clear details of how risks were to be minimised to ensure safer outcomes for residents. The medication system was generally well managed but needed some further improvements to ensure it was entirely safe. EVIDENCE: Four residents files were sampled. All included assessments of daily living needs but the information on these had not been carried forward to the care plans. The quality of the care plans was very poor and they did not identify all the individual needs of the residents or how any of their needs were to be met. There was little consideration of individual likes, dislikes or preferences or of what the residents were able to do for themselves. Statements included such things as ‘assistance with personal care’, ‘two carers to hoist’ but these were not clarified as to what assistance, what hoist or sling size. It was noted that one of the residents whose file was sampled was very hard of hearing and was Grey Gables DS0000016772.V288573.R01.S.doc Version 5.1 Page 12 wearing a hearing aid but this was not reflected in a care plan. One of the files did not include any care plan. Three of the files included general summaries of the care needs of the residents which did give some individual likes and dislikes however one of these was completed in 2004 and when observing the resident in question and reading her daily notes it was evident her needs had changed. The staff at the home were reviewing the care of the residents on monthly basis and sending summaries out to relatives/representative however there was no evidence on the files to suggest that wherever possible the residents had been consulted about this sharing of information. Three of the four files sampled included manual handling risk assessments. One was for a resident who was hoisted at all times but it did not state the hoist or the sling size to be used. There were no instructions available for staff on the assessments as to how residents were to be moved from the floor if they fell and were uninjured. There were no documented personal risk assessments for the residents and daily records clearly evidenced issues that needed to be risk assessed, for example, wandering at night, trying to get out of the building, agitation, refusing to be assisted with personal care. One of the residents had been having some falls and there was some detail on the daily notes of reducing the risk of injury but as more recordings were being made this information would be lost and filed away. These issues were discussed with the manager and she was advised she must undertake personal risk assessments for all residents and include details of how staff were to minimise any risks. Where any challenging behaviours were identified there needed to be strategies in place for managing these consistently by staff. The weights of the residents were being monitored. And there was documented evidence of visits made by health care professionals including G.P.s, district nurses, chiropodists and dentists. The records for visits made by health care professionals were difficult to track as different forms were being used and these were getting mixed up. It was strongly recommended that one recording sheet be used for all health care visits. The residents spoken with were satisfied that their health care needs were being met and they spoke of having new glasses, being able to see the doctor if they wished and having their toe nails cut by a ‘nice gentleman’. None of the residents had tissue viability or nutritional screenings. These needed to be undertaken to highlight if there were any issues that needed to be followed up or monitored. Some of the residents were having visits from the district nurse and one for a pressure sore but there was no information in the individual’s file of how the risks of any further tissue damage were being managed. There was evidence of pressure relieving equipment and incontinence aids being obtained for the residents. Grey Gables DS0000016772.V288573.R01.S.doc Version 5.1 Page 13 The medication administration records were checked for four residents. The system was generally well managed and all medication was acknowledged when received and administered and there was a clear audit trail. Some issues did arise that needed to be addressed to ensure the system was entirely safe. These were: a controlled drug register needed to be purchased for recording the administration of controlled medication correctly, all residents that were self administering medication needed to have risk assessments undertaken to ensure they were able to do this, a homely remedy policy and procedure needed to be implemented in the home and administration of homely remedies agreed with the G.P. and any had written entries on the MAR (medication administration charts) needed to be signed by two staff as correct. Residents spoken with were satisfied that they could have privacy when they wanted it. They could have keys for their bedrooms if they wished, most residents had their own telephones in their bedrooms and there was also a telephone for their use in a quiet area of the home. Medical consultations took place in the privacy of their bedrooms and there were several areas in the home where residents could receive visitors if they did not want to take them to their bedrooms. Staff were observed to knock on bedroom doors before entering and address residents respectfully. The manager did need to ensure she consulted with residents wherever possible before sharing personal information about them to ensure they agreed with this, for example, sending out the monthly overviews of their care. Grey Gables DS0000016772.V288573.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. There was a programme of activities in the home but this did not meet with the expectations of all the residents. The arrangements for visiting the home enabled visitors to come at any reasonable hour. The menus at the home were varied and nutritious and the residents were happy with the catering arrangements. EVIDENCE: There did not appear to be any rigid rules or routines in the home and the residents spoken with were happy they could spend their time as they chose. Residents confirmed with the inspectors that they could get up and go to bed when they wished, have breakfast in bed or in the dining room, spend time in their rooms throughout the day and take part in organised activities. One of the care assistants at the home was the activities coordinator and the majority of her time on shift was dedicated to this. The home had a documented four week programme of activities and this included such things as arts and crafts, quizzes, going out shopping, church visitors, flower arranging and dominoes. There was some indication on the residents personal files that some activities did take place however these were not recorded on an ongoing basis. On the day of the inspection the hairdresser and the aromatherapist were in the Grey Gables DS0000016772.V288573.R01.S.doc Version 5.1 Page 15 home. The residents spoken with had mixed views about the activities provided some stating they were happy other stating they regularly got bored. The manager needed to ensure some consultation took place with the residents about the amount and variety of activities offered in the home to ensure the activities programme met with their needs. Staff needed to ensure that all activities were recorded to evidence residents’ social needs were being met. There also needed to be some evidence that the residents who did not participate in group activities had some one to one staff time. There were no restrictions on visitors to the home within reasonable waking hours. Visitors were seen to come and go from the home throughout the course of the inspection. The residents spoken with stated they could have visitors any time and this was also evidenced in the daily recordings. One of the residents continued to go out independently, others regularly went out with relatives and friends and there were occasional trips out with staff for shopping, walks and so on. It appeared that residents were encouraged to exercise choice and control over their lives in such things as choosing what they did during the day, what to wear, when to get up and go to bed and what to eat. One resident did comment that she was checked every hour during the night and this disturbed her and she would prefer not to be checked so often. It was also noted that in all the personal files there were forms stating when the resident’s bath/shower time was and if they refused at this time an alternative may not be offered. These practices were not seen as offering choice and self-determination. Residents needed to be able to choose on an ongoing basis when they would like a bath or shower and issues such as night time checks needed to be discussed with the residents and based on an individual risk assessment. Residents had been encouraged to personalise their rooms to their choosing and personal effects were seen in all the bedrooms. The menus at the home were varied and nutritious and offered choices at all meals. The inspectors joined the residents for lunch during the course of the inspection. The food served to the residents was well cooked and presented. Where residents did not want one of the choices on the menu another alternative had been prepared for them, for example, one resident had egg on toast telling the inspector she did not like cooked meals very much and preferred teatime when there jacket potatoes, soups, sandwiches and so on. On the day of the inspection it was one of the residents birthdays and the chef had made a very nice large iced cake for the residents to share at teatime. The dining areas throughout the home were generally comfortable and one had had all new furniture since the last inspection. It was recommended that the menus were put on display in the dining areas to remind residents of what was being served on a daily basis. Grey Gables DS0000016772.V288573.R01.S.doc Version 5.1 Page 16 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, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents were issued with a complaint procedure and appeared confident that senior staff would listen to any issues they raised. To ensure the protection of the residents all staff needed to undertake training in adult protection issues and how to report these appropriately. EVIDENCE: No complaints had been lodged at the home or with the commission since the last inspection however one of the previous complaints remained ongoing. There was a complaint procedure and residents received a copy of this in the service user guide. A minor amendment was needed to this however this was being addressed at the time of the inspection. The residents spoken with stated they would have no concerns about raising any issues they may have with the manager or other senior staff. The home’s adult protection procedure remained in need of review and this was outstanding from previous inspections. The procedure on site did not comply with the multi agency guidelines for adult protection. At the time of the inspection the home’s copy of the multi agency guidelines could not be located. The manager of the home had a good understanding of the procedure to be followed in the event or suspicion of abuse and had in the past referred staff for inclusion on the POVA register. Some staff had received prevention of abuse training however the manager needed to ensure that all staff undertook this training. Grey Gables DS0000016772.V288573.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25, 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Although the home had been further improved since the last inspection continued work is needed to ensure a homely safe environment for the residents EVIDENCE: Further improvements and remedial works had been undertaken in the home since the last inspection but further work was needed to ensure the home met the required standard. The home is a large rambling adapted building and as such needed to have an ongoing programme of maintenance and refurbishment in place to ensure areas requiring attention were done in order of priority. Several areas of the home were in need of redecoration and general maintenance; for example, plaster needed repairing, tiling in some bathrooms needed to be addressed and some of the small kitchen areas around the home Grey Gables DS0000016772.V288573.R01.S.doc Version 5.1 Page 18 were in need of refurbishment. The manager had audited all the rooms and made a list of what was required however this had been combined with the risk assessments. The programme of redecoration, refurbishment and maintenance needed to be documented separately and timed to enable progress to be monitored. A copy of the programme needed to be forwarded to the CSCI. The home had recently had an inspection from the fire officer and some issues were raised that needed to be addressed within the given time scales unless otherwise agreed by the fire officer. It was also noted during the tour of the home that the external fire escapes were rusting badly and this needed to be addressed. Some of the internal fire escapes lead onto steep, flights of stone steps, these doors were not alarmed and it was difficult to see how staff would know if a resident had gone through these exits. Some type of alarm system needed to be fitted to these doors to alert staff if residents did exit through them. Several areas of the home had had new carpets fitted and this work was ongoing at the time of the inspection. Some areas in the home and some of the windows had been repainted and the windows to on the front of the building were due to be replaced. There were ample communal areas in the home and these were generally comfortable. One of the dining areas had all new furnishings and some new armchairs had been purchased for one of the sitting areas. Areas that still require new furnishings must be included in the programme of refurbishment. The home had a very pleasant, well maintained garden that had some seating available for the residents. Access to the garden was problematic for the residents with mobility difficulties as the ramped access was quite narrow. Safe access to the garden for all the residents must be explored. The home had a number of bathrooms and one floor level shower where staff were able to give full assistance. The majority of the bathrooms had bath hoists installed. The shower room had a wash hand basin but the other bathrooms needed to have these fitted. It was also noted that the emergency call system was not accessible from all the bathing and showering facilities. The tiling in some of the bathrooms also needed attention. The home was very difficult to find your way around, as it was very large and spread out. Redecoration of the corridors had started and different colours were being used in different areas to help identify where you were. There also needed to be some signage so that residents knew how to find their way to communal areas and so on. Some of the corridors had hand rails other did not and were needed to ensure residents could move around safely. Other aids and adaptations were available in the home including passenger lifts, hoists, wheelchairs hand and grab rails in the toilets and an emergency call system. Grey Gables DS0000016772.V288573.R01.S.doc Version 5.1 Page 19 Bedrooms were all singles and all but one had en-suite facilities of a toilet and wash hand basin. The bedroom without an en-suite had a toilet directly opposite solely for the use of the occupant of that room. The majority of the bedrooms seen were comfortable and spacious however some were in need of redecoration and this must be included in the programme of works to be forwarded to the CSCI. Bedrooms were lockable but not all had a lockable facility where residents could safely store personal effects. Residents spoken with were generally happy with their bedroom and several had their own telephones, televisions and radios. Heating lighting and ventilation in the majority of areas was appropriate and the residents were able to control the heating in their bedrooms as temperature controls had been installed since the last inspection. One of the bedrooms had had a supplementary heater installed and the surface temperature of this was very hot and it needed to be guarded. Window restrictors throughout the home needed to be checked as some were missing and other windows did not have them fitted. It was also noted that the temperature of the hot water in one of the bathrooms was excessively high and this needed to be addressed. The manager suggested this might have been because the home had a new boiler installed as they had been having ongoing problems with providing sufficient hot water in the home. The home was found to be generally clean and odour free. There were three laundries in the home one was equipped with a sluice washing machine. None of these rooms were locked giving residents free access, which could have been hazardous to them. The flooring in one of the laundries was in very poor state of repair and all the tiles were lifting, laundries did not have wash hand basins and all needed redecoration. Throughout the home ventilation fans needed to be thoroughly cleaned. Residents had access to COSHH substances in one area of the home and these needed to be locked away. It was also noted that personal toiletries had been left in some of the communal bathrooms. These needed to be returned to the residents’ rooms after use. As stated previously the small kitchens were in need of refurbishment. The main kitchen was clean and well organised and received a very good report from the environmental health officer on the most recent visit. Grey Gables DS0000016772.V288573.R01.S.doc Version 5.1 Page 20 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, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Adequate staffing levels were being maintained. To ensure residents were being cared for the home needed to make improvements to the staff induction programme to ensure staff were fully equipped to deliver adequate and appropriate care. To ensure the protection of the residents all the required checks needed to be carried out on employees prior to them commencing their employment. EVIDENCE: The pre inspection questionnaire that was given to the inspector at the start of the inspection detailed a very high turnover of staff from June 2005 to January 2006. 25 staff had left the home during this period of time. 20 of these staff left, as they would not work to new policies and procedures. The rotas evidenced that adequate numbers of care staff were on duty throughout the waking day and there were always senior staff on duty. The manager’s hours were supernumery to the care rota. During the night there were three waking night staff four nights a week and two for the other three nights. The manager was in the process of changing this to two waking staff and one sleeping in every night. The home also employed domestic staff, housekeeper, chef and kitchen assistant. Grey Gables DS0000016772.V288573.R01.S.doc Version 5.1 Page 21 Residents were positive in their comments about the staff stating they were ‘kind and helpful’ and they were generally satisfied with the care they received. Since the last inspection staff were being deployed to specific units in the home and this appeared to have resolved the issue raised by residents at the last inspection that they could not summon help quickly enough. The recruitment records for four staff were sampled during the inspection. All had completed application forms however only three had two written references. The CRBs on the files were from previous employers. The manager was advised that CRBs were not portable and new ones would have to be obtained for all new employees. The manager was advised that any future employees must not commence employment without a minimum of a POVA first check being in place whilst awaiting the CRB and two written references. There was no evidence available for new employees that they were undertaking an induction programme in line with the specifications laid down by skills for care and completed within the first twelve weeks of employment. The training matrix for the home showed some staff training had taken place but much of this appeared to be out of date. The pre inspection information included details of a variety of training that had been undertaken over the last year including fire procedures, manual handling, safe handling of medicines, bereavement and NVQs but not who had undertaken this. The manager needed to ensure that all staff had up to date regulatory training including, fire procedures, manual handling, food hygiene, first aid, health and safety and infection control. Several of the staff had completed NVQ level 2 or 3 and the manager had assumed that staff that were also doing their nursing training were classed as having the equivalent qualification, however until the training is complete this is not the case. Due to this the home do not have the required fifty percent of staff with NVQ level 2 or the equivalent another three staff need to qualify to attain the required level. Grey Gables DS0000016772.V288573.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. There were clear lines of accountability in the home and senior staff had delegated responsibilities. Further improvements were needed in the management of the home to ensure residents were not put at risk. EVIDENCE: The manager of the home had been registered with the commission since the last inspection. There had been some improvements in the management of the home since the last inspection. There were clear lines of accountability and senior staff had been given specific responsibilities. The home had had a very turbulent time in relation to staffing however the relationships within the staff team appeared to have improved. The manager was aware that the home still had several areas that needed to improve to ensure the best quality of life for Grey Gables DS0000016772.V288573.R01.S.doc Version 5.1 Page 23 the residents and that they were safe. She appeared committed to meeting the numerous requirements that were discussed with her during the inspection. The manager of the home had not been allocated with any budgets for food, maintenance, redecoration and so on therefore it was difficult for her to plan for the needs of the home. The responsible individual for the home needed to ensure the manager was aware of what money was available for her to spend on specific items and over what period of time. The home had a formal quality assurance system in place that was audited once a year by an outside agency who then prepared a report of their findings. This was discussed with the manager, as it did not appear that any recommendations or findings in their report were being followed through. It was also noted that residents meetings at the home had lapsed and this should form part of the quality assurance system and it was strongly recommended that these were reinstated. The home did not handle any finances on behalf of the residents and the manager was satisfied that residents got access to as much money as they required. When residents had their hair done or purchases were made on their behalf their relatives/representatives were invoiced direct. Staff supervision sessions were not being carried out the required frequency. This was particularly important, as there were several new employees at the home and their practice needed to be monitored and training needs identified. There was no evidence that the responsible individual was making any unannounced visits to the home to oversee the management/conduct of the home. It is a requirement that these visits takes place and that the responsible individual inspects the environment, samples administration and speaks to the residents and then prepares a report on the outcome of the visit. There were issues raised during the inspection in relation to health and safety including fire exit doors, hot water, COSHH substances not being secure and so on. Other issues that needed to be addressed were: • The fire risk assessment needed to be completed. • The fire drill records needed to detail the action taken when staff did not respond appropriately. • The premises risk assessment needed to be further developed to show the action taken and when any issues had been resolved. • The most up to date gas safety certificate needed to be forwarded to the CSCI. • Accident records were not always being completed in full and were all left in one book. • One member of staff had disclosed an illness on her application form and no risk assessment had been undertaken. The manager needed to ensure the assessment was carried out so that neither the residents nor themselves were put at risk. Grey Gables DS0000016772.V288573.R01.S.doc Version 5.1 Page 24 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 2 2 2 X 2 2 1 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 2 3 2 2 2 Grey Gables DS0000016772.V288573.R01.S.doc Version 5.1 Page 25 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(1)(2) Requirement Residents who are receiving regular respite at the home must have their needs reassessed on a regular basis and prior to a permanent placement being offered. All residents must have comprehensive care plans that detail how all their needs in relation to health and welfare are to be met by staff. (This requirement has been outstanding since 21/07/03) All residents must have manual handling risk assessments that detail the action to be taken by staff in the event of a fall. Where the use of a hoist is indicated the type and sling size must be detailed. All residents must have personal risk assessments undertaken. Where any challenging behaviours have been identified strategies for managing these must be included. All residents must have tissue viability and nutritional screenings undertaken. If any DS0000016772.V288573.R01.S.doc Timescale for action 01/06/06 2. Op7 15(1)(2)b 01/07/06 3. OP7 13(5) 14/06/06 4. OP7 13(4)(c) 01/07/06 5. OP8 12(1)(a) 01/07/06 Grey Gables Version 5.1 Page 26 6. OP9 13(2) risks are identified there must be a plan in place to manage these. A controlled drug register must be purchased for the home. A homely remedy policy and procedure must be implemented in the home. Risk assessments must be undertaken for any residents who self-administer their medication. Any hand written entries on the MAR charts must be signed by two staff as being correct. Wherever possible residents must be asked if they agree before information about them is shared with other parties. Residents that are unable to enjoy group activities must have some one to one staff time on a routine basis and this must be recorded. (This requirement has been outstanding since 31/08/05) The residents must be consulted about the amount and variety of activities offered in the home. The manager must ensure that residents are encouraged and enabled to make decisions in respect of the care they are to receive. The home must produce an adult protection step-by-step procedure that is compatible with the local social services department. (This requirement remains outstanding from 01/03/05) The manager must obtain a copy of the multi agency guidelines for adult protection. All staff must receive training in all aspects of adult protection. DS0000016772.V288573.R01.S.doc 11/05/06 7. OP9 13(2) 07/05/06 8. 9. OP9 OP10 13(2) 12(4)(a) 26/05/06 01/06/06 10. OP12 16(2)(n) 31/07/06 11. OP14 12(2) 31/07/06 12. OP18 13(6) 30/06/06 13. OP18 13(6) 31/07/06 Page 27 Grey Gables Version 5.1 14. OP19 23(2)(a) (b) 15. 16. 17. 18. OP19 OP19 OP19 OP20 23(4)(a) 23(4) 13(4)(c) 23(2)(o) 19. OP21 13(3) (This requirement remains outstanding from 01/03/05) The home must produce a timed programme of refurbishment and redecoration that takes into account all the issues highlighted and discussed at the inspection. A copy must be forwarded to the CSCI. (This requirement remains outstanding from 31/01/06) The requirements made by the fire officer must be addressed within the given time scales. The rusting external fire escapes must be addressed. Fire doors that lead out onto the flights of stone steps must be alarmed. The registered provider must ensure safe access to the garden. (This requirement remains outstanding from 30/11/04) Wash hand basins must be provided in all bathrooms where there is a toilet sited. (This requirement remains outstanding from 22/07/05) Repair to tiling in bathrooms and toilets must be undertaken. (This requirement is outstanding since 31/01/05) Both requirements must be in the schedule of work sent to the Commission by The emergency call system must be accessible from all bathing and showering facilities. Corridors must have appropriate rails to assist residents. (This requirement is outstanding since 28/02/05) The homes decoration must assist service users to know 01/07/06 01/06/06 01/07/06 31/07/06 31/07/06 31/07/06 20. 21. OP21 OP22 13(4)(c) 23(2)(n) 01/07/06 31/07/06 Grey Gables DS0000016772.V288573.R01.S.doc Version 5.1 Page 28 where they are in the building and appropriate signage must be introduced. (This requirement is outstanding from 28/02/06) These must be included in the schedule of work to be sent to the Commission by Immoveable lockable storage is required in residents’ bedrooms where this currently not available. (This requirement remains outstanding from 31/03/06) The supplementary heating identified during the inspection must be guarded. The excessively high water temperature in the bathroom must be addressed. All windows in the home must be checked to ensure the window restraints are fitted where necessary. (This requirement remains outstanding from 30/11/04) Laundry areas must have wash hand basins. (This requirement remains outstanding since 30/11/04) All personal toiletries must be returned to residents’ bedrooms after use. All COSHH substances must be locked away when not in use. Laundry rooms must be kept locked when they are not staffed. (This requirement remains outstanding from 31/01/06) The loose tiling on the laundry floor must be addressed. Extractor and ventilation fans throughout the home must be thoroughly cleaned. DS0000016772.V288573.R01.S.doc 22. OP24 23(2)(m) 31/07/06 23. 24. 25. OP25 OP25 OP25 13(4)(c) 13(4)(c) 13(4)(c) 11/05/06 08/05/06 01/07/06 26. OP26 13(3) 31/07/06 27. OP26 13(3) 05/05/06 28. OP26 13(3) 06/05/06 29. 30. OP26 OP26 13(3) 13(3) 11/05/06 14/06/06 Grey Gables Version 5.1 Page 29 31. 32. OP26 OP28 23(2)(d) 18(1)(a) 33. OP29 19(1) Sch2(7) 19(1) Sch2(5) 19(1) 34. 35. OP29 OP29 36. OP30 18(1)(a) 37. OP30 18(1)(a) 38. OP33 24(1) 39. OP34 25(1) 40. OP36 18(2) All laundry rooms must be redecorated. The home must have a programme to ensure that at least 50 of staff have the NVQ2 in care or the equivalent. (This requirement is outstanding from 31/07/05) As a minimum any new employees must have a POVA first check prior to commencing their employment. All staff must have two written references prior to their commencing their employment. Recent employees who have CRBs from previous employers must have another check undertaken. All new staff must undertake induction training in line with the specifications laid down by Skills for Care and completed within the first twelve weeks of employment. All staff must undertake all regulatory training. As a minimum this must include: • Fire procedures • Manual handling • Basic food hygiene • First aid • Health and safety • Infection control The manager must develop systems for improving the service at the home based on the yearly quality assurance review. The responsible individual must ensure she discusses with the manager the budgets available to her for the running of the home. All care staff must have recorded supervision not less than 6 times a year. (This requirement remains DS0000016772.V288573.R01.S.doc 01/08/06 31/08/06 05/05/06 11/05/06 01/07/06 01/07/06 01/09/06 01/08/06 01/06/06 01/07/06 Grey Gables Version 5.1 Page 30 41. OP37 26 42. 43. 44. OP38 OP38 OP38 23(4)(a) 23(4)(e) 23(2)(c) 45. OP38 13(4)(c) 46. OP38 17(2) S4 12a D P Act outstanding since 30/11/05) The responsible individual for the home must visit the home unannounced at least monthly and prepare a report about the conduct of the care. These reports must be made available for inspection. The fire risk assessment must be completed. Fire drill records must detail the action taken when staff do not respond appropriately. Evidence that the gas equipment has been serviced must be forwarded to CSCI. This information was received prior to this report being published. The premises risk assessments must be further developed to show the action taken and when any issues had been resolved. Accident reports must be fully completed with time, date and action taken. Accident records must be removed from the accident book and appropriately stored once completed. When a staff member discloses an illness a risk assessment must be undertaken to ensure that either the residents or themselves are put at risk. 01/07/06 11/05/06 06/05/06 11/05/06 01/07/06 01/06/06 47. OP38 13(4)(c) 01/06/06 Grey Gables DS0000016772.V288573.R01.S.doc Version 5.1 Page 31 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. Refer to Standard OP8 OP15 OP32 Good Practice Recommendations It is recommended that one type of recording sheet be used for all health care visits. It is recommended that menus be on display in the dining areas. It is strongly recommended that residents meetings be held on a regular basis. Grey Gables DS0000016772.V288573.R01.S.doc Version 5.1 Page 32 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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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