Inspection on 04/12/06 for Red Gables

This inspection was carried out on 4th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Red Gables 20/02/06

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Red Gables 1 Pinnocks Croft Berrow Burnham-on-sea Somerset TA8 2NF Lead Inspector Pippa Greed Unannounced Inspection 4th December 2006 09:15 Red Gables DS0000061625.V319039.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Red Gables DS0000061625.V319039.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Red Gables DS0000061625.V319039.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Red Gables Address 1 Pinnocks Croft Berrow Burnham-on-sea Somerset TA8 2NF 01278 786607 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) Milbury Care/ Voyage South Ltd Mrs Tina Ann Thomas Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Red Gables DS0000061625.V319039.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service Users may be admitted to the home that have a concurrent physical disability. The home may admit service users aged 16 and 17 years. Date of last inspection 20th February 2006 Brief Description of the Service: Red Gables is a large detached property on the outskirts of Berrow. Service user accommodation is provided over two floors. All bedrooms have en-suite bathroom facilities. There is a range of communal space available to service users, including an activities room and training kitchen. The home has been decorated and furnished to a high standard, and appropriate adaptations have been provided to meet service users needs. Red Gables is registered with the Commission for Social Care Inspection to provide accommodation for up to ten service users. The home is able to admit service users aged 16-65 years who have a learning disability. Service users who also have a concurrent physical disability may be admitted to some ground floor rooms. Tina Thomas is the Registered Manager for the home. The Registered Provider is Milbury Care/ Voyage South Ltd. The current scale of charges is £1,400 and £2,200. Red Gables DS0000061625.V319039.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The previous inspection was unannounced and took place on 20th February 2006. At that inspection five requirements and one recommendation were made. Those requirements have been met. This unannounced Key inspection was conducted on 4th December 2006 over one day (8hrs) by CSCI Regulation Inspector Pippa Greed. On the morning of the inspection, six support workers and the manager on duty and during the afternoon there were five support workers. There were two waking night staff rostered for that evening. The registered manager Mrs. Tina Thomas was available to assist the inspector during the unannounced visit. On the day of the inspection seven service users were at home. One service user attended full-time education and another service user left the home around mid morning to attend a swimming session. The atmosphere was relaxed and informal. The inspector viewed all communal areas, two vacant bedrooms and five service users rooms with their expressed permission. The inspector met with and engaged with five service users. The inspector sat with and observed lunchtime routine with the service users and staff and also observed daily routines within the home. Staff were seen to work in a professional manner. A selection of records was examined. These included three service users care plan and three staff recruitment files. CSCI sent out feedback cards for five service users, three relatives, seven staff, four social workers and one General Practitioner. Two service users surveys has been received, which was completed with advocated support. These surveys confirmed that service users had opportunity to visit the home prior to moving in. Three care staff comment cards confirmed that they were aware of policies and procedures. One comment card was received from parents, which confirmed that they were kept informed of important matters, aware of the complaint procedure and felt satisfied with the overall care provided. One GP comment card has been received and this confirmed that the service provides good care. The GP wrote ‘An excellent home’. The inspector would like to thank the service users, staff, and manager for their time and hospitality shown to the inspector during her visit. Red Gables DS0000061625.V319039.R01.S.doc Version 5.2 Page 6 The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the service does well: What has improved since the last inspection? The home has purchased new sofas and new carpets laid throughout communal areas. The walls on the ground floor hallway have been redecorated with split-level cladding. All the male service users have enjoyed a holiday to the Calvert Trust and all the female service users enjoyed a holiday to Center Parcs at Longleat. Two service users have been supported with one to one staffing on a holiday to Cornwall. The manager has taken appropriate action to address all of the requirements made at the last inspection. These were related to the following; dining room Welsh Dresser drawers have been repaired, free-standing wardrobes made secure, improved infection control strategy, fire door on first floor has been planed in order to make sure it opens more easily, laundry door has been fitted with a closure device and all ground floor fire exit have been fitted with a security alert device. Red Gables DS0000061625.V319039.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Red Gables DS0000061625.V319039.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Red Gables DS0000061625.V319039.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users and their families are provided with relevant information regarding the home. Social and health assessments are completed to ensure that the home is able to meet service users’ needs. EVIDENCE: The home has a Statement of Purpose that provides details of the services and facilities provided at Red Gables. The Statement of Purpose is presently being updated to reflect the changes within the organisation. The service users contract is stored at head office. It is good practice to include a copy in the service user’s care plan. The Statement of Purpose outline criteria for admission. Initial referrals may come from either a parent/ carer or from a social worker. A written profile and detailed assessment is obtained from the social worker, which would allow for Voyage’s Operations Manager to assess the suitability for placement. There is no set timescale as each case is judged on the service user’s needs. Red Gables DS0000061625.V319039.R01.S.doc Version 5.2 Page 10 The Service Users Guide is provided in a simple easy to understand format. It is written using Picture Bank images for ease of understanding. The Service User’s Guide covers the following: What Red Gables can offer you, Your rights, How much it costs?, What to do if you don’t like something?, What other service users want to happen at Red Gables and Where to find copy of CSCI report and contract. A copy of the Service Users Guide should be stored in individual care plans as good practice. One service user’s survey explained that the service user had support from parents in choosing this home. The service user visited the home with parents as part of trial. Staff from Red Gables also visited the prospective service user’s family home as part of the transitional process. There are two vacancies at present. The manager is aware of the need to ensure that an assessment of care need is completed prior to any prospective service user viewing the home. Red Gables DS0000061625.V319039.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has developed an appropriate care plan for each service user. Service users are encouraged to exercise choice and participate in all aspects of life within the home. Service users are supported in taking risks. Records relating to service users are stored securely and appropriately maintained. EVIDENCE: Care plans are maintained for each service user. Three care plans were examined in detail. Care plans included a photograph of the service user, and provided information regarding service users needs. This included general health (dental, optical, chiropody), medication, diet, self-help skills, daily living skills, activities, communication, social and behaviour. Red Gables DS0000061625.V319039.R01.S.doc Version 5.2 Page 12 The monthly summary are completed by the key support worker and were completed on a regular basis. This ensures that the home continues to meet the needs of each service user. The care plan also includes a summary of risks. Risk Assessments seen were up to date. Service users are encouraged to exercise choice, and independence is promoted. A service user has a preference of relaxing on the floor and makes personal choice of which tactile toy to explore. Service users were seen to move around the communal parts of the home freely and choose who they would like to be with. Service users are enabled to use their own bedrooms in order to engage in their choice of pastime. Some bedrooms are equipped with personal effects such as sensory lights, cushion wedge, adapted computer, television, DVD and music system. Staff will support service users in managing their finances where required. Financial records were examined for two service users. Two staff signatures supported all entries. The entries were correct for expenditures and tallied with the balance. Two staff members check the tin daily and both sign to confirm the balance. Currently, no service users have an advocate but the home will arrange this through Somerset Advocacy Service if needed. All records relating to service users are stored securely and kept confidential. Red Gables DS0000061625.V319039.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home offers service users opportunities to engage with peers, access appropriate leisure activities, and exercise choice. Service users are supported with friendship and family contact. Service users are offered a choice of menu, and the options are developed around their preferences and dietary needs. EVIDENCE: On the day of the inspection, seven service users were at home. One service user left around late morning to attend swimming at another service in Wellington and another attended full-time education. Service users are supported in developing and maintaining daily living skills. Service users were encouraged to carry out simple housekeeping task on the day of the Red Gables DS0000061625.V319039.R01.S.doc Version 5.2 Page 14 inspection. Service users were also seen to engage in their chosen activities such as relaxing with preferred tactile stimulations. During the afternoon, service users were engaged in an arts & crafts activity such as use of stickers and making Christmas cards. Staff from the home will assist service users in continuing to access social and leisure resources. The manager is presently sourcing a range of activities and hopes to place a music therapist for the home. The possibility of horse and cart session and other seasonal activities has been looked into. The manager has asked for the local college to assess and advise on suitable courses for service users. This is planned for the New Year. Activities provided by the home and in the wider community includes the following: - swimming, physiotherapy, ‘atmospherics’, horseriding, cookery & bread making, trampoline, college, holistic therapy, use of the sensory room, social club, ten pin bowling, cinema and local pubs/ restaurants. The home displayed an activities timetable on the kitchen cupboard. It is recommended that consideration is given toward a more widley accessible communication system in order to enable the service users to understand and anticipate planned activities. The home has use of two minibuses to access local facilities. The manager informed the inspector that the service users were supported with a holiday trip to the Calvert Trust and Center Parcs during the summer. Also, two service users enjoyed a holiday break with one-to-one staffing to Cornwall during the summer. The home has regular contact with service users family members. Care plans provide details of service users personal and family relationships. There are many photographs of service users and their families in individual bedrooms. Red Gables staff team have fundraised money to enable one service user to go on holiday with a parent to Lapland. The social worker is said to be full of praise for the staff team’s support. This is commendable. The home has a menu that reflects the likes and dislikes of the service users. The menus appear to provide a variety of foods that are nutritious and appetising. The meal on the day was liver, bacon and onions with mashed potatoes and vegetables. The Inspector observed the lunchtime routine. Service users were seen to be enjoying their meals and staff offered care and support in a timely and kind manner. The fridge and freezer were in good working order and daily temperature recorded. Food probe records were also regularly maintained. Cleaning schedules were seen. All of which were completed appropriately. Red Gables DS0000061625.V319039.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are provided with appropriate assistance to meet their personal care needs. The home supports service users in accessing healthcare services. The home also provides appropriate aids and equipments. The home has a medication policy. Medication Administration Records are managed safely. EVIDENCE: Service users are provided with support to undertake personal care tasks as required. Many service users have complex health care needs. Staff supports service users in accessing healthcare services and ensure that specialist advice is sought as necessary. The care plans that were sampled contained documentation of the visits made to health care professionals. These included visits to the GP, dentist, chiropodist, optician, speech and language therapist, and physiotherapist. Red Gables DS0000061625.V319039.R01.S.doc Version 5.2 Page 16 A record is maintained in care and support plans of healthcare appointments and outcomes. The home has aids and adaptations to assist the service users in their personal support. Where needed service users have the use of technical aids and equipment. The health and safety checks for these equipments are maintained regularly. The bedrooms have en-suite facilities so this promotes service users’ dignity when supported with personal care. Staff are provided with medication training. Further medication training update has been arranged. Currently medication is stored securely. No current service users are able to self-medicate. The Inspector sampled the Medication Administration Record and storage of medication. This was considered to be well maintained. The Medication Administration Record file had medical footnote and photograph ID of each service user. The home records as good practice the temperature of the room. The inspector sampled records, which demonstrated medication received into the home and also disposed medication leaving the home. There are weekly audits in place to check quantity of medication. Two staff signatures support this. The home maintains records of service users medication leaving the home for overnight visits. This is good practice. No gaps were seen on the Medication Administration Record. The medication storage area was clean and tidy. It is recommended as good practice that liquid medications are labelled to demonstrate dates when opened and when to dispose by. It is also recommended that variable dosage recording be implemented to ensure accurate monitoring. The home has a policy relating to ageing and death. The care plans do not contain details relating to standard 21. Red Gables DS0000061625.V319039.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has a clear Adult Protection policy, which is accessible. Staff are clear on correct reporting procedure. The home has systems in place to protect the service users from abuse. EVIDENCE: The home has appropriate policies relating to the Protection of Vulnerable Adults, Whistle Blowing, Complaints policy, and Grievance policy. Three staff comment cards were received. These confirmed they knew where Protection of Vulnerable Adults information were kept. They also stated that they understood how to report any concerns about poor care or allegations of abuse. POVA training has been offered in-house to staff. The complaint log was sampled and the last recorded complaint was made in November 2006. The manager has communicated effectively and has been proactive in following through and resolving the matter. A review meeting was recently held with positive outcome. The inspectors viewed the organisation’s Complaints procedure. This is well written and includes time scales for acting on and addressing complaints made. To further enhance the complaints procedure it would be helpful if the Red Gables DS0000061625.V319039.R01.S.doc Version 5.2 Page 18 organisation stated that at any time the complainant could contact the regulator to discuss their concerns. The organisation’s Vulnerable Adult policy was sampled. It sets out the expectations of the alerter (staff) to report issues to the organisational line management structure. If the issue of concern relates to the staffs immediate line manager the policy instructs the person to go directly to their managers manager, and so on. This may be a weakness in the procedure, as the member of staff may not wish to report to senior management their manager on suspicion alone. Stating in the policy that the staff member can go directly to any of the statutory agencies at any time to report their concerns could rectify this. The Public Interest Disclosure Act 1998 provides clear ‘good practice’ guidance. Three staff recruitment files were sampled and these contained information required by Schedule 2, Care Homes Regulations 2001. Criminal Records Bureau (CRB) checks are in place for all staff except one staff member. POVA 1st checks have been carried out on newly recruited staff, including the staff member whose CRB remains pending. The manager has arranged for extra paperwork and identification to be sent to the CRB in order to aid the process. This staff member has been risk assessed and does not carry out personal care for service users. Red Gables DS0000061625.V319039.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has been decorated and furnished to a high standard. The home has sufficient communal areas and bathrooms to meet service users’ needs. The home was found to have a good standard of cleanliness. EVIDENCE: Red Gables is a large detached property situated in the village of Berrow. The home has ready access to local shops within Berrow and Brean. Service user accommodation is provided over two floors. The home comprises of two lounges, a dining room, training kitchen, and two conservatories. There are sufficient communal spaces for service users to access. There is a large secluded garden to the rear of the property and sufficient parking to the front of the property. Red Gables DS0000061625.V319039.R01.S.doc Version 5.2 Page 20 Service user rooms are single occupancy. All rooms have an en-suite bathroom. Service users rooms have been decorated to a good standard and are personalised with their own belongings such as photographs of family, television and DVD player, sensory lighting and decorative posters. The home has purchased new sofas and new carpets laid throughout communal areas. The walls on the ground floor hallway have been redecorated with split-level cladding. The laundry area was secure, clean and well organised. The laundry door has been fitted with a closure device in order to meet a requirement from the last inspection. Appropriate hand washing facilities had been provided for staff throughout the home. The home had been maintained to a high standard of cleanliness. In the kitchen the Inspector saw records of daily fridge and freezer temperatures. These were found to be within safe range. The food stored in the fridge was date labelled to promote good food hygiene practice. Food probe records were seen and maintained within appropriate range. The kitchen is equipped sufficiently and kept clean. Red Gables DS0000061625.V319039.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff are experienced and provide a good standard of care. Staffing levels are appropriate to meet service users’ needs. The home has a robust recruitment procedure. Staff have been provided with regular opportunities to attend training. Staff are supervised and well supported by the manager. EVIDENCE: Duty rotas are appropriately maintained. On the morning of the inspection, three support workers and the manager were on duty. Three further support workers were on duty during the day. During the afternoon, there were five support workers on duty. Two waking night staff were rostered for that night. Since the last inspection, one staff member has joined the team at Red Gables. The manager stated that all staff have completed all mandatory training. The training file confirms this. Red Gables DS0000061625.V319039.R01.S.doc Version 5.2 Page 22 Staff are provided with regular opportunities to receive training, and have attended courses on Non Violent Crisis Intervention (NVCI), Diabetes study day (in-house), Institution of Occupational Safety and Health (IOSH), Infection Control, Intensive Interaction and Protection of Vulnerable Adults (in-house). Three of the twenty staff employed (excluding the manager) have obtained the NVQ level 2 or above qualification in care. The manager has addressed this by registering seven staff to undertake NVQ 2 learning. It is recommended that manual handling update training for staff are provided annually to reflect the needs of the service. Three staff recruitment files were examined. These were maintained appropriately. Each was found to contain the documentation required within Schedule 2 of the Care Home Regulations 2001. The inspector viewed the records in relation to staff supervisions. The manager has an overview of all staff supervisions that have been conducted. However, it is recommended that staff are provided with formal one to one supervision at least six times a year. Red Gables DS0000061625.V319039.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is managed well. There is a relaxed and open atmosphere within the home. Appropriate actions have been taken to promote the health and safety of staff and service users. EVIDENCE: Tina Thomas has many years experience working with vulnerable people. Since 1999, Ms Thomas has worked with young adults in a variety of setting. She has attained National Vocational Qualification (NVQ) level 3 in Care and has registered to undertake the Registered Managers Award. Tina Thomas is supported by one deputy manager and four senior support workers. Red Gables DS0000061625.V319039.R01.S.doc Version 5.2 Page 24 Staff spoken with confirmed that the manager was approachable and that they would be able to raise any concerns. Relative and GP comments cards also commented positively on the home. A GP wrote ‘An excellent home’. The home operates a comprehensive system of health and safety audits. Fire safety records were examined. Fire equipment had been serviced and tested as required. The portable appliances, landlord gas safety certificates, water temperature and hoist checks have been appropriately maintained. Accidents have been recorded and an analysis completed on a monthly basis. The monthly analysis are complied by the manager and sent to Voyage Head Office in Taunton for further audit. This is considered as good practice. Records are kept of daily fridge and freezer temperatures, food probes and hot water temperatures. These were maintained regularly. Red Gables DS0000061625.V319039.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 4 26 4 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 3 3 3 3 Red Gables DS0000061625.V319039.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 YA14 Good Practice Recommendations It is recommended that consideration be given toward a more accessible communication system in order to enable the service users to understand and anticipate planned activities. It is recommended that variable dosage recording be used to indicate actual quantity given. Also, labels on all medication to indicate when it was opened and when to dispose by. It is recommended that the complaints policy make clear to complainants that they are able to contact the Commission for Social Care Inspection at any stage of a complaint. The organisation may wish to consider its policy (point 4.4) with regards to vulnerable adults so that it empowers the individual to contact either of the statutory agencies with their concerns. DS0000061625.V319039.R01.S.doc Version 5.2 Page 27 2. YA20 3. YA22 4. YA23 Red Gables 5. 6. YA36 YA32 It is recommended that staff are provided with formal one to one supervision at least six times a year. It is recommended that manual handling update training for staff are provided annually to reflect the needs of the service. Red Gables DS0000061625.V319039.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Red Gables DS0000061625.V319039.R01.S.doc Version 5.2 Page 29 - 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. 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