Inspection on 04/07/06 for Red Gables

This inspection was carried out on 4th July 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 17/06/08

Red Gables 21/06/07

Similar services:

Snydale Care Home

Staveley Birk Leas Nursing Home

Fairmount Nursing Home

Currergate Nursing Home

Brookfield

Castlethorpe Care Home

Elmleigh Convent

Woodlands Respite Care Centre

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

CARE HOMES FOR OLDER PEOPLE Red Gables Parish Ghyll Drive Ilkley West Yorkshire LS29 9PR Lead Inspector Sean Cassidy Key Unannounced Inspection 09:30 4th July 2006 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 Red Gables DS0000064964.V296244.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 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. Red Gables DS0000064964.V296244.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Red Gables Address Parish Ghyll Drive Ilkley West Yorkshire LS29 9PR 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) 01943 601113 01943 602425 Queensland Care Limited Heather Furness Care Home 32 Category(ies) of Dementia - over 65 years of age (32), Physical registration, with number disability over 65 years of age (32) of places Red Gables DS0000064964.V296244.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Red Gables is situated in an elevated position close to Ilkley town centre. The town offers a good selection of shops, cafes, restaurants, sports facilities and a theatre and has rail and road links with Leeds, Bradford and other towns in the region. Residents in the home are likely to require transport to access local amenities due to the steepness of the route leading to the home. The large detached Victorian style property has been extended during its lifetime to provide a variety of communal areas and additional purpose built bedrooms with en-suite w/c and hand washing facilities. All rooms have a pleasant outlook and residents are encouraged to bring their own belongings into the home to personalise their rooms. There is level access to a pleasant patio area overlooking the landscaped gardens at the rear of the property. Off road parking is available with ramped access to the property. The home provides nursing care and operates with a trained nurse on duty at all times assisted by a team of care and ancillary staff. Red Gables DS0000064964.V296244.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk This was an unannounced inspection; it took place over one day. The inspection was carried out between 9.30am and 4.00pm on 04/07/06. The last inspection of this home took place in October 2005 and a number of concerns were identified, some of which were outstanding from previous inspections. During the inspection all key standards were assessed. These are identified in the main body of the report. The inspector reviewed in detail the care of three residents living in the home. I examined their care records; spoke to the residents about their care needs and spoke to the staff about how they deliver care. I also inspected the environment in which these residents receive care and observed care practices. Residents were spoken to, a tour of the building took place and records, including maintenance records, staff files and training records were examined. A pre-inspection survey was completed by the home before the visit; the information provided was used during the inspection. Detailed feedback was given to the registered manager at the end of the visit. It is important to note that hard work and effort has been put into improving the standard of care and facilities within this home. This work has been recognised from all elements of the staff team ranging from the management team right through to the domestic staff and the maintenance staff. It is hoped that the standard of improvement will be maintained and further developed. This is a home that has recognised where its strengths and weaknesses lie. It appears to be committed to improvement and it is hoped that this continues well into the future. The fees charged by the home range from £500-£700 pounds per week. What the service does well: Red Gables DS0000064964.V296244.R01.S.doc Version 5.2 Page 6 The staff are very helpful, polite and interact well with the resident group and others. The home offers a wide and varied activities package that is well used by the resident group. The standard of cleanliness within the home is well maintained. The surrounding gardens are maintained to a good standard and are well used by residents. What has improved since the last inspection? What they could do better: Red Gables DS0000064964.V296244.R01.S.doc Version 5.2 Page 7 Now that the new Service User Guide has been developed, all residents must be supplied with a copy. More improvements are needed with the provision of care planning and risk assessment to ensure that the appropriate care needs are being provided for. Significant improvement is needed to ensure that the dementia care provided within the home is evidenced based and person centred. A snack should be offered to all residents on an evening as the gap between teatime and breakfast is longer than twelve hours. Improvements are needed to ensure all staff working in the care home have received suitable training in Adult Protection. Lockable storage facilities should be provided to all residents. The numbers of staff working on shift should be reviewed using a suitable staffing tool. An appropriate training programme must be identified and provided to the staff group. A recognised system of quality assurance must be identified and implemented within the home. The environment of the home must be suitably risk assessed to ensure residents are appropriately protected. 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. Red Gables DS0000064964.V296244.R01.S.doc Version 5.2 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 Red Gables DS0000064964.V296244.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5. Standard 6 does not apply to this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Written information about the services provided by Red Gables is made available to residents. Residents are provided with contracts stating the fees to be paid, but not all are provided with the home’s Terms and Conditions. The needs of residents are assessed before they are admitted into the home. Prospective residents and their representatives are invited for a trial visit prior to admission. EVIDENCE: The home has developed a Statement of Purpose that is provided to all prospective residents to assist them with making a choice of moving into the home. This was confirmed by speaking to relatives during the inspection. A Service User Guide has been developed to provide the existing residents with Red Gables DS0000064964.V296244.R01.S.doc Version 5.2 Page 10 information regarding the home. This document is available at the entrance but is not provided to each resident when they enter the home. It was noted that in two resident bedrooms the Service User Guide was out of date as the information contained related to the previous owners of the home. The manager agreed that this document would be provided to all residents. The three residents that were case tracked during the inspection all had contracts in place that highlighted the fees that were to be paid. These documents were also signed by themselves or their representatives. It was unclear whether all had received and signed a copy of the homes Terms and Conditions. The manager agreed that a system would be developed to ensure this would be evidenced at the next inspection. No resident is admitted to the home without a full assessment being carried out by a qualified person. This was confirmed through discussions with residents and also from the paperwork examined as part of the inspection. Further assessment is carried out when the resident arrives at the home and care plans are developed using both documents. This is good practice. Trial visits are offered whenever possible and this is included in the Statement of Purpose for the home. Where a resident is unable to visit due to their medical condition, representatives of that person are invited to the home to look around the environment and chat with staff and residents. This was confirmed during the inspection Red Gables DS0000064964.V296244.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Improvements have been made with the care plans and risk assessments since the last inspection. However, more work is needed if the home is to ensure the outcomes can be met for residents. The homes policies and procedures for medication help to ensure residents are appropriately protected. Residents are enabled to self medicate when appropriate. Residents and relatives spoke highly of the staff group and expressed that their dignity and privacy is well protected. EVIDENCE: The manager has attempted to ensure that all residents are provided with a care plan for each need that has been identified from the assessment. Although care planning has improved since the last inspection more work is Red Gables DS0000064964.V296244.R01.S.doc Version 5.2 Page 12 required to ensure the outcomes can be met for residents. The Roper Logan and Tierney nursing model is used to provide for the care needs of the residents living at the home. This is fine when it comes to providing for the physical needs of the residents, however, a large number of residents living at the home have Dementia and the care plans do not provide evidence to show that a person centred approach will assist care staff with meeting the complex dementia care needs of the resident group. The care files inspected lacked sufficient detail to ensure that all care needs would be met. Examples of this are: • A resident’s Communication care file stated that “carers to liaise with residents husband about her needs.” The care should clearly highlight the care needs in this area. Two residents’ Safe Environment care plans stated that there were no problems in this area when it was quite evident from the high dependency levels that there were many issues. One resident identified as being high risk of developing a pressure ulcer did not have a care plan in place. Residents identified as having continence problems were not appropriately assessed in this area and the detail of the care to be provided was insufficient. Nutritional care plans for two residents did not include the changes in the care programme identified in the daily updates. One resident’s notes included instruction that fluids should be thickened. This was not incorporated into the care plan. One resident identified as experiencing pain in her hands did not have a care plan developed to meet this need. The language used in some of the care plans was unclear e.g. “ensure assistance given with nutrition” “ensure toileted regularly” “use pads and pants”. These do not give the carer sufficient information to ensure the care needs of the individual can be met in these areas. • • • • • • Improvements were noted in the risk assessments now carried out in areas such as moving and handling, pressure ulcer development, nutrition and falls. The inspector highlighted that it is important that when these documents are used they should be filled in correctly to ensure the resident is appropriately protected. One resident nutritional score had been recorded wrongly and therefore was not appropriately triggered to ensure a GP or dietician was involved with the care. Red Gables DS0000064964.V296244.R01.S.doc Version 5.2 Page 13 Care plans were reviewed monthly and evidence was seen to show residents or their relatives gave agreement to the process. It should be noted that the home is currently reviewing the care planning documentation with a view to introducing a new system which they feel will benefit the resident group. The medication system adopted by the home was good. There are clear policies in place to assist staff in this area. Two residents were self-medicating at the time of the inspection. They had been appropriately assessed to do so and were involved with the process. All medication charts were appropriately recorded. The manager confirmed that they also have a contract with a suitable company to ensure the safe disposal of medications in the home. During the course of the inspection the inspector noted the interactions of staff with the resident group. Staff appeared friendly, helpful and courteous at all times. The residents spoke very highly of the staff group. They felt they were treated with dignity and respect at all times. Comments made were, “they respect my privacy and are very pleasant” “ the staff are very genuine and caring” “ The staff always respect our privacy and dignity. They always knock on the door before entering and always say your welcome when you say thank you.” Residents and relatives were keen to point out that the staff group tried hard to ensure their privacy and dignity is always maintained. One female resident said that she only likes her personal care to be provided by a female carer and that this does happen. Red Gables DS0000064964.V296244.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The home provides residents with flexible and interesting activities to suit the varied needs of the resident group. The home ensures that contacts with families and friends are maintained as much as possible. Residents said they felt the home assisted them to make choices for themselves. The home provides a wholesome and appealing diet for the residents. EVIDENCE: Significant improvements have been made in the provision of social and recreational activities both in and outside the home. A new activities coordinator has been employed by the home to assess the needs of the residents and ensure these needs are met in as many different ways possible. The activities coordinator has quickly developed a programme of activities that Red Gables DS0000064964.V296244.R01.S.doc Version 5.2 Page 15 has been acknowledged by residents, relatives and staff alike. One resident said, “There used to be nothing going on in the home. We all just sat about staring at the floor. Now there’s a load of things you can do.” Activities include: • • • • • • • • Exercises for the elderly Gardening and growing vegetables Quizzes Craft classes Baking Art Classes Reminiscence therapy Visiting entertainers The above are examples of the activities that are now provided within the home. Planned days out for the residents have started and are planned for the future. Five residents were taken out on a recent trip on a canal boat. The home is hoping to plan a trip to Blackpool for a ballroom dance. One resident that has eyesight difficulty has been involved with the planting of vegetables in the garden and thought it was one of the best days of her life. One resident said about the activities coordinator, “She is a very nice friend to have in this place.” The care files do not yet provide evidence that the residents’ interests are recorded and planned for. The manager agreed that she would be working with the activity coordinator to ensure this work is carried out. The home has an open door policy for visiting, which was confirmed by both residents and relatives. The new activities coordinator is currently looking at new ways in which the residents can get involved with the local community. Plans are in place to contact local schools and community centres for assistance in this matter. It was clear from the evidence provided by residents and their families the home enables residents to bring in their own personal belongings if they wished. A Payphone is available to make private calls and mail is provided to residents as it comes into the home. Residents were very vocal about the quality of the food. They were satisfied that they were provided with a varied and appealing diet. The menu for the day was well displayed and it offered a choice to residents if they wanted it. Regular drinks of lemonade, water and orange juice were made available to residents throughout the course of the day. Residents and relatives confirmed that this done on a daily basis. A Snack is not consistently provided to residents before bedtime. Some residents said that they thought it was available if you asked, but not all residents are able to ask. The gap between the evening meal and breakfast is longer than fourteen hours and is deemed to be too long without having a snack offered in between. Red Gables DS0000064964.V296244.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. The home enables residents and others to make a complaint. Residents feel confident their complaints will be correctly dealt with. More measures should be taken by the home to ensure the care staff are suitably trained to ensure residents are appropriately protected from abuse. EVIDENCE: The complaints procedure is displayed in the main entrance and is also included in the home’s Service User Guide. The manager confirmed there was a complaints book but was unable to produce this at the inspection. She stated no complaints had been recorded since the last inspection. The manager expressed that complaints would be dealt with appropriately and outcomes would be provided within the correct timescales. Residents and their families said that they knew how to complain and whom to take their complaints to. Confidence was expressed with regards to the home investigating any complaints that might be made. The adult protection training was examined and it showed that there were gaps in training in this area. The manager stated that she was aware of this and advice was given as to whom she could contact regarding information on the matter. Discussions held with staff identified that there were some gaps in knowledge in this area that need filled. Red Gables DS0000064964.V296244.R01.S.doc Version 5.2 Page 17 The inspector has recently been consulted regarding a serious adult protection issue within the home. Advice was given and appropriate action was taken. The home does have policies and procedures in place to assist residents to deal with finances and valuables. At the time of the inspection the home did not have responsibility for any resident’s finances or valuables. Red Gables DS0000064964.V296244.R01.S.doc Version 5.2 Page 18 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Service users are provided with a home that is suitable and well maintained. The environment of the home appears clean, pleasant and hygienic. EVIDENCE: The location and layout of the home are is suitable for the resident group living there. A number of notable improvements have been made within the environment which residents and relatives have found very beneficial. The lounge at the front of the house has been redecorated and is now solely used by the residents for relaxing in. The dining room has undergone a refurbishment and has had a new floor and furnishings added. All newly decorated rooms are provided with a lockable storage facility. It was highlighted with the manager that this facility should be provided to all residents living in the home to ensure they have a facility to lock away valuables and also medicines. Five bedrooms have been redecorated to a very Red Gables DS0000064964.V296244.R01.S.doc Version 5.2 Page 19 high standard. The home intends to continue with this refurbishment as part of their ongoing annual plan. Appropriate locks are being added to doors to assist residents with ensuring their privacy and dignity is upheld whenever possible. Garden furniture has been purchased for the front and the back of the house that was well used by the residents on the day of the inspection. Gazebos have also been purchased to ensure appropriate protection from the sun is provided. The gardens at both the front and back of the house are maintained to a good standard and many comments were made by residents regarding the attractive gardens. New adjustable beds have been bought and various pressure relieving equipment has been purchased. All areas of the home that were inspected were clean and tidy with no odours identified. West Yorkshire Fire Services carried out an inspection of the home in May 2006. The manager said work was in progress to deal with the issues identified during this inspection. Red Gables DS0000064964.V296244.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. The home should review the staffing numbers using a suitable staffing tool to ensure all the care needs of the residents are being met The numbers of staff trained to NVQ level 2 or above falls short of the recommended levels for care homes. The recruitment procedure adopted by the home ensures residents are protected. The training programme provided by the home does not ensure that staff are appropriately equipped to meet the care needs of the resident group. This is particularly relevant to those residents with dementia. EVIDENCE: The home has a staffing rota in place that ensures suitable numbers of staff are on duty at the correct times. The residents spoken to spoke highly of the staff group but they did make comments that they appeared busy and had little time to sit and chat with them. This was acknowledged through conversations held with staff and relatives. The following comments were made by residents,” The staff are kept on the go, they don’t have much time to rest.” “The staff don’t appear to have a lot of time to sit and chat with the residents.” Staff spoken to also said that they were constantly on the go and when they did have time to sit and chat they sometimes felt guilty about not doing other Red Gables DS0000064964.V296244.R01.S.doc Version 5.2 Page 21 physical jobs within the home. There are a significant number of residents in the home with dementia and who depend on staff to spend quality time with them other than the physical time meeting their needs. The manager acknowledged this as an issue that she has already identified as requiring attention. It is important that the care staff numbers are correctly identified to ensure all the needs of the client group can be met. The numbers of staff that have obtained training to NVQ level 2 standard still has not reached the recommended levels. The home is aware of this and it was confirmed that action is being taken to ensure that the staff are trained appropriately. Although this training is required it should be noted that residents and relatives spoken to felt that the staff worked hard and appeared confident and competent in their roles. The recruitment file of the two most recent employees showed that all the relevant information was obtained on each employee before they were able to work in the home. This is an area that the home has improved on. The training files of the staff working in the home were examined. The manager and inspector agreed that the mandatory training provision to staff has improved and still needs more input. There was an absence of training in areas that are particularly relevant to the resident group. Examples of these areas are, Diabetes, nutrition, continence management, and pressure area care. The inspector recommended that training needs analysis be carried out by the manager and that a thorough training package be developed for delivery to staff. The manager confirmed that the registered nurses working in the home could be consulted and asked to provide relevant training in these areas. Three members of staff have attended a “Positive Dementia Course”. The staff that attended the course gave some good insight into how to improve the lives of residents with dementia. Discussions were held with the manager about this specialist care need. It was clear from the care files and also from the environment of the home that there is a lot of work to be done to show how the home is actively meeting the specialist dementia needs of the resident group. The manager and other staff have had experience with working with people with dementia, which is beneficial, however evidence is needed to show that good practice in Dementia is being carried out in the home. Red Gables DS0000064964.V296244.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Residents are beginning to benefit from the improvements that are being implemented by the new registered manager. Residents are yet to benefit from the implementation of recognised quality assurance systems. The homes policies and procedures relating to residents’ monies help to ensure residents are appropriately protected. The home is making good progress with ensuring the health and safety of the residents is promoted and well protected. Red Gables DS0000064964.V296244.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager of the home has recently been registered with the Commission and is in the process of completing the registered managers award. The manager has continued to make improvements with this service since the last inspection. Positive work has been carried out that has evidently improved the lives of the residents. The residents, staff and relatives all expressed confidence in the management team and they felt supported when they had a concern. Regular visits from the Responsible Individual are carried out and sent to the Commission for review. This is good practice. Discussions were held with the manager with regards to the quality assurance systems adopted by the home. It was clear from these discussions that this is an area that needs development and training if it is to be successfully completed. The quality assurance report for the home has not been developed for this year. It was recommended that the manager developed her knowledge in this area to ensure the service users were to benefit from the home’s quality assurance systems. The home has specific policies and procedures in place to assist residents with having control over their own finances. Residents spoken to stated they looked after their own money and they were happy with this system. Although the home makes this service available they do encourage residents and relatives to manager finances. Improvements have been made with the provision of mandatory training. The home environment still needs to be appropriately risk assessed by someone competent to do so. It was recommended that the manager implement a temporary system of risk assessment until this is formally carried out. Improvements have been made with the cleaning procedures used by the domestics since the last inspection. Residents spoke highly of the work carried out by the domestic and also by the maintenance man. All necessary paperwork for the maintenance of the electrical system, gas system, lifts and equipment within the home were in place. Red Gables DS0000064964.V296244.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x x x x x x 3 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 3 x 2 x 3 x x 2 Red Gables DS0000064964.V296244.R01.S.doc Version 5.2 Page 25 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 2 Standard OP1 OP7 Regulation 5 15 Requirement The registered person must ensure each resident is provided with a Service User Guide. The registered person must ensure a thorough detailed care plan is provided to meet residents’ assessed needs. (The previous timescale of 31/12/05 was not met) The registered person must ensure that proper provision is made for the health and welfare of the resident group. Particular attention must be focussed in the specialist area of dementia care. (The previous timescale of 31/12/05 was not met) Residents should be offered a snack if the gap between mealtimes is longer than twelve hours. The registered person must make suitable arrangements to ensure staff are suitably trained to ensure residents are protected from harm or abuse. Suitable lockable storage facilities should be provided for residents in their bedrooms. DS0000064964.V296244.R01.S.doc Timescale for action 31/08/06 30/09/06 3 OP8 12 30/09/06 4 OP15 16 30/08/06 5 OP18 13 30/09/06 6 OP24 12,23 30/09/06 Red Gables Version 5.2 Page 26 7 OP27 18 8 OP28 18 9 OP30 12 10 OP33 24 11 OP38 12 The registered person must ensure that suitable numbers of staff are working in the care home to ensure the care needs of the residents are being met. The registered person must ensure that suitably qualified, competent and experienced persons are working at the care home to ensure the care needs of residents are being met. The registered person must be able to demonstrate that the specialist care provided within the home is based on current good practice. The registered person must establish and maintain a system for evaluating the quality of the service provided by the home. The registered person must ensure someone trained to do so carries out a risk assessment of the premises. 30/09/06 30/11/06 30/10/06 30/11/06 30/09/06 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 Refer to Standard OP2 OP12 Good Practice Recommendations The home should ensure all residents are provided with a copy of its Terms and Conditions. The home should ensure that residents social interests and hobbies are recorded and planned for in the care documentation. Red Gables DS0000064964.V296244.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Red Gables DS0000064964.V296244.R01.S.doc Version 5.2 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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