Inspection on 17/07/06 for The Gables

This inspection was carried out on 17th July 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Gables 05/11/08

The Gables 11/08/08

The Gables 11/09/07

The Gables 23/01/06

The Gables 18/08/05

The Gables 17/03/05

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Gables, The 29/31 Ashurst Road Walmley Birmingham West Midlands B76 1JE Lead Inspector Brenda O`Neill Key Unannounced Inspection 17th July 2006 09:10 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 Gables, The DS0000062346.V301696.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. Gables, The DS0000062346.V301696.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gables, The Address 29/31 Ashurst Road Walmley Birmingham West Midlands B76 1JE 0121 351 6614 0121 313 2752 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) Karamaa Ltd Miss Kelly Jean Kinsella Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Gables, The DS0000062346.V301696.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. That the registration category is 24 older people that may include up to 5 people with Dementia. Registration category 24 (OP) 5 DE(E) Bedrooms to be audited for furniture against the National Minimum Standards and arrangements made to provide items that are currently not in place by March 2007. Office space that affords some degree of privacy for staff when on the telephone, completing records or dealing with private matters must be created by March 2007. Bedroom nine must be extended by March 2007 or cease to be used as a bedroom. In addition to the manager and ancillary staff maintain minimum staffing levels of three care staff throughout the waking day and two care staff on waking night duty one of whom should be designated senior. 23rd January 2006 Date of last inspection Brief Description of the Service: The Gables is a number of post war houses that have been extensively converted to provide care and accommodation to 24 older people. The home is located in a quiet road within easy access of shopping facilities, local churches and regular public transport services. The home comprises of nine single bedrooms on the ground floor and fifteen single bedrooms on the first floor. Two of the bedrooms have en-suite facilities of toilet and shower. There is one assisted shower facility and one assisted bathing facility and numerous toilets located throughout the home. Service users are able to gain access to the first floor via stairs or by lift. Communal areas within the home are located on the ground floor and comprise of one very large lounge/dining room which also includes a conservatory and a smaller lounge. The larger lounge overlooks a very well maintained garden. The home also has a kitchen and a large combined laundry and food store which is located in an outbuilding. There is access to the home for people with mobility difficulties by means of a ramped front entrance with handrails. The fees at the home range from £418.00 to £434.00 per week. Gables, The DS0000062346.V301696.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was carried out by one inspector over one day in July 2006. During the course of the inspection a tour of the premises was carried out, three resident and three staff files were sampled as well as other care and health and safety documentation. The inspector spoke with the manager, deputy, two staff members and seven of the twenty-four residents. Prior to the inspection the manager had completed a pre inspection questionnaire which included a variety of information about the home. What the service does well: What has improved since the last inspection? All residents had new style care plans which were quite comprehensive and detailed their needs and how staff were to meet them. Improvements had been made to documenting how the identified health care needs of the residents were followed up and monitored to a satisfactory conclusion. Visits from health care professionals were being documented Gables, The DS0000062346.V301696.R01.S.doc Version 5.2 Page 6 separately from the daily records which made it very easy to track when a visit had been made. Activities outside the home had improved with residents being taken out to the theatre, social clubs, circus and local pub. The proprietors were reimbursing residents for meals taken when at luncheon clubs as these were paid for in their fees. All the required documentation had been obtained for any new staff and was available for inspection ensuring the residents were safe guarded. Several improvements had been made to the environment making the home more comfortable with extra facilities available including, the improved assisted bathing /showering facilities, one of the bedrooms had been extended, several bedrooms had been redecorated and had new furniture and an office that afforded some degree of privacy had been created. Staff had had their fire training up dated ensuring they knew what to do in the event of the fire alarm going off. 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. Gables, The DS0000062346.V301696.R01.S.doc Version 5.2 Page 7 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 Gables, The DS0000062346.V301696.R01.S.doc Version 5.2 Page 8 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): 2, 3, 5 The quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. The pre admission assessment process needed to be further developed to ensure all the needs of the residents were known prior to admission. Prospective residents were able to visit the home prior to admission to assess the suitability of the home and were issued with a contract stating their terms and conditions of residence at the point of admission. EVIDENCE: The files of two residents recently admitted to the home were sampled. There was evidence that the manager had undertaken pre admission assessments for both individuals. The documentation being used for the assessments did cover several areas of the individuals’ lives and highlight any needs in these areas however it did not cover all the required areas and needed to be cross referenced to standard 3.3 of the National Minimum as this details all areas to be assessed. The files also evidenced that residents were able to visit the home prior to admission and were issued a contract stating their terms and conditions of residence at the point of admission to the home. Gables, The DS0000062346.V301696.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 The quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The systems in place at the home for care planning and risk assessments were comprehensive ensuring the staff knew how to meet the needs of the residents and minimise any identified risks. The medication system was well managed and ensured residents were not placed at risk. EVIDENCE: At the last inspection the manager had been in the process of changing the care planning system in the home. At the time of this inspection this had been completed. Three care plans were sampled, two for new admissions to the home, one of whom had a diagnosis of dementia, and the other was for a resident who had been in the home for a considerable amount of time and was physically quite frail. The care plans were quite comprehensive and included details of what the residents were able to do for themselves, where they required assistance from staff and what type of assistance. The plans also included the likes, dislikes and preferences of the residents in areas such as diet and social activity. Areas covered by the plans included, health, personal care, mobility, diet, social and cultural needs. It was noted that for one Gables, The DS0000062346.V301696.R01.S.doc Version 5.2 Page 10 resident the care plan had specific details of a communication need as the individual was quite deaf however there was no mention in the other two plans of any communication needs. It was strongly recommended that communication was addressed as a separate need on the care plans to ensure it was considered for all residents. Care plans had been put in place for short term health care needs, for example, an infected toe and broken skin on a leg. All relevant risk assessments were in place on the files sampled including, manual handling, personal, tissue viability and nutrition and where a risk had been identified there was a corresponding care plan. The manual handling assessments needed to be further developed in some instances detailing the actual handling methods to be used, for example, turning in bed needed to detail how staff were to do this and actions to be taken when someone fell and was uninjured. The manager also needed to ensure that any care plans for pressure relief detailed the equipment to be used as on one file this was detailed on the professional visit sheet but not on the care plan. Wherever possible residents were being weighed on a regular basis but due to the scales in the home this was not practical for all residents. It was strongly recommended that the manager consulted with the district nurses about alternative ways of monitoring residents’ weights, for example, measuring the upper arm. There was evidence in the daily records that the personal care needs of the residents were being met. Staff were identifying health care needs and there was evidence of these being followed up and monitored. The recording of the monitoring of health care needs had improved since the last inspection, for example, a pressure area had been noted and the district nurse had been called and records detailed every visit, the progress being made and when the individual was discharged. The visits by health care professionals were being recorded separately, which had been a recommendation at the last inspection, and these were much easier to track. The medication system remained the same and was administered via a 28 day monitored dosage system which was generally well managed. All medication was being acknowledged when received and balances at the end of the month were carried forward to the next medication administration sheet making the system easy to audit. All balances checked at the time of the inspection were correct. It was noted that there were a few gaps on the medication administration sheets when checking the corresponding medication it had not been given but the code had not been entered as to why it was not given. Protocols had been put in place for the administration of PRN (as and when necessary medication). There was some controlled medication being administered which was being stored, administered and recorded appropriately. The policies and procedures for medication administration were not assessed during this visit. Gables, The DS0000062346.V301696.R01.S.doc Version 5.2 Page 11 No issues were raised by the residents during the course of the inspection in relation to their privacy and dignity. The interactions between staff and residents were very friendly and respectful. Staff assisted residents with personal care needs sensitively. Consultation with health care professionals took place in the privacy of residents’ bedrooms. Residents were able to lock their bedroom doors if they wished and if they wanted private time during the day in their bedrooms this was not seen as an issue. At the time of the inspection a newly fitted toilet door had come off which did not allow residents any privacy however this was refitted the day after the inspection. Gables, The DS0000062346.V301696.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 The quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. There were no rigid rules or routines in the home and residents were able to spend their time as they chose. There were activities on offer and residents were able to maintain contact with families and friends. The meals in the home were good and choices or alternatives were available at all meals. EVIDENCE: There did not appear to be any rigid rules or routines in the home and residents were able to spend their time as they chose. Residents were seen to spend time in their rooms, sit chatting, reading, listening to music and spend time with their visitors. Residents were able to get up and go to bed when they chose, some residents were still having breakfast when the inspector arrived others had finished and some were still getting up. Some residents chose to spend the vast majority of their time in their bedrooms and have their meals taken to them. The manager had improved the activities on offer for the residents particularly in respect of trips out of the home. Residents were being taken out in small groups to a variety of places including, the theatre, social clubs, the circus, local pub and museum. One of the residents spoken with commented how Gables, The DS0000062346.V301696.R01.S.doc Version 5.2 Page 13 much she had enjoyed going out to the theatre the week before the inspection. There was also evidence of visiting entertainers going into the home every two months. Staff did facilitate some in house activities and one of the residents commented on playing bingo and ball games however staff were not recording the in house activities. Records in the home needed to demonstrate that the social needs of the residents were being met. Visitors were seen to come and go throughout the course of the inspection and appeared to be made welcome by the staff. Daily records evidenced frequent visitors to the home and that some residents go out with their relatives. Two of the residents continued to go out to a luncheon club. Staff encouraged residents to make choices wherever possible, for example, in how to spend their time, when to go to bed and get up, what to eat and what to wear. All the bedrooms were personalised to the occupants choosing and some residents continued to handle some of their own finances. The menus at the home were varied and nutritious and although there were no stated choices the food records clearly demonstrated that residents often had alternatives to the main menu. Breakfast varied from cereals/prunes/grapefruit and toast to full cooked breakfast depending on what residents preferred. Residents were asked prior to teatime what they would like and some ate in the dining room others had trays. Lunchtime was a relaxed time and residents had a variety of drinks including beer, wine or juice. Comments from the residents indicated they were happy with the catering arrangements at the home but that they did not know what was on the menu at lunchtime. It was strongly recommended that the menus were on display in the home and as there was no choice at lunch time a list of alternatives were made available for the residents as not all residents would say if they did not like what was on the menu. Gables, The DS0000062346.V301696.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. There was an appropriate complaints procedure and all residents or their representatives received a copy. To ensure that residents were protected from abuse staff had undertaken adult protection training. The policies and procedures needed to be accessible to staff at all times so that they could refer to them, if necessary, in the event or suspicion of any abusive situations. EVIDENCE: Residents had all received a complaints procedure in the service user guide. The manager stated that a complaint had been lodged with the home in relation to one aspect of personal care and this had been investigated by the responsible individual and was not upheld. This had not been logged in the home therefore the inspector could not assess if the investigation and outcome had been satisfactory. No complaints had been lodged with the CSCI. No issue had been raised at the home in relation to adult protection and staff had received training in adult protection. The home did have a copy of the multi agency guidelines for adult protection but the homes procedures were not on site as the responsible individual for the home had updated them. Staff needed to have access to these policies and procedures at all times so that they could refer to them, if necessary, in the event or suspicion of any abusive situations. Gables, The DS0000062346.V301696.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25, 26 The quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. Further improvements had been made to the environment which provided residents with a comfortable and safe home to live in. EVIDENCE: There had been several further improvements made to the environment since the last inspection some of which were conditions of registration for the owners and had been completed well before the time given. One condition was that office space that afforded some degree of privacy was created as it was on the first floor landing. This had been completed with an office being installed on the ground floor. Another condition was to extend one bedroom, which was very small, and this had also been completed. There had also been some general redecoration of corridors and some new carpets had been fitted. The home was safe and well maintained. Gables, The DS0000062346.V301696.R01.S.doc Version 5.2 Page 16 Communal space was ample and the décor, furnishings and fittings were generally domestic in character and of an acceptable standard with the exception of some worn armchairs. The garden was very well maintained and there was a ramped exit from the home however the lawned area would be difficult for anyone with anyone with mobility difficulties to access and as at the last inspection it was strongly recommended that the possibility of a ramp be explored. There had bee some changes to the bathing and toilet facilities in the home. A walk in shower had been installed on the ground floor of the home in what used to be the assisted bathroom and the assisted bathing facility had been moved to the bathroom on the first floor. One toilet had been taken out of use to extend the bedroom and create some office space but another had been installed in the same area of the home to compensate for this. The bathrooms had been retiled and were just having the finishing touches put to the décor at the time of the inspection. Two of the bedrooms also had en-suite showers. The aids and adaptations throughout the home appeared to meet the needs of the residents and included, shaft lift, hand and grab rails, assisted bathing facilities and an emergency call system. The bedrooms varied in size and were all generally well furnished and equipped and all were personalised to the occupants choosing. Appropriate locks had been fitted and some had a lockable facility. The bedrooms had been audited against the National Minimum Standards to highlight items not available. Several rooms had been redecorated, had new carpet and furnishings to ensure they met with the minimum standards and this work was ongoing until all rooms were complete. The heating, lighting and ventilation in the home met with the needs of the residents. The home was clean and odour free with appropriate systems in place for the disposal of clinical waste. Liquid soap and disposable towels were available in all communal facilities and staff had access to protective clothing when necessary. The home had a mechanical commode pot washer for effective cleaning of commode pots however it was noted that some of the commode chairs were rusted and in need of replacing. The outstanding issues from the last inspection had been addressed in the kitchen and food storage in relation to monitoring the temperatures of the food store in the same location as the laundry, monitoring the core food temperatures, and the untiled wall in the kitchen had been repainted with a finish that was easy to clean. Gables, The DS0000062346.V301696.R01.S.doc Version 5.2 Page 17 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, 30 The quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. Appropriate staffing levels were being maintained that enabled the residents’ needs to be met but only with the use of the manager’s hours on occasions. Long standing staff had received the appropriate training to enable them to care for the residents. Induction training for new staff needed to be further developed to ensure they were equipped with all the necessary skills and knowledge. The recruitment procedures were robust and ensured the protection of the residents. EVIDENCE: The home retained a core group of staff who had worked there for a considerable amount of time which was good for the continuity of care of the residents. Only one new staff member had been recruited since the last inspection. Minimum staffing levels as set out in the conditions of registration were being met most of the time however on some occasions the manager was covering the care rota. The manager’s hours needed to be supernumerary to the care rota unless an emergency situation arose, for example, sickness but for ongoing issues such as annual leave there must be adequate staff employed to cover the rota. It was evident throughout the course of the inspection that there were very good relationships between the staff and the residents and that staff knew the Gables, The DS0000062346.V301696.R01.S.doc Version 5.2 Page 18 needs of the residents. All residents spoken with were very positive about the staff team and the help they received from them. The training matrix for the home and individual training records evidenced that staff had undertaken a variety of training including, fire training, food hygiene, manual handling, health and safety adult protection and dementia care. Details of future training planned were given on the pre inspection questionnaire and included, reporting and recording, communication, first aid responsible person’s certificate and stress management. Only four staff had completed their NVQ level 2 which equated to approximately twenty percent. The requirement for this is fifty percent of staff to be qualified, several staff were on the waiting list for this training. New staff did undertake induction training. The newest member of staff had been employed for seven days and there was a first day induction completed with other training to follow. The manager was advised that by September 2006 all new staff must undertake induction training in line with the specifications laid down by Skills for Care which must be completed within 12 weeks of them commencing their employment. The recruitment records for the one new employee were sampled and found to be complete. There was a completed application form, two written references, medical declaration and a POVA first check had been undertaken. Gables, The DS0000062346.V301696.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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, 38 The quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. The manager ensured the smooth running of the home in a competent manner. The home needed to have a quality assurance system in place based on seeking the views of the residents with a view to continuously improving the service. The health and safety of the residents and staff were well managed. EVIDENCE: The manager of the home had worked there for a considerable amount of time but not always as the manager. She had become much more familiar with her role as manager and her confidence had grown. She had worked very hard to improve the systems in place at the home and this was very evident when sampling care plans and risk assessments. She had a very good knowledge of the needs of the residents in her care and relationships between her and the Gables, The DS0000062346.V301696.R01.S.doc Version 5.2 Page 20 staff team appeared good. She was undertaking her Registered Manager’s Award qualification. The home did not have a formal quality assurance system in place but the manager had begun to gather some information in relation to this and undertaken some research into quality assurance. She had developed some questionnaires some of which had been completed for those living in the home, just after admission to the home and a relative’s questionnaire. A letter had been sent to the relatives thanking them for completing the forms and detailing the findings and what had been done about the comments made. The manager was also in the process of developing a questionnaire for professional visitors to the home. There were also residents meetings every two months to discuss such things as menus, activities and to address any issues. Staff meetings were also held every two to three months. The manager was managing some money on behalf of some of the residents although several residents continued to manage some of their own money and one managed all her own financial affairs. The records kept by the manager were auditable, there were receipts available for expenditure and two signatures were being obtained for any transactions made on behalf of the residents. All the balances checked at the time of the inspection were correct. The issue of the residents paying for their own meals at luncheon and stroke clubs had been addressed and the owners of the home were paying for the meals. Health and safety in the home was well managed. Staff had received training in safe working practices and fire training had been updated as required at the last inspection. All the in house checks on the fire system were up to date and a fire drill had taken place. There was evidence on site that some of the equipment had been serviced including fire extinguishers, gas appliances, the electrical wiring and the bath hoist. The certificates for the servicing of the fire alarm, emergency call system and portable electrical appliances could not be found and there was no evidence that the water system had been checked for the prevention of legionella. Evidence of all of these up to date checks were faxed to the inspector the day after the inspection with the exception of the emergency call system. Accident and incident recording and reporting were appropriate. Gables, The DS0000062346.V301696.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 2 3 3 X 2 3 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Gables, The DS0000062346.V301696.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1)(a) Requirement The registered manager must ensure that pre admission assessments cover all the areas detailed in 3.3 of the National Minimum Standards. The manual handling risk assessments must clearly detail any handling methods to be used. Care plans for pressure relief must detail the equipment to be used. The medication policy must include details of: - Risk assessments and compliance checks for residents who wish to self administer medication. - The homely remedies policy must include a list of permitted medication and then that the GPs agreement is to be obtained for administration. - All policies must be signed and dated. Previous time scale of 01 April 2006 not assessed for compliance at this visit. DS0000062346.V301696.R01.S.doc Timescale for action 01/09/06 2. OP8 13(4)(c) 13(5) 01/09/06 3. OP9 13(2) 01/09/06 Gables, The Version 5.2 Page 23 4. OP9 13(2) 5. OP12 12(1)(a) 6. OP16 22(8) 7. OP18 13(6) 8. OP19 16(2)(c) 9. OP24 16(2)(c) 10. 11. OP26 OP27 13(3) 18(1)(a) 12. OP28 18(1)(a) 13. OP30 18(1)(a) There must be no gaps on medication administration records unless it is for PRN medication. Staff must record how residents are spending their days to evidence their social needs are met. The registered manager must ensure that there is a record of any complaints lodged with the home to include details of the investigation and the outcome. The homes adult protection procedure must be available to staff at all times. Previous time scales of 01 October 2005 and 01 March 2006 not met. Any worn armchairs must be replaced. Previous time scales of 01 April 2005, 01 November 2005 and 01 April 2006 not met. All bedrooms must be audited against the National Minimum Standards and arrangements made to provide items currently not in use. Partially met but previous time scale had been extended. Any rusting commodes must be replaced. Adequate numbers of staff must be employed to ensure the manager does not have to cover care shifts on an ongoing basis. 50 of care staff must be qualified to NVQ level 2 or the equivalent. Previous time scale of 31 December 2005 not assessed for compliance at this visit. The induction training for staff must be in line with the specifications laid down by the Skills for Care and completed within 12 weeks of commencing DS0000062346.V301696.R01.S.doc 14/08/06 01/09/06 01/09/06 01/09/06 01/10/06 01/03/07 01/09/06 01/10/06 01/12/06 01/09/06 Gables, The Version 5.2 Page 24 14. OP31 9(2)(b)(i) 15. OP33 24(1)(a) (b) 16. OP38 23(2)(c) employment. The manager of the home must 01/12/06 be qualified to NVQ level 4 in management and care. Previous time scale of 31 December 2005 not met. The home must have an effective 01/10/06 quality assurance and quality monitoring system in place that is based on seeking the views of the residents. Previous time scales of 01 April 2005 and 01 April 2006 partially met. Evidence that the emergency call 14/08/06 system has been serviced must be forwarded to the CSCI. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP7 OP8 OP15 OP20 Good Practice Recommendations It is strongly recommended that communication is addressed as a separate need for all residents to ensure it does not get overlooked. It is strongly recommended that the manager consults with the district nurses about alternative ways of monitoring residents’ weights. It is strongly recommended that the menus are on display in the home and as there is no choice at lunchtime a list of alternatives is made available for the residents. It is strongly recommended that the possibility of having a ramp installed to give easy access to the lawned area of the garden be explored. Gables, The DS0000062346.V301696.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Gables, The DS0000062346.V301696.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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