Inspection on 09/12/05 for Grey Gables

This inspection was carried out on 9th December 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 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 Jill Brown Unannounced Inspection 9th December 2005 09:30 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.V272687.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.V272687.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) Grey Gables Committee 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.V272687.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th June 2005 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. Grey Gables DS0000016772.V272687.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on an unannounced inspection undertaken in December and the result of a complaint investigation undertaken in late October. Two inspectors undertook the announced inspection over 6 hours and the complaint investigation took place over a number of days. The inspectors spoke to 18 residents and two relatives during the inspection. Four residents care records was looked at and a tour of the building was undertaken. The Commission is undertaking reduced inspections and to gain a fuller view of the home this report should be read with the report of the announced inspection carried out in June. What the service does well: What has improved since the last inspection? The home has started reviewing the care plans of residents and have plans to write to named representatives about how the resident has faired over the last month. The home has undertaken remedial environmental work. New carpets have been put in the hall and the stairs have protectors. A number of windows have been replaced or repaired and painted. A number of residents’ bedrooms have been redecorated. All radiators that residents have access to have been covered. The required electrical work has been undertaken in the home and the recommended work is being actioned. The home has provided a large television for one of the lounges. Grey Gables DS0000016772.V272687.R01.S.doc Version 5.1 Page 6 Activities planned for December were good. The home had responded to the requirements as a result of the complaint to ensure that residents have appropriate call alarms if they were at risk at a night of falling and a senior member of staff was put on duty on a number of night shifts. The Committee for Grey gables has shown that are prepared to release funds for repairs and improvement on the home quicker than previously. The care manager has applied to the Commission to be the Registered Manager. What they could do better: The home provides a good general service for residents however it needs to consider the individual needs and choices of residents to provide a service that satisfies them. Residents wanted more choice and frequency of assisted bathing and showering. A number of residents wanted greater access to activities and for these to be sited in their lounge. Residents that were unable to access group activities needed a plan for how their day could be enhanced. The care plans did not reflect the good information collected at the assessment stage and did not prompt staff to provide the care in the way the resident wanted or needed. So care plans did not state the type of hoist, continence pad or behaviour management to be used and this potentially puts residents at risk. A record of checks on residents that are at risk because of their behaviour were not always completed. Policies on restraint and adult protection needed to be reviewed and amended. The home needed to ensure that personal care details were not on general display. Environmentally the home has work still to do. The Commission needs to be informed of the dated programme of these works so that it can assess the homes performance on these standards. A number of the works needed were health and safety concerns and these must be completed as a matter of urgency. These hazards were carpets that could cause a trip hazard, tiling falling off in a number of assisted bathrooms, the lack of window restraints on a number of windows, door closures on bedroom doors, provision of dining room chairs without wheels and the exposure of wires from a ceiling light. These hazards could potentially put residents at risk. Other work to maintain the fabric of the home and to improve the residents’ experience of the home needed to be completed. These included signage Grey Gables DS0000016772.V272687.R01.S.doc Version 5.1 Page 7 around the building, further repair and decoration and replacement of an aid in one of the communal bathrooms. The home had some practice issues in ensuring that fridge temperatures and the date of prepared food in the small kitchens were recorded and laundry doors locked when not staffed. The health and safety issues need to be managed and responded to quickly. The management of staff supervision needed to be improved to prevent the number of complaints that were being made. A number of requirements from the previous inspection and the complaint investigation were not re-inspected on this occasion and these were brought forward. 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.V272687.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.V272687.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): 3&5 The arrangements for assessment prior to admission were good but needed a process for review to ensure that any new needs could be identified and met. EVIDENCE: The home has a comprehensive assessment format that covers the standard. This would be improved by having information on the date of when and where the assessment was completed. Assessments for a resident that has regular respite were not checked to ensure that the resident’s abilities had not deteriorated. It was clear that there had been an improvement in ensuring that residents had an assessment on the day of their visit to the home. The home ensured that residents visit the home prior to their stay. A complaint investigation showed that not all moving and handling of residents was undertaken in a safe and approved manner. Requirements were made for staff to be given guidance and be retrained where necessary in moving and handling. These requirements were not inspected on this occasion and are brought forward. Grey Gables DS0000016772.V272687.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Arrangements for care planning, medication and meeting health care needs were variable and did not respond to individual choice. These failures potentially put residents at risk and increase residents’ the dissatisfaction of the service. EVIDENCE: Details that were found in the assessment was not always carried on to the care plan and good information was lost such as likes and dislikes in food, number of pillows liked and so on. The home had put together summaries of care for the majority of residents and these were useful giving some detail about each resident. This information was also kept in the residents’ bedrooms for staff to consult. The care plans for residents did not always reflect the assessed need and there were gaps in detail, which could cause inconsistencies in care. Examples of these were: Moving and handling assessments not containing information on type of hoist, slings, slide sheets or moving belts to be used when these were necessary. Grey Gables DS0000016772.V272687.R01.S.doc Version 5.1 Page 11 Continence plans did not contain information on how regular toileting was necessary or type of continence pad used and, Detail on how behaviour such as wandering on a night was to be managed. It was clear that residents were starting to have their plans discussed with them. In two cases care plans for respite residents had not been completed and this must be done without delay. The home had begun a programme of reviewing the care of residents and was intending to send copies of the reviews to a named relative. The home had involved health professionals in the care of residents where needed. Records of visits for visits from GPs, district nurses and so on were kept. Residents felt that their health care needs were met. Arrangements for personal care of residents appeared to be met on the day of the inspection however residents stated they were limited to one bath a week. Although this frequency satisfied some residents a number were dissatisfied. A resident stated ‘I am offered a shower but I would like a bath especially in the winter.’ Monitoring charts were being used were being used on a night, however a resident that had wandering behaviour hadn’t had her chart completed for several days. Two residents during the inspection said they did not want to be checked through the night as it prevented a good night sleep and this should be accommodated subject to a risk assessment. In particular the 7am check was mentioned and one mentioned being assisted out of bed at that time even though she wanted a lie in. Although medication administration was not assessed on this occasion a complaint investigation showed that the home had not ensured that a prescription had been gained for a medication that had run out in the middle of the home’s cycle of medication. Requirements to ensure that repeat prescriptions were gained in a timely way and that the record was completed at the time of giving medication were made. The inspectors found a bathing list of residents on display and this did not preserve the dignity of residents. Grey Gables DS0000016772.V272687.R01.S.doc Version 5.1 Page 12 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): 12,15 Arrangements for planned group activities had improved but activities did not reflect the individual interest, history and ability of residents. Meal provision was good and this enhances residents’ lives. EVIDENCE: The home’s arrangements for activities were variable. A number of residents were happy with the activities provided saying that there was a lot happening especially over the Christmas period. The timetable for December showed many activities. A number said that they had been to Notcutts garden centre recently. Others thought the activities were not good, a number stating that they were based at a different part of the building and some activities should happen in their area. The home had some way to go to show that activities reflected the interests, abilities and individuality of the residents in the home. Residents in the home generally thought the food was good but some felt that there could be a bit more variety. The home had a new chef and intended to consult with residents again about changes to the menu. The inspectors saw that residents were given a drink midday however they were given biscuits whether they wanted them or not. Grey Gables DS0000016772.V272687.R01.S.doc Version 5.1 Page 13 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 Complaint and adult protection processes needed improvement to ensure that residents are protected. EVIDENCE: The Commission has received a number of complaints about the home since the last inspection mainly anonymously. A number of the complaints were based on misinformation and detailed issues that had already been investigated. Dissatisfaction about changes that had to be made in the home over the time of the last two managers were raised as well as a number of areas where improvement was needed. The Committee of the home were looking to all the complaints made and are to report back to the Commission. A complaint was investigated by the Commission about the actions of staff following a fall of a resident and requirements were made about this complaint and these are detailed at standards 4, 7, 9, 22, 27 and 31. The home’s adult protection policy and restraint policy still required reviewing to meet the standard. The home is aware of the need to contact the various agencies if adult protection issues are raised and has when needed referred staff to the protection of vulnerable adults register. The training records were not assessed on this occasion. Grey Gables DS0000016772.V272687.R01.S.doc Version 5.1 Page 14 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): 19,20,21,22,26 Although the home has undertaken some improvements since the last inspection continued work is needed to ensure a homely and safe environment for residents. EVIDENCE: The home had undertaken some remedial work on the environment since the last inspection but further work was required to bring the home up to the required standard. The home is a large rambling adapted building and several areas needed work. The home had replaced the carpets in the entrance hall and placed protectors on the edges of the stair carpet. However, the home still has areas of carpet that are worn and in a number of places the carpets were a trip hazard. The lower dining room needed safer chairs that did not have wheels. The inspectors left immediate requirements for these hazards to be rectified. The home had replaced a number of the windows where these were irreparable but still had not completed its upgrading. Grey Gables DS0000016772.V272687.R01.S.doc Version 5.1 Page 15 The home had planned to improve on the seating arrangements in some of the lounges to reflect the needs of the residents. The home has a large number of bathrooms many of which have adaptations to assist residents. However bathrooms needed wash hand basins. The tiling in a number of the used assisted bathrooms needed attention and in some cases this was a hazard. A number of bedrooms had been redecorated and all empty bedrooms were to be redecorated prior to being reoccupied the choice to be given to incoming residents. A radiator that had not been covered had been and this will protect residents from accidental burns. Redecoration of the corridors, adequate signage and fitting of the handrails were needed to assist residents to move safely and find their way around the building. One resident said ‘ The girls bring you down here that’s all well and good but how do you get back it’s a maze of corridors.’ It was clear that work had been done to improve the plastering in areas of the home but this had not been successful with areas around a number of doors requiring attention. The home was generally clean and fresh with many residents commenting on this aspect of their care. Residents said the laundry service was good. There were outstanding requirements in respect of ensuring that the small kitchens fridge temperatures were taken routinely and the provision of wash hand basins in the laundries. Food was opened in the fridge and was not dated when it had been opened and this could pose a risk of contamination. Some requirements concerned with heating and lighting were not inspected on this occasion and these requirements were brought forward however a resident mentioned that it could get hot in summer and another relative stated that a bedroom was cold. A toilet frame and seat in one bathroom needed replacement. A proposed schedule of outstanding work must be sent to the Commission with proposed dates of completion for the Commission to be assured that repairs are completed in a timely fashion. As a result of a complaint the home was required to have appropriate alarms for alerting staff that specific residents had moved out of bed. The home had a number of sensors in place at the time of the inspection. Grey Gables DS0000016772.V272687.R01.S.doc Version 5.1 Page 16 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 The deployment of staff needed improvement to ensure that residents’ needs were met in a timely way. EVIDENCE: Staffing at the home was raised by a number of residents. Residents felt that at times it was not possible to summon staff quickly enough if they needed assistance during the day. However residents were still positive about the care in the home. Rotas showed that staffing levels varied and that agency staff had to be used. Rotas did not show the names of agency staff used. The home was not full at the time of the inspection and there appeared to be appropriate levels of staff on duty during the inspection and on the rota. The deployment of staff did not always respond to the needs of residents. The home had a requirement to review the staffing levels on a night as a result of the complaint. The same number of staff were on duty at night except for a senior member of staff was now undertaking some shifts per week in addition. Grey Gables DS0000016772.V272687.R01.S.doc Version 5.1 Page 17 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, 38 The management of health and safety issues and supervision of staff was poor and this potentially puts residents at risk. EVIDENCE: The home’s manager has applied to the Commission to become the registered manager for the home. A complaint showed that during after a fall there weren’t clear levels of responsibility and decision-making. This was not assessed on this occasion and the requirement was brought forward. The care manager stated that supervision of staff had not taken place to the required standard. The inspector for the home was informed prior to this inspection that the process for gaining money from the Committee for health and safety repairs had now improved. Grey Gables DS0000016772.V272687.R01.S.doc Version 5.1 Page 18 The home sent evidence to the Commission that the required electrical wiring work had been completed other recommended work was to be completed. A number of bedroom doors needed the self-closures checking to ensure the door closed against the rebate and was not of such a force to knock over an elderly person. Some windows still required window restrictors for safety purposes. A ceiling rose in a bedroom was not flush with the ceiling and was exposing wires. However laundry doors were left open while no one was in the room and this poses a risk to some residents. Grey Gables DS0000016772.V272687.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 2 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 1 2 2 2 X X X 2 STAFFING Standard No Score 27 2 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X X X 2 Grey Gables DS0000016772.V272687.R01.S.doc Version 5.1 Page 20 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 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 moving and handling of residents must be undertaken in a safe and approved manner. Staff must be reissued with the guidance or where necessary re trained. (This requirement was not inspected on this occasion and was brought forward.) All repeat respite care residents must have their assessments reviewed periodically to ensure that the needs identified are still appropriate. All needs or risk raised must have a corresponding plan of how that need or risk is to be met. (This requirement was outstanding since 21/07/03) Timescale for action 28/02/06 2 OP4 13(5) 15/02/06 3 OP5 14(2) 31/01/06 4 OP7 15,12(1)a 12(2)3&4 28/02/06 Grey Gables DS0000016772.V272687.R01.S.doc Version 5.1 Page 21 5 OP7 12(3) 6 OP8 17(2) 7 OP8 17(1)(a) Sch 3 (3)(j) &(o) 13(2) 8 OP9 9 OP9 13(2) 10 OP9 13(2) 11 OP10 12(4)(a) 12 OP12 16(2)(n) The needs of residents should be met in a way that reflects the choice of the resident wherever possible. Monitoring charts must be completed where in place. (This requirement was oustanding since 30/11/04) A record of all checks made on the resident must be noted following a fall. (This requirement was not assessed and was brought forward from the 07/11/05) Regular staff drug audits must be undertaken to confirm staff are administering the medication as prescribed in all instances. (This standard was not assessed and this requirement was brought forward.) The medicine administration record must be completed at the time the medication is given. (This standard was not assessed and this requirement was brought forward.) The registered manager must review the chain of responsibility for ordering medication to ensure that no resident is left without medication. (This standard was not assessed and this requirement was brought forward.) Lists of personal care needs of residents must not be on display on walls that used by residents and relatives. 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 was outstanding since 31/08/05) 28/02/05 31/01/06 31/01/06 31/01/06 31/01/06 31/01/06 31/01/06 28/02/06 Grey Gables DS0000016772.V272687.R01.S.doc Version 5.1 Page 22 13 OP16 22(2) The Committee must provide a report of the investigation into complaints to the Commission. The home must produce an adult protection step-by-step procedure that is compatible with the local social services department. (This requirement was outstanding from 01/03/05) The home must have a restraint policy that reflects the residents in the home and includes any locking of doors. (This requirement was outstanding from 01/03/05) The home must ensure that all staff receive training in all aspects of adult protection. (This requirement was not inspected on this occasion and was brought forward from 01/03/05.) The home must produce a timed programme of redecoration and refurbishment that takes into account the requirements listed from standards to 19–26 and 38. A copy of this programme must be sent to the Commission. The registered provider must ensure safe access to the garden this must be included in the schedule of work. (This remained outstanding from 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 Commission. (This requirement was outstanding since 30/11/04) 15/02/06 14 OP18 13(6) 28/02/06 15 OP18 13(7) 28/02/06 16 OP18 13(6) 28/02/06 17 OP19 23(2)(b) (c)(d) 31/01/06 18 OP19 23(2)(o) 31/03/06 19 OP19 23(2)(b) 15/02/05 Grey Gables DS0000016772.V272687.R01.S.doc Version 5.1 Page 23 20 OP19 23(2)(b) 21 OP19 13(4)(c) 22 23 OP19 OP20 23(2)(b) 12(1)(a), 23(2)(n) 24 25 OP20 OP21 13(4)(c) 13(3) 26 OP21 13(4)(c) 27 OP22 23(2)(n) 28 OP22 23(2)(n) 29 OP22 23(2)(n) The remaining windows of the home must be audited and where necessary repaired and repainted (This requirement was outstanding since 30/11/04) Carpets identified at the inspection such as at the top of stairs and where joined and causing a trip hazard must be rectified and made safe. Areas where the plasterwork has come away from the wall must be renewed. The residents sitting areas must have chairs that reflect the needs of the residents. (This requirement was not assessed and was brought forward.) The dining room chairs with wheels must be replaced to provide safer alternatives. Wash hand basins must be provided in all bathrooms where there is a toilet sited. (This was requirement remained outstanding from 22/07/05) Repair to tiling in bathrooms and toilets must be undertaken. (This requirement is outstanding since 31/01/05) 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 where they are in the building and appropriate signage must be introduced. (This requirement is outstanding since 28/02/05) A toilet frame and seat in one communal bathroom must be replaced. 31/03/06 12/12/05 31/03/06 31/03/06 31/01/06 31/03/06 31/01/06 31/03/06 31/03/06 28/02/06 Grey Gables DS0000016772.V272687.R01.S.doc Version 5.1 Page 24 30 OP24 23(2)(d) 31 OP24 23(2)(m) 32 OP25 13(4)(c) 23(2)(p) 33 OP25 23(2)(j) &13(4)(c) 34 OP25 23(2)(p) 35 OP26 13(3) & 16 (2)(k) 23(2)(p) 36 OP26 37 OP26 13(3) Routine monitoring checks of safety must be undertaken of each residents bedroom. (This requirement was not assessed on this occasion and is brought forward.) Immoveable lockable storage is required in residents’ rooms where this currently is not provided. (This requirement was not assessed on this occasion and is brought forward.) All lighting in the home must have the appropriate shades. (This requirement was not assessed on this occasion and was brought forward.) 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. (This requirement was not assessed on this occasion and was brought forward.) 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) Laundry areas must have wash hand basins. (This requirement was outstanding since 30/11/04) Ventilation fans must be audited for repair and installation. (This requirement was not assessed on this occasion and is brought forward.) Fridges in the small kitchen must have their temperatures recorded. (This requirement was outstanding since 30/11/04) DS0000016772.V272687.R01.S.doc 28/02/06 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 31/01/06 Grey Gables Version 5.1 Page 25 38 OP26 39 OP27 40 OP28 41 OP31 42 OP36 43 OP38 44 OP38 45 OP38 46 OP38 All opened food and drink in fridges must have a date of opening. (This requirement was outstanding since 30/11/04) 18(1)(a) The deployment of staff must be such that residents that need assistance for their personal needs are able to gain this. 18(1)(a) The home must have a programme to ensure that at least 50 of staff have the NVQ2 in care or the equivalent. (This requirement was not inspected on this occasion and is brought forward.) 18(2) & The registered manager and (4) responsible individual must ensure that the staff are clear of the hierarchy within the home and levels of responsibility. (This requirement was not inspected on this occasion and is brought forward.) 18(2) All care staff must have recorded supervision not less than 6 times a year. (This requirement was outstanding since 30/11/05) 13(4)(c) Missing window restraints must be replaced. (This requirement was outstanding since 30/11/04) 13(4)(c) The home must consider whether the needs of the residents require that the fire doors to unfrequented stairwells require an alarm. (This requirement was outstanding since 30/11/04) 13(4)(c) The closures on bedroom doors 23(4)(c)(ii must be audited to ensure they i) close against the rebate and are safe for residents. (This requirement was outstanding since 30/11/04) 13(4)(c) A ceiling rose must be re-fixed to the ceiling. DS0000016772.V272687.R01.S.doc 13(3) 31/01/06 28/02/06 31/03/06 28/02/06 28/02/06 31/12/05 31/03/06 31/01/06 31/01/06 Page 26 Grey Gables Version 5.1 47 48 OP38 OP38 13(4)(c) 13(4)(c) All bedrooms must be checked for health and safety before reletting. Laundry room doors must be locked when not staffed. 31/01/06 31/01/06 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 OP3 OP15 OP27 Good Practice Recommendations It is recommended that assessments are dated and have detail where the assessment was carried out. It is recommended that the chef routinely ask residents of meals they enjoy so these can be evidenced as part of the menu. It is recommended that all agency staff names appear clearly on the rota as agency staff. Grey Gables DS0000016772.V272687.R01.S.doc Version 5.1 Page 27 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. Extracts may not be used or reproduced without the express permission of CSCI Grey Gables DS0000016772.V272687.R01.S.doc Version 5.1 Page 28 - 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. 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