Inspection on 07/06/05 for Grey Gables

This inspection was carried out on 7th June 2005.

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 03/05/06

Grey Gables 09/12/05

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 B27 7TH Lead Inspector Jill Brown Announced 7 & 8 June 2005 th th 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 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 E54_S16772_GreyGables_V223431_070605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Grey Gables Address 39 Fox Hollies Road Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 706 1684 0121 706 2025 Grey Gables Committee Anne-Marie Hosty (not registered) Care Home 40 Category(ies) of Care Home 40 registration, with number of places Grey Gables E54_S16772_GreyGables_V223431_070605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. That Mr Evans completes the Registered Managers (Adults) Award NVQ4 by April 2005. Date of last inspection 5 October 2004 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 unincoporated 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 home’s 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. Grey Gables E54_S16772_GreyGables_V223431_070605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days in June. The inspector spoke with 7 residents, 4 residents’ representatives, 3 staff, the care manager, the administrator and a representative from the committee. The Commission received 13 comment cards; 7 from health professionals, 6 from relatives and 2 from residents Case records of 6 residents and three staff files were sampled. Maintenance and inspection records in respect of fire, utilities and lifting equipment were inspected. The pharmacist inspector joined the inspector on this visit to audit the medication. What the service does well: What has improved since the last inspection? Staff had worked hard to improve medicine management within the home. Activities in the home had improved and scheduled activities were now available. Continued improvement was needed for residents that were unable to join group activities. Grey Gables E54_S16772_GreyGables_V223431_070605 Stage 4.doc Version 1.30 Page 6 Radiators had been covered in the home ensuring the safety of residents from burns. Work had been undertaken on the water quality and further work was planned to ensure the safety and consistency of regulation of hot water temperatures. The home had an independent quality assurance audit undertaken. What they could do better: Whilst the home has made some changes to promote good recording of care to be provided and given, practice needed some amendment along with full implementation. The homes checking on weight changes, the causes of falls and small injuries were not thorough enough to protect residents. Comments received from relatives said that staff were caring but they didn’t always feel that their concerns were responded to and were not given information in a timely way about their relative. The homes décor had not been scheduled to be renewed which has meant that several areas of the home have not been decorated for several years. This lack of decoration has meant that windows now need at least repair and sealing before decoration. A number of carpets in the home need replacement and or repair, and there are elements of repair to lighting, ventilation fans and so on throughout the building required. Some needs of residents are not met in the home; the lack of appropriate signs to help residents know where they are in the building, same size chairs despite residents differing heights and disability are examples. Evidence is needed of the work already completed on the hard wiring and of a schedule for all the future work to improve the system. There had been a period of instability in staffing arrangements of the home which could compromise good care delivery. Staff supervisions and performance management could achieve this stability. Routine risk assessments of all areas of the building need to be undertaken to ensure residents’ safety. Grey Gables E54_S16772_GreyGables_V223431_070605 Stage 4.doc Version 1.30 Page 7 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 E54_S16772_GreyGables_V223431_070605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Grey Gables E54_S16772_GreyGables_V223431_070605 Stage 4.doc Version 1.30 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 standard(s) 3,4 & 5 The home collects appropriate and sufficient information that prospective needs are met. EVIDENCE: The assessment paperwork of the home has been changed recently. Although these changes have not had time to fully become established they represent an improvement on previous paperwork and should make it easier for information to be accessed by the carers. The home did usually ensure that potential residents were assessed prior to admission, had the opportunity of visits including a day’s assessment. The timing of the assessment collection was varied and the inspector recommends that this undertaken, using the larger form, on the days assessment visit. One resident was admitted as an emergency and the assessment was not available to the inspector. The inspector noted that where residents had specific difficulties detailed information on that difficulty was retained on files such as; communication with residents with dementia, wandering, and social activities and this is commended. Grey Gables E54_S16772_GreyGables_V223431_070605 Stage 4.doc Version 1.30 Page 10 The home has begun to collect information on preferred lifestyle and as well as residents’ needs. The home was able to evidence that the home’s recent admissions were in line with their category of registration. Staff spoken to were aware of the residents needs. There had been some staff turnover since the last inspection and residents varied in their response to this. Grey Gables E54_S16772_GreyGables_V223431_070605 Stage 4.doc Version 1.30 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 standard(s) 7,8,9 & 10 The arrangements for care planning whilst improved were variable and therefore the home could fail to meet all residents’ needs. Implementation of these improvements to care planning should provide benefits to residents. Residents’ health and personal needs were not fully met which could compromise their well-being. The medicine management has improved since the last inspection and overall arrangements have been installed to ensure residents’ medication needs are met in most instances. EVIDENCE: The home had recently implemented a care-planning programme for all residents in the home. The care plans that resulted although improved did not respond to all the needs that the assessments raised and the gaps in some cases were significant. The home had also put together a summary of care that was to inform staff of the care needed and some of the resident’s likes and dislikes. These needed some refinement but were useful. The inspector was advised that the summaries of care and where appropriate monitoring of care given would be held in the residents’ rooms in the near future. This was to make the charting Grey Gables E54_S16772_GreyGables_V223431_070605 Stage 4.doc Version 1.30 Page 12 easier for carers but also to improve the access of information for residents and their representatives. This move is commended and should be reviewed after implementation. Monitoring charts currently were not always completed fully. This has lead to a lack of clarity about the amount of personal care offered and given. Care plans had only started to be discussed with residents and relatives and reviewed monthly and this requirement will remain until this becomes established practice. Some comment cards from health professionals raised concerns about falls and small injuries in the home and availability of senior staff. The home had taken advise from health and safety department. As a result the home had recently set up nighttime, falls and accident monitoring systems. These records had not yet been analysed and responded to in individual care plans and risk assessments. The home has had a period of unsettled management and this appears to be resolving. Weights were sporadically taken. The home stated that they had purchased sit on scales and were awaiting delivery. Weight records did not show the date of the month they were taken and did not follow a consistent time so analysis was not possible. Weights were not crossed referenced to nutritional assessments and food taken. The majority of the audits undertaken to assess whether medicines had been administered as prescribed were correct. A few minor discrepancies were found. Staff has worked hard to improve the medicine management within the home and this was commended. There was evidence that some residents locked their rooms and rooms were locked at the point of a resident’s admission to hospital. One bathroom has a window to a corridor a privacy blind is required. Grey Gables E54_S16772_GreyGables_V223431_070605 Stage 4.doc Version 1.30 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 standard(s) 12,13,14 &15 Improvements to the arrangements for residents to participate in activities, social occasions along with contacts with relations, enhances their quality of life. EVIDENCE: The considerations of residents’ preferred lifestyle was beginning to be built into care plans. A member of staff had been allocated to co-ordinate the formal activities of the home. The home has a programme of routine activities and a sing along session and a bingo session were held during the inspection. The home has latterly recorded the names of the residents that have taken part. Residents that are unable to take part in these types of activities must have some individual time with staff and this should be recorded. Relatives commented that they are able to visit when they want, that generally staff were helpful and there was evidence that relatives could meet residents privately. Comments received were ‘that they were made welcome at any point in the day’ ‘they felt included.’ Residents were allowed to bring personal belongings with them. Menus were available and there was choice offered in meals. Overall residents spoken to were happy with the food provided however some residents did speak of the food being ‘bland’. The food sampled was well Grey Gables E54_S16772_GreyGables_V223431_070605 Stage 4.doc Version 1.30 Page 14 cooked and presented at the main meal of the day. Customer satisfaction surveys and suggestions from residents were not found as part of the menu planning. The home have a requirement for the chef to receive training at the intermediate level of food hygiene from the Food Department and this remains outstanding. Grey Gables E54_S16772_GreyGables_V223431_070605 Stage 4.doc Version 1.30 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 standard(s) 16 The home has a satisfactory complaints procedure but have not demonstrated that they have listened and acted upon the concerns of residents and their representatives, which could lead to poor outcomes for all involved. EVIDENCE: The Commission had received no complaints since the last inspection. The home had received one complaint directed to the Grey Gables committee and this was not logged in the complaint record held by the home. The home had recently put out a comment book but no comments had been received. The inspector was aware of the committee holding an event at the home as away of receiving comments. Some comments have been made to the inspector via comment cards, which suggest the home has some work to do in ensuring that representatives of residents feel their concerns receive appropriate attention. Previous requirements in respect of procedures for adult protection and restraint, and adult protection training were not inspected on this occasion and these requirements were brought forward. Grey Gables E54_S16772_GreyGables_V223431_070605 Stage 4.doc Version 1.30 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 standard(s) 19, 20, 21, 22, 24, 25 & 26 The standard of décor within the home is poor. Current maintenance programmes fail to make provision for improvement. The environment does not fully respond to the needs of the service users and therefore does not provide a safe, homely and comfortable place to live. EVIDENCE: Areas of the home including corridors, residents’ bedrooms have not been decorated for several years and were not up to standard. A number of carpets in the home were in need of repair or replacement. The home did not have a schedule of planned decoration and repair work resulting in a decline in standards. The external paint and woodwork of the home was poor. Windows in some cases were bare of paint were hard to open and needed repair. The home has a pleasant rear garden that does not have disabled access from the main lounge dining room. Grey Gables E54_S16772_GreyGables_V223431_070605 Stage 4.doc Version 1.30 Page 17 Chairs had been purchased for the front lounge however; these were all the same and so did not consider the different heights or disabilities of the residents. The home has an adequate number of assisted bathing facilities and has one assisted shower in the home. Bathroom and laundry areas had no wash hand basins to maintain good infection control for staff. Some bathrooms had broken tiling and were clinical in appearance. There was evidence of appropriate aids within the home including lifting equipment, large numbered telephones and individualised walking aids. One resident needed an assessment for more comfortable slings for the hoist. The home had divided the building into units since the last inspection but still needed some colour coding and signage to assist residents and visitors in finding their way around. One en suite checked did not have the appropriate grab rails for the needs of the resident. Residents’ rooms had evidence of personal belongings. Appropriate routine checks of the safety of some of the furniture and the use of electrical extension leads and gang sockets were not being undertaken. All residents’ rooms have a call alarm system. Some residents need a call system that could incorporate floor buzzer pads to maintain safety. Lockable immovable storage was found in some rooms but not all. The home had covered all radiators except one, which was an oversight and contact had been made with the contractor for this to be covered without delay. Some communal bathroom hot water taps appeared to be running above 43 degrees centigrade. The home had undertaken some remedial work on the water systems in the home and until these works are completed staff must use a thermometer before a resident has a bath. Some lighting in the home did not have appropriate shades making a poor impression of the decor. Generally the home was fresh except for one bedroom. Two ventilation fans were found not to be working and one did not switch off. The fridges of the home’s serving kitchens did not have daily checks on their temperature recorded and a perishable drink opened did not have a date of opening. Grey Gables E54_S16772_GreyGables_V223431_070605 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 &30 The home has a good recruitment and vetting procedure for new staff but staff training in insufficient to ensure that residents needs can be appropriately responded to. There are occasion when the staffing arrangements would compromise the good care and safety of residents. EVIDENCE: Examination of the rotas highlighted there were problems staffing some evening shifts and the recent bank holiday. There was evidence of insufficient staff on duty at these times, which could compromise resident care. Staffing has been an issue for the home since the last inspection and there has been a turnover of some staff. Staff files were improved since the last inspection. There was evidence of a robust recruitment practice, checks were undertaken and CRB checks had been returned. Newer staff had a formulised induction procedure to follow. The home did not have in place a matrix of staffs’ attendance at training and copies of certificates of qualification were not routinely available for all staff. Thirty percent of staff had achieved the NVQ2 this is not as high as previously due to staff changes. Grey Gables E54_S16772_GreyGables_V223431_070605 Stage 4.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 35, 36, 37 & 38 The arrangement s to remedy health and safety matters within the home is slow and therefore poor and this puts residents at risk. EVIDENCE: The home’s care manager had returned to the home after a period of maternity leave and was beginning to acquaint herself with the current issues of the home. The manager had relevant qualifications and experience to run the care home but had yet to undertake the fit person procedure with the Commission. The home has an independent quality assurance assessment from a reputable organisation. The new responsible individual has undertaken monthly visits on behalf of the committee of Grey Gables and the inspector receives these reports. Grey Gables E54_S16772_GreyGables_V223431_070605 Stage 4.doc Version 1.30 Page 20 The inspector did not look at the accounts of the home on this occasion. A previous requirement to provide the Commission with assurances, that where necessary to ensure the health and safety of residents, money will be provided quickly for work to be done remains outstanding. The home did not hold money for individual residents. Residents or their representatives are invoiced for services such as hairdressing and chiropody and this is good practice. The home has not yet put in place an adequate supervision programme for staff which overall fails to ensure that they appropriately and adequately supported, trained and developed. Record keeping in the home has improved and changes have meant that key information can be kept together. Fire records, checks, maintenance and drills were in place. Training in fire prevention and procedures was scheduled. The home needs to consider whether the needs of the residents warrant alarming of doors to the stairs. One door closure on a resident’s bedroom was found to be broken. The home had undertaken work on the hard wiring of the home. Confirmation from the electrical contractor that the key work had been undertaken was needed. A Gas Landlords certificate and certificates for the maintenance and inspection of lifts and hoists were in place. Some window restraints were not in place. The home could not demonstrate that they were undertaking routine risk assessment checks for the building. Grey Gables E54_S16772_GreyGables_V223431_070605 Stage 4.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 1 2 2 2 x 1 2 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x 2 x 3 x 3 1 3 1 Grey Gables E54_S16772_GreyGables_V223431_070605 Stage 4.doc Version 1.30 Page 22 yes 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 op1 Regulation 5(1)(2) Requirement Evidence of a copy of the service user guide must be given to residents and or their representatives. (this standard was not assessed on this occasion but has been a requirement since 01/05/04 All residents wherever possible must receive an assessment before admission or in an emergency without delay afterwards. All needs or risk raised must have a corresponding plan of how that needor risk is to be met. Where possible residents and or residents representatives must be involved in drawing up the care plan and this must be evidenced. Care plans must be reviewed monthly, the outcome of which must be documented and changes explained to the resident or their representative. (these two requirements were outstanding since 21/07/03) Monitoring charts must be Timescale for action Next inspection. 2. op5 14(1)(2) 09/06/05 and ongoing 07/07/05 3. op7 15 & 12(1)(a), 12(2)(3)& (4) 07/07/05 07/07/05 4. op8 14(2) & 30/06/05 Page 23 Grey Gables E54_S16772_GreyGables_V223431_070605 Stage 4.doc Version 1.30 15(2)(b) (c )(d) completed where in place. (this requirement was oustanding since 30/11/04) Residents weights, falls, and small injuries must be recorded, analysed and appropriate action taken where needed including entry into the careplan. (this requirement was outstanding since 21/08/03) Regular staff drug audits must be undertaken to confirm staff are administering the medication as prescribed in all instances. The bathroom that has a window on to a corridor must have a privacy blind. 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. The chef must undertake the food hygiene certificate at intermediate level as required by the Food Safety Department. The management of the home must ensure that the process of making a complaint is seen as enabling by the residents and their representatives. (this requirement is outstanding since 21/08/03) The home must produce an adult protection step-by-step procedure that is compatible with the local social services department. The home must have a restraint policy that reflects the residents in the home and includes any locking of doors. The home must ensure that all staff receive training in all aspects of adult protection. 07/08/05 and ongoing 5. op9 13(2) one day and ongoing 14/06/05 31/08/05 6. 7. op10 op12 12(4)(a) 12(4)(b) & 16(2)(n) 13(3) 8. op15 30/09/05 9. op16 22(2) 31/07/05 10. op18 13(6) 31/07/05 30/09/05 Page 24 Grey Gables E54_S16772_GreyGables_V223431_070605 Stage 4.doc Version 1.30 11. op19 23(2)(o), 23(2)(b), 13(4)(c) (the requirements for this standard were not inspected on this occasion and were brought forward from 01/03/05.) The registered provider must ensure safe access to the garden this must be included in the schedule of work. 22/07/05 The windows of the home must be audited and where necessary repaired and repainted. The results of the audit and timescale for remedial work must be sent 22/07/05 to the Commission by (these requirements were outstanding from previous inspections 30/04/05; 30/11/04) Carpets in the home must be audited for replacement and other measures to maintain the safety of residents. A copy of the results of the audit and dates for remedial work to be undertaken must be sent to the 22/07/05 Commission by The carpet between the office and the hall must be taped down to prevent a trip hazard. The residents sitting areas must have chairs that reflect the needs of the residents. Wash hand basins must be provided in all bathrooms where there is a toilet sited. 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 Corridors must have appropriate rails to assist residents. 22/07/05 09/06/06 31/08/05 12. 13. op20 op21 12(1)(a), 23(2)(n) 13(3) 14. op22 23(2)(n) Grey Gables E54_S16772_GreyGables_V223431_070605 Stage 4.doc Version 1.30 Page 25 (this requirement is outstanding since 28/02/05 The homes decoration must assist service users to know where they are in the building and appropriate signage must be introduced. (these requirements are outstanding from previous inspections) These must be included in the schedule of work to be sent to the Commission by One named resident must be reassessed for her lifting requirements to provide more comfortable slings. 22/07/05 30/06/05 Residents en suites must be audited for the appropriateness of the grab rails against the need 22/07/05 of the resident. Remedial action must be taken. (This requirement is outstanding from previous inspections) Call alarms must be reviewed for residents that require buzzer pads on the floor and arrangements made. The home must produce a timed programme of redecoration and refurbishment that takes into account the requirements of the standard. A copy of this programme must be sent to the Commission by (This requirement is outstanding since 31/12/04) Routine monitoring checks of safety must be undertaken of each residents bedroom. Remedial action must be taken on identified bedrooms where Grey Gables E54_S16772_GreyGables_V223431_070605 Stage 4.doc Version 1.30 Page 26 22/07/05 22/07/05 15. op24 23(2)(d) furniture is wobbly and where electrical extension leads and gangs are used. Immoveable lockable storage is required in residents rooms where this currently is not provided. All lighting in the home must have the appropriate shades. The outstanding radiator must be covered. Work on the water system must continue and until resolved all baths must have an appropriate thermometer to ensure that the water is at the right temperature. Radiators must be adjustable in bedrooms to provide a comfortable temperature for residents. This must be part of planned works. ( this requirement is outstanding since 21/09/03) The odour in one bedroom must have remedial action taken. (this requirement is outstanding sice 30/11/04) 16. op25 13(4)(c ) 23(2)(p) 22/07/05 17. op26 13(3) & 16 (2)(k) 15/07/05 Laundry areas must have wash hand basins. Ventillation fans must be audited for repair and installation. A copy of the audit and timed works must be sent to the Commission by 22/07/05 ( these requirements are outstanding since 30/11/04) Fridges in the small kitchen must have their temperatures recorded. All opened food and drink in Grey Gables E54_S16772_GreyGables_V223431_070605 Stage 4.doc Version 1.30 Page 27 30/06/05 18. op27 18(1)(a) 19. op28 18(1)(a) 20. op30 18(1)(a) & 1(c ) 21. op31 9 22. op34 13(4)(c ) 23(2)(b) 23. op36 18(2) 24. op38 13(4)(c ), 23(4)(c ) (i) 23(2)(b) fridges must have a date of opening. The home must as a minimum have 6 care staff and a senior on duty during waking day. (this requirement is outstanding since 30/11/04) The home must have a programme to ensure that at least 50 of staff have the NVQ2 in care or the equivalent. A matrix of staff attendance at training and a copy of achieved certificates must be available. (this requirement is outstanding since 21/08/03) The manager must undertake the fit person process with the Commission. (this requirement remains outstanding since 31/12/04) The registered provider must inform the Commission of how finances are to be released quickly to undertake health and safety requirements. (this requirement was outstanding since 31/12/04) All care staff must have recorded supervision not less than 6 times a year. This must be routinely in practice by Missing window restraints must be replaced. (this requirement was outstanding since 30/11/04) The home must consider whether the needs of the residents require that the fire doors to unfrequented stairwells require an alarm. The closure on one bedroom must be repaired or replaced. Ongoing recommended electrical work must be scheduled. The 30/06/05 15/07/05 31/07/05 15/07/05 31/07/05 10/07/05 30/11/05 30/06/05 22/07/05 30/06/05 22/07/05 Grey Gables E54_S16772_GreyGables_V223431_070605 Stage 4.doc Version 1.30 Page 28 Commission must be sent this schedule by 25. op38 23(2)(b) The home must send to the Commission evidence from the electrical contractor that schedule one work has now been completed. 08/07/05 26. 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 op15 Good Practice Recommendations It is recommended that the chef routinely asks residents of meals they enjoy so these can be evidenced as part of the menu. Grey Gables E54_S16772_GreyGables_V223431_070605 Stage 4.doc Version 1.30 Page 29 Commission for Social Care Inspection Birmingham and Solihull Local 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. Extracts may not be used or reproduced without the express permission of CSCI Grey Gables E54_S16772_GreyGables_V223431_070605 Stage 4.doc Version 1.30 Page 30 - 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!