CARE HOME ADULTS 18-65
The Gables 11 Heathside Road Withington Manchester M20 4XW Lead Inspector
Steve O`Connor Key Unannounced Inspection 1st September 2006 12:00 The Gables DS0000021616.V309433.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 The Gables DS0000021616.V309433.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. The Gables DS0000021616.V309433.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service The Gables Address 11 Heathside Road Withington Manchester M20 4XW 0161 445 7757 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) Mrs Teresa Williams Ms Christine Davies Care Home 9 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (2) of places The Gables DS0000021616.V309433.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. The home provides care for a maximum of 9 service users requiring care by reason of learning disability. Two named service users are aged 65 or over. Should these service users leave the home, the places will revert to the service user category LD. The home must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 3rd May 2006 Date of last inspection Brief Description of the Service: The Gables is a registered care home providing 24-hour accommodation and support for nine adults with a learning disability. The home is situated close to the centre of Withington and is in keeping with the surrounding area and comprises two semi-detached houses converted into one. The accommodation is arranged on two floors. The furnishings and fittings of the home are domestic in style. The Gables aims to create a supportive environment, which enables service users to maximise their independent living skills. The home has long established links with the local community and good working relationships with the local health and social services. The proprietor employs a full time manager who oversees the day-to-day running of The Gables. The Gables DS0000021616.V309433.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is the home’s second key inspection report and is based on information and evidence gathered by the Commission for Social Care Inspection (CSCI) since the home was last inspected in April 2006. This information includes the inspection report and the areas of work that the home needed to improve. It also includes information provided by the owner of the home. Because a number of areas of work had not been carried out by the home the CSCI had sought the views of the local authority on the quality of the service it was providing to people. A visit was made to the home without telling them that an inspector was coming. Time was spent talking to people who stay at the home, staff on duty and the Manager. Staff were observed in how they work with people. Documents and files relating to people and how the home is run were also seen and a tour of the building was made. The visit was an opportunity to look at all the core standards of the National Minimum Standards (NMS) and was used alongside other information passed to the CSCI to make a decision on the quality of the service and to decide what action and how much work the CSCI needs to do with the home in the future In the last inspection report 11 areas were identified where the home needed to make improvements and six recommendations regarding improved working practices were identified. The home had taken some action to address the areas of work identified. This resulted in a reduction of requirements to five to reflect the work that the home has completed. The CSCI has not received any complaints or concerns regarding the home since the last inspection report. What the service does well:
The home provides people with a comfortable, clean, well-maintained and decorated place to live that has a homely atmosphere. People can spend time in their own rooms or have a number of different areas where they watch television, listen to music or do some home-based activities such as crafts. This allows people the opportunity for privacy and to join in with the group. People take part in the daily routine and domestic tasks of the house according to their ability and the staff team support people to maintain these skills and to keep them as independent as possible. During most days (mid-week) people do still attend a range of day services, local colleges and other specialist services for people with learning disabilities.
The Gables DS0000021616.V309433.R01.S.doc Version 5.2 Page 6 People spoken to said that they enjoyed these activities that ranged from arts, crafts, music and further education. The home does arrange for some social activities for people such as day trips and social evenings in the house and with the other care home the owner has. The home continues to encourage and support people to maintain relationships with their families and welcomes visitors to the home. The home has continued to make sure that people are as healthy as possible by supporting them to go to their local G.P, dentist, optician and chiropodist when needed. Records were kept of all people’s appointments and instructions on what to do to make sure they stay healthy. What has improved since the last inspection?
The previous inspection report highlighted a numbers of areas where the home needed to make improvements. A number of these areas had been repeated in a number of previous inspection reports and the owner was asked to a meeting with the CSCI to make them aware of the CSCI concerns over them not making the changes needed. The CSCI has also talked to the local authority who fund people’s place at the home to look at ways that the home can be helped to make improvements. The owner has been asked to provide the CSCI with information as to how improvements are going to be made but they have provided little information to show what action they were taking. Despite this the home has shown that it is working towards making good the areas identified in the inspection reports and have made progress in the following. The standard of the example of a care plan seen that set out people’s support needs and goals they want to achieve has improved. The care plan described personal goals that the person wanted to achieve themselves, such as joining a snooker club, rather than what the home thought was important. The information written about the person was detailed and told like a story of the person’s life and the significant events that have affected them. However, only a few of these care plans had been completed and work was still needed to make sure that everyone had the opportunity to have their own person centred care plan. Changes to the medication system had been made to make sure that records were correct and people received the right homely medication. There has been some improvement in the way that the home manages and looks after people’s monies and finances. However, there are still areas of work that the home have to complete to make sure the way they look after people’s monies is more safe. The Gables DS0000021616.V309433.R01.S.doc Version 5.2 Page 7 Improvements have also been made by the home to make sure that the staff they employ are safe to work with vulnerable adults. Also, that they receive the right training when they start work to be able to support people properly. What they could do better:
People who live in care homes do so for a variety of reasons but generally they need help and support to allow them to live as independently and safely as possible. Care homes must show that they understand what help people need and so they are required to develop individual care plans that sets out clearly, and in sufficient detail, all the needs and goals that people have and how they are going to support the person. Care plans should be regularly reviewed to see if the care plan is still working and takes into account any changes in people’s needs. For the last five inspections, going back over 18 months, the home has been advised that it must improve the quality of peoples’ individual care plans to clearly show what it is doing to support them. They have undertaken some work with a few people to improve the care plans but generally the standard required has not been met. In addition, the home supports people with learning disabilities. The Government produced a White Paper called Valuing People that sets out the principals and aims for learning disability services. One of the key areas in the White Paper is to develop, what is called, more ‘person centred’ planning and services. This issue has been raised with the home over several inspections and work is progressing very slowly to introduce a more person centred care planning system. The majority of people living at the home need help to make sure that they take the medication they need to remain healthy. To make sure that people remain healthy and that mistakes are avoided, all care homes must have a clear medication administration system and procedures. Although the home had made improvements other problems were found with the home’s medication systems. This includes, making sure that those people who take their own medication do so in a safe way and that the home has a way of checking that the medication has been taken. The majority of people the home support are unable to manage their own finances and benefits. They rely on the home to help them with spending and to look after their monies. To do this safely and to protect people care homes should have policies, procedures and practices for the management of people’s finances. These will make sure that every transaction and decision made on a person’s behalf can be checked and monitored. The Gables DS0000021616.V309433.R01.S.doc Version 5.2 Page 8 Although the home has made some improvements to this area there are still several problems with the home’s systems that could place people and staff at risk. In terms of spending people’s money when they may not be able to make an informed choice, there was no clear policy or procedure for helping people make these decisions or when decisions regarding spending money are made for them. Having a sufficient size staff team with the competence, skills and values to support and promote the quality of life of vulnerable people with high levels of need is essential for all care homes. The home is still experiencing a number of issues in relation to the staffing. For the last four inspections it has been highlighted to the owner that the home does not provide sufficient levels of staff support to meet peoples’ social, leisure and community based goals and needs. The home relies heavily on specialist learning disability services and provision to provide people with activities during the day. Recently, peoples’ access to these activities has been reduced and this trend has continued. This means that more people will be at home during the day and more pressure on staff time to meet peoples’ basic needs. The home have introduced some extra hours per week to make sure that people have the opportunity to go out but it is unclear whether this will continue. They have been asked to provide the CSCI with their plans for how they are going to support people to do the social and leisure activities that they want to do. Another area that the home must do better has again been raised with the owner, through the inspection reports, over the last four inspections is the issue of providing the manager with the time and resources required to address the outstanding statutory requirements and undertake their day-today managerial role. The manager has now been allocated more time to carry out all the work that has been identified and to ensure the home meets the required standards. But, for the majority of their time they still carry out a support role and so do not have the time to undertake the work required. 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 Gables DS0000021616.V309433.R01.S.doc Version 5.2 Page 9 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 The Gables DS0000021616.V309433.R01.S.doc Version 5.2 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home ensures that people’s needs were assessed before coming to live at the home. EVIDENCE: Since the last inspection visit a new person had come to live at the home. The home had worked with the purchasing local authority to find out what support the person needs and had visited them before they came to stay at the home. To make sure the home had all the information it needs a Care Management Assessment was provided by the purchasing local authority and an assessment of the person’s needs was undertaken by the home as well, prior to and in the early stages of the stay. The Gables DS0000021616.V309433.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home did support people in making choices regarding their day-to-day lives. However, the home’s systems and practices for care planning, risk assessment and recording did not yet fully reflect people’s needs and goals. EVIDENCE: The purchasing local authority had provided the home with a Care Management Care Plan for the person who had arrived at the home in July 2006. This set out broad areas of the person’s needs such as financial management, involvement in the community and monitor health. At the time of the site visit the home had not developed a care plan for the person. An example of a new care plan was seen that aimed to be more person centred and focus on what was important for the person as well as the support the home needed to provide. People were much more involved in producing these care plans. This was an improvement on the previous care plans and contained better quality information about the person and included their own personal goals.
The Gables DS0000021616.V309433.R01.S.doc Version 5.2 Page 12 However, the home had not yet completed care plans for all the people living at the home and also had not yet implemented a care planning review system to see how people are progressing with their goals. In addition, the most recent person to come to live at the home does not have a care plan at all. As a result of this the previous requirement for care planning was reiterated. The degree of choices and decision making a person had was determined by their reliance on the home to meet their needs. Several people were quite independent and decided what activities they wanted to do, where they wanted to go and could actively make their voices heard in decisions that impacted on their lives. Other people relied on the home and its staff to make most judgements and choices as to what the person may want based on their knowledge of that person. The home did understand and have an in-depth knowledge of the people they support. The previous two inspection reports highlighted the need for the home to ensure that it had developed clear risk assessments and support guidance that cover issues such as restrictions of choice and decision making, hazards associated with managing people’s finances and medication and relating to risks from people’s behaviour that may be challenging. The Gables DS0000021616.V309433.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People were supported to take part in activities that they enjoyed and were supported and encouraged to maintain relationships with their family. However, changes in specialist service provision and insufficient staffing levels means that not all of people’s identified social, leisure needs are being met. The home provides people with balanced meals and was aware of people’s nutritional needs. EVIDENCE: The majority of peoples’ daily activities still involve attending specialist learning disability and mental health services. This includes day services, dropins and local college courses. People discuss the social and leisure activities that they are interested in during house meetings. Small groups of people are supported to visits to the cinema, bowling, eating out and day trips to local attractions. Most people go on holiday at least once a year. People are encouraged and supported to maintain and develop their independence skills
The Gables DS0000021616.V309433.R01.S.doc Version 5.2 Page 14 through allocated domestic tasks within the home and through maintaining their own bedrooms. People are also supported and encouraged to become involved in appropriate work placements. An issue that was raised in the last inspection report that was beginning to have an impact on peoples’ activities is that local specialist services and colleges are reducing the availability of places and this includes the reduction of leisure classes at local colleges. Since the last inspection report this situation has meant further reductions in people being able to access specialist day services. These events have had a clear impact on the activities that people participate in. As a result the home has been investigating other activities within the home and the community that people can participate in. The home must provide the CSCI with an action plan on how it is going to support people social, leisure and development needs. The issue of the home having sufficient staffing levels required to support people to take part in social, leisure and educational activities was again raised. This issue will be addressed in the Staffing section of the report. The home continued to encourage people and their families to maintain contact and relationships with their families and visitors were welcomed to the home. The routine of the home was determined to some extent by the daytime activities people participated in. This centred, during the weekdays, on transport to and from the specific activities and generally on a persons’ own routines that had developed over the years. People will undertake domestic tasks according to their abilities. The home had a good supply of fresh food and other food stores. People were involved in the choice of menus and were offered a range of meals. Mealtimes were usually part of the normal home routine but could be flexible depending on what activities people were involved with. The Gables DS0000021616.V309433.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home supports people to maintain their personal and healthcare needs. The prescribed and homely medication administration systems were not sufficient to show that people are fully protected. EVIDENCE: Several people require hands on personal care support whilst the remaining people were encouraged and prompted to maintain their own personal care. The care plans identify people’s personal care needs but without going into much detail regarding the support provided. The home seeks the advice and guidance from relevant healthcare specialists in relation to people’s personal care and mobility needs. The home has identified people’s health needs and specific health related conditions. Everyone living at the home is supported in accessing general healthcare services such as G.P’s, chiropodists, dentists and opticians. All visits to healthcare providers are recorded. The Gables DS0000021616.V309433.R01.S.doc Version 5.2 Page 16 The previous inspection report required the home to make some improvements in the way it manages the medication administration system. Evidence was seen that changes in people’s medication regime had been signed by the prescribing doctor, all errors on the Medication Administration Records (MAR) were recorded correctly and the home had developed a new ‘Homely Medication’ Policy that had been agreed with a local G.P. These actions met the requirements made at the last inspection. It was found that a person self-administers some of their own medication. There was no risk assessment or support guidance relating to this in the person’s care plan. The home must undertake a risk assessment in relation to people self-administering medication. The Gables DS0000021616.V309433.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home encourages people to express their views and concerns. The home is aware of the issues around adult protection but they do not have the systems, procedures or work practices required to ensure that people’s monies are fully protected. EVIDENCE: The previous inspection report highlighted a number of areas of concern in the way that the home manages people’s money. A number of requirements were made to improve the systems used. The registered provider did send the CSCI a policy for the storage and use of people’s cash cards and PIN numbers and they have arranged for an external audit of the finance records of peoples spending and personal monies. Money kept in the house is now being maintained at a minimum level. However, the home has not reviewed its policies and procedures relating to the management of peoples’ monies or the process for making decisions when spending peoples’ monies. In addition, the contract setting out the terms and conditions for people living at the home has not been updated to include reference to any additional charges that people may have to pay. These requirements were therefore reiterated. The issue of the home charging people for the removal of soiled waste was raised with the registered provider at a meeting with the CSCI on the 12 June 2006. They stated clearly that the practice of charging people had stopped and
The Gables DS0000021616.V309433.R01.S.doc Version 5.2 Page 18 that the monies already paid would be reimbursed. There was no evidence to show that the monies had been returned to people. This issue will be taken up with the registered provider. There had been no complaints made during the previous 12 months. The complaint procedure was available to people and their representatives and they had been made aware of their rights to make complaints. Any formal complaints would be logged using the procedure. Policies and procedures in the protection of vulnerable adults from abuse were in place. The staff had all received training in the awareness of abuse. The Gables DS0000021616.V309433.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a safe, clean and homely environment. EVIDENCE: The home’s premises were comfortable and well maintained with furnishings and fittings being homely in nature. There was sufficient flexibility and range of space to allow free movement around the home to meet people’s needs. The premises were clean, and free from offensive odours. The service supported people who had continence needs and had the guidance and protective clothing required to prevent cross infection. The laundry facilities were situated in a separate building next to house and the washing machines had the required programmes to cope with all soiled items. The Gables DS0000021616.V309433.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home have a staff team with a range of skills and knowledge to understand people’s support needs. However, the level of staffing is not sufficient to fully meet people’s needs. EVIDENCE: The home provided the CSCI with information stating that three staff were undertaking the NVQ level 2 qualification. It is recommended that the home should have in place a system for providing its staff team with the required vocational qualifications. The previous inspection report highlighted the issue of the impact of a reduction in people accessing specialist day services and how the home needed to provide sufficient staff to support people’s social and leisure needs. The home had provided additional hours of support during the day (Monday to Friday). This was used to support small groups of people to participate in social and leisure activities. At the time of the site visit it was not known if the funding to continue this additional support would continue. From November 2006 there would be further reductions in the day services that a number of people attend. Accessing further services would require the home to provide
The Gables DS0000021616.V309433.R01.S.doc Version 5.2 Page 21 the staff support themselves. Therefore, as the future staffing situation is still unclear the requirement is reiterated. The previous inspection report highlighted the need for the home to ensure staff have the required recruitment checks. A new umbrella body had been found who were now processing the home’s CRB applications and making POVA First checks. The home provides an induction and core-training programme based on the Learning Disability Award Framework. This core programme consists of Moving and Handling, First Aid, Food Hygiene and Health and Safety. The home’s induction programme was being updated to meet the Skills for Care Induction modules. Resources had been purchased and the manager would introduce the new programme with new staff. The manager was working on updating the staff training plans to include full details of training undertaken and those events that they need to attend or require refresher training. It is recommended that the work in updating the staff training plans continue. The system for annual staff appraisals was being implemented and linked with the staff supervision. At the time of the site visit no appraisals had been undertaken. It is recommended that all staff receive an annual appraisal of their work and development needs. The Gables DS0000021616.V309433.R01.S.doc Version 5.2 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had the required systems and procedures in place to maintain people’s health and safety in the home. The home listens to people and others views regarding the quality of the service they provide. The home does not have the management systems in place to ensure that people benefit from a well run home. EVIDENCE: The manager stated that they had reduced the number of support hours they were providing and setting aside more time to undertake managerial and operational tasks. They still felt that the majority of their time was spent supporting people but this would change with additional staff becoming available. As the situation regarding staffing was still uncertain the requirement was reiterated. The Gables DS0000021616.V309433.R01.S.doc Version 5.2 Page 23 In March 2006 the home asked people, their relatives and other relevant professionals to complete a questionnaire looking at the quality of the service the home provides. A number of questionnaires were returned and the comments made were almost all positive about the standard of care people received. At the time of the visit there was still no formal action plan of what to do with the information and any of the issues raised. It is recommended that the home develop an annual action plan from the information gathered through the quality assurance process. From the information the home provided through the Pre-Inspection Questionnaire and evidence found on the site visit it was shown that the home were still undertaking the required checks for fire and environmental safety. Relevant fire, electrical and gas equipment was being serviced on an annual basis and the home had the procedures and practices in place for maintaining people’s health and safety. The Gables DS0000021616.V309433.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 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 X 2 3 3 X 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 3 X The Gables DS0000021616.V309433.R01.S.doc Version 5.2 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 Requirement Peoples care plans must contain all the information required by Regulation 15 and Schedule 3 of the Care Homes Regulations 2001 and be reviewed at least every six months. (The timescale of 04.01.05, 04.06.05, 01.09.05, 31.12.05 and 30.06.06 was not met). A plan of action must be submitted to the CSCI within the timescales stated. All changes in people’s needs, 30/12/06 restrictions of choice, decision making, risk assessments and support must be reflected in each person’s care plan. A plan of action must be submitted to the CSCI within the timescales stated. (The previous timescale of 31.12.05 and 30.06.06 was not met). The home must provide the CSCI 01/11/06 with an action plan on how it is going to support people social, leisure and development needs.
DS0000021616.V309433.R01.S.doc Version 5.2 Page 26 Timescale for action 30/12/06 2 YA9 13 3 YA13 YA14 12 The Gables 4 5 YA20 YA23 13 13 The home must undertake risk 01/11/06 assessments in relation to people self-administering medication. 1. The owner must provide clear 30/11/06 evidence that the terms and conditions include the charges for any services not provided within the residential fees. 2. The owner must develop a clear policy and procedure for decision making when spending people’s money on their behalf. (The timescale of 30.06.06 was not met) Sufficient staff must be made available to fully meet all service users needs at all times. (The previous timescales of 04.06.05, 01.07.05, 31.12.05 and 30.06.06 was not met). The manager must be provided with sufficient time and resources to be able to undertake the work required for the operational management of the service. (The timescales of 04.06.05, 01.07.05, 31.12.05 and 31.05.06 was not met). 6 YA33 18 01/11/06 7 YA37 12 01/11/06 The Gables DS0000021616.V309433.R01.S.doc Version 5.2 Page 27 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 YA32 Good Practice Recommendations It is recommended that the home provide the CSCI with an action plan setting out how they are going to meet the targets for achieving 50 of staff obtaining NVQ level 2 within the timeframe set. It is recommended that the work in updating the staff training plans continue. It is recommended that the manager clarify with the CSCI the timescales for them to complete the required management qualification. It is recommended that all staff receive an annual appraisal of their work and development needs. It is recommended that the home develop an annual action plan from the information gathered through the quality assurance process. 2 3 4 5 YA35 YA37 YA36 YA39 The Gables DS0000021616.V309433.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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