Inspection on 02/07/07 for The Gables

This inspection was carried out on 2nd July 2007.

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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Gables 26/02/09

The Gables 30/03/07

The Gables 24/08/06

The Gables 13/02/06

The Gables 03/03/05

The Gables 03/09/04

The Gables 03/02/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 The Gables Moreland Drive Gerrards Cross Bucks SL9 8BB Lead Inspector Christine Sidwell Unannounced Inspection 2nd July 2007 11:00 The Gables DS0000023055.V337301.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 DS0000023055.V337301.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 DS0000023055.V337301.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Gables Address Moreland Drive Gerrards Cross Bucks SL9 8BB 01753 890399 01753 890399 admin.thegables@fremantletrust.org 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) The Fremantle Trust Georgina Crothers Care Home 7 Category(ies) of Learning disability (0) registration, with number of places The Gables DS0000023055.V337301.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th March 2007 Brief Description of the Service: The Gables is a home for seven adults with learning disabilities and high care needs. The home is situated within close proximity of Gerrards Cross town centre. There is a main bus route from the town centre to nearby towns. The house is in a large cul-de-sac, next to a school. The accommodation is over two floors, however the majority of service users have bedrooms on the ground floor. There are two bedrooms upstairs for the more mobile service users. All bedrooms are individually decorated to personal taste. The home has a large communal lounge, dining room and a separate sensory room. There is a large garden at the back of the home and some parking spaces at the front. The property is not identifiable from the outside as a care home. Fees for the service: £997.22 per week. The Gables DS0000023055.V337301.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted over the course of three days and included a one day unannounced visit to the home. The key standards for adult services were covered. Information received about the home since the last inspection was taken into account in the planning of the visit. Prior to the visit a questionnaire was sent to the manager with survey questionnaires for distribution to service users, relatives and visiting professionals. Six family members and three healthcare professionals returned the questionnaires. Residents and families were also spoken to on the day of the unannounced visit. Discussions took place with the manager, nursing, care and ancillary staff. Care practice was observed. A tour of the premises and examination of some of the required records was also undertaken. The homes approach to equality and diversity was considered throughout. What the service does well: The assessment process is thorough and gives the prospective resident, his or her family and the homes care team the opportunity to ensure that the home could meet their needs before they move in permanently. Prospective residents have the opportunity to visit the home for increasingly longer times before deciding to move on a permanent basis. The assessment documentation guides the staff to consider potential residents’ religious and cultural needs. Residents are supported to make individual choices and to take appropriate risks to retain their autonomy, as far as they are able. The care plans are being updated to have a person centred approach, which will reinforce this concept. Although many of the residents cannot express their wishes verbally the home has identified the behaviours that they express to reflect their feelings. The home works closely with families to ensure that their knowledge of the family member is incorporated in the care plans. Residents are encouraged and supported to live a varied lifestyle and their choices are respected by staff. Most residents attend day centres and outings and holidays are taken. The care team support residents to ensure that their personal, healthcare and medication needs are met. The healthcare professionals who returned the questionnaires said that their recommendations were incorporated into the care plans. One said that ‘it is a happy and well run home’. Complaints and safeguarding issues are dealt with appropriately giving residents and their families confidence that their concerns will be addressed and residents will be safeguarded. The Commission for Social Care Inspection The Gables DS0000023055.V337301.R01.S.doc Version 5.2 Page 6 has not received any complaints since the last inspection and has not een notified of any allegations made to the local authority. The Gables is a comfortable, clean and well-maintained home. Residents rooms are homely and reflect their individual characters and interests. The garden is accessible to residents who use a wheelchair. There are sufficient staff with the right skills and attitudes to meet the needs of residents. The home has some staff vacancies, which the manager is trying to fill. The manager stated that when necessary regular agency nurses are used, who are known to the residents. The recruitment procedures are thorough ensuring that residents are protected from unsuitable carers. The home is well managed and provides a safe environment for residents. The manager is experienced and the Fremantle Trust has a quality assurance programme in place tomonitor the standards of care and service offered by the home. There are health and safety policies and procedures in place and regular checks and maintenance of services and equipment is carried out. What has improved since the last inspection? What they could do better: The Fremantle Trust must update the control of infection policies and procedures to reflect guidance issued by the Department of Health in June 2006 and available on www.dh.gov.uk. The equal opportunities and diversity policies and procedures appear to be eleven years out of date (dated 1999) and should be updated. The Fremantle Trust should update its other key policies and procedures which were last updated eight years ago to ensure that they reflect up to date practice in the field, for the benefit of residents. The Gables DS0000023055.V337301.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Gables DS0000023055.V337301.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Gables DS0000023055.V337301.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. The assessment process is thorough and gives the prospective resident, his or her family the opportunity to ensure that the home can meet their needs before they move permanently. EVIDENCE: There have been no admissions to the home since the last inspection. The manager described the process that would put in place should a vacancy arise. The Care Manager would undertake a full assessment and a referral would be made to the home. The manager would visit the prospective residents and undertake an assessment. The documentation seen to guide the assessment is comprehensive and meets the standard. Information about a prospective resident’s religious or cultural needs is also sought at this time. The prospective resident would be introduced to the home and to other residents, over a period of time, by having the opportunity to visit for tea initially and progressing to longer stays. The prospective resident, his or her family, care manager and home manager would review the placement after six weeks to agree whether the home could meet the prospective residents needs and to ensure that the residents would be happy. The initial care plan would be developed during this time in line with the prospective resident’s needs. The Gables DS0000023055.V337301.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. Residents are supported to make individual choices and to take appropriate risks to retain their autonomy, as far as they are able. The care plans are being updated to have a person centred approach, which will reinforce this concept. EVIDENCE: There are support plans in place for each resident. They comprise two documents. A comprehensive file, which is stored in the manager’s office and a shorter summary, which describes everyday needs and is stored in the lounge and easily available to care staff. The manager is in the process of updating the main care files and introducing a person centred approach with new documentation. One has been completed since the last inspection. The support plan holds information about the specialist requirements of the resident and the actions necessary to meet them. There are risk assessments in place, which cover moving and handling, medication, travelling, Waterlow (pressure sore) risk assessment, nutritional risk assessment, and risk assessments covering house activities such as using stairs, having a bath or shower, and being in the garden. Most of the residents are unable to The Gables DS0000023055.V337301.R01.S.doc Version 5.2 Page 11 communicate verbally and there was evidence in the plan that their non verbal communication behaviours had been identified, to help staff understand how residents were feeling. The home has a key worker system in place although the manager said that not all key workers would be able to complete residents support plans. In this case she would update them. The day-to-day documents held in the lounge contained a summary of the main support plan and the daily reports written by care staff. Whilst support plans are in place and contain the essential information about residents they are not yet in a systematic person centred format, which should be addressed. The manager said that she hoped to complete these within the next four months. Staff were observed to support residents and to approach them gently and try to establish their wishes before offering care e.g. a drink or putting on the television. Residents were treated with care and sensitivity. Service users are assessed as having high or moderate levels of dependency and the staff spoken to were knowledgeable about residents as individuals. Staff and residents appeared to have a good relationship. The weekly menu is planned with service users and usually one resident may go shopping with a carer. Residents have high or moderate levels of dependency and therefore their ability to take unaccompanied risks is limited. The manager and care staff however are focussed on helping individuals to retain as much independence as possible. One resident had unfortunately caused a flood by putting clothing in her bedroom sink unit, which overflowed. The response to this was not to restrict her freedom but to set up a closer, unobtrusive monitoring system when she went to her room on her own. The Gables DS0000023055.V337301.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 and 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. Residents are encouraged and supported to live a varied lifestyle an their choices are respected by staff. EVIDENCE: Six service users regularly go to a day centre – four to a centre in Beaconsfield and two to a centre in Burnham. One service user generally spends the day at home with staff but goes out on Fridays with a community worker and to a ‘Wednesday Group’ once a month. There is good communication between the home and the Beaconsfield centre and each resident has a diary, which describes their activities during the day. The communication with the Burnham day centre is less good and staff are not told of the activities that the residents had undertaken during the day. The manager said that she had tried to address this but without success. The Fremantle Trust should address this. The home has its own minibus, which was purchased by families of residents. This is used for shopping trips and outings. Six service users (two groups of three each time) have had holidays in Cornwall over the past year. The The Gables DS0000023055.V337301.R01.S.doc Version 5.2 Page 13 Fremantle Trust contributes £450 towards the cost and the resident or their family pays the rest. All seven service users are currently in touch with their families and the families returned the questionnaires distributed before the inspection. The families have formed an association named, Friends of Gables, which provides support to the home. Family members were complementary about the care offered at the Gables. One said that ‘the time and attention given to residents is excellent in all aspects including health care, social activities, shopping and holidays’. The Fremantle Trust has a policy, which provides guidance to staff in relation to personal relationships involving service users. Individual daily routines are reported to be very important to each service user and the staff were observed to be respecting these. The staff said that there were no restrictions on when residents got up or when they went to bed. Three regularly like to get up early (before 8:00 am). Breakfast is served around 8:30 and on Monday to Friday service users go to their day centre just after 9:00 am. Residents return from their day centres at around 3:00pm. Staff were observed to welcome them back and residents appeared happy to be back. Drinks were offered and residents relaxed in the lounge. The staff said that supper would be served at about 5:30 pm. After dinner service users pursue their own interests, which may include watching TV, listening to music or drawing. The staff reported that residents go to bed when they wish. The routine is very flexible at the weekends and residents are encouraged to have a ‘lie-in’ if they wish. Family visits and outings are planned. Residents help with menu planning. The menu is varied and can be presented in picture and widget form. Advice has been provided on managing swallowing difficulties. There is a large dining table, which promotes a sociable atmosphere at meal times. A well-stocked fruit bowl and drinks are available at all times. The Gables DS0000023055.V337301.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. Residents are supported by the care team to meet their personal, healthcare and medication needs in a way in which their individual choices are respected. EVIDENCE: The care plans seen showed that residents or their families had been asked about the way in which personal support should be provided. The homes routines are flexible. Residents were well dressed and they had been helped with their personal support needs. The home has adaptations to meet the needs of those with physical disabilities. There is a policy regarding same gender care. The manager said that they had sufficient male and female staff to meet residents’ or their families’ wishes for care to be given by a care staff of the same gender as the resident. There was evidence in the care plans that residents are seen regularly by the local Community Learning Difficulties Team and by members of the local Primary Healthcare team. The general practitioner said that staff demonstrate a clear understanding of the care needs of residents and take note of any specialised advice. There was evidence in the care plans that residents have regular health checks, including dental and eyesight checks. The Gables DS0000023055.V337301.R01.S.doc Version 5.2 Page 15 Medicines are prescribed by the service user’s GP and are dispensed by Boots Chemists. The storage and administration of medicines in the home is governed by the policy of the Fremantle Trust. The medications policy was last updated in 1999 and should be reviewed by the organisation. A record of the signatures of staff authorised to administer medication is kept. All staff attend training provided by Boots Chemists. The manager assesses competence before individual staff are permitted to administer medicines and records were seen to confirm this. A record of medicine received in the home and those returned to the pharmacy is kept. The medication administration charts are maintained accurately. There were no gaps in the administration records. The arrangements for the storage of medicines appeared satisfactory. A cupboard containing currently prescribed medicines (most in the Boots monitored dosage system) and a refrigerator for storing medicines requiring cool storage are in the kitchen on the ground floor. Both cupboards and the refrigerator had appropriate locks. Temperature checks are undertaken on the refrigerator and medicines are labelled with their date of opening if they have an expiry date. The Gables DS0000023055.V337301.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. Complaints and safeguarding issues are dealt with appropriately giving residents and their families confidence that their concerns will be addressed and residents will be safeguarded. EVIDENCE: There are complaints policies and procedures in place, which were last updated in 2003. A complaints log is kept. All the family members who returned the questionnaires said that they knew how to make a complaint. One said that if she had any concerns she would speak to the manager and the issue would be resolved quickly. The pre-inspection documentation indicated that two complaints had been made in the last year both of which had been resolved within the 28-day timescale set. There are safeguarding and whistle blowing policies and procedures in place, which were last updated in 2004. Staff have had safeguarding training and records were seen to confirm this. The staff spoken to said that they would not hesitate to report any concerns to the manager and knew that they could speak to a senior manager of the Fremantle Trust if they wished. The Fremantle Trust has a physical intervention and restraint policy, which is dated Feb 1999. This is now eight years old and should be updated by the organisation. The training records showed that staff have training in how to handle aggression. Service users’ money is managed using the Fremantle Trust’s residents’ savings scheme, with receipts kept of purchases and individual records to explain expenditure. The Fremantle Trust and independent auditors audit the financial systems in the home. The Gables DS0000023055.V337301.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. The Gables provides a homely, comfortable, clean and wellmaintained home for residents to live in. EVIDENCE: The Gables is a large detached house, set in a residential street next to a school. Accommodation is on two floors, with most of the single bedrooms on ground floor level, each arranged and decorated to reflect the wishes of the resident. Residents are encouraged to personalise their rooms and all had chosen to do so with the support of their families. Most had photographs of family members and music and television. The downstairs bathroom has been refurbished. The kitchen and laundry were in tidy and clean on the day of the unannounced visit. The manager said that the kitchen was due to be replaced. There was evidence that the work surface is permeable and it is difficult to reach some services. The permeable work surface represents an infection risk and should be addressed. There were no offensive odours in the home. The home is accessible to wheelchair users. Upstairs there are two further bedrooms, the office, a bathroom, shower room and storage cupboards. A recommendation was made at a previous inspection that a shower was fitted to The Gables DS0000023055.V337301.R01.S.doc Version 5.2 Page 18 the bath to assist with hair washing. This was done but unfortunately does not reach the resident and the staff are still dependent on jugs. This should be addressed. There is a large enclosed garden at the rear with seating areas. The Friends of the Gables have recently paid for additional paved areas to be laid and an awning to provide more outside, shaded sitting space for residents. There is no regular gardening support and the garden was in need of weeding and some maintenance. The front of the property is well maintained with a few parking spaces and ramped access. All parts of the home were clean, well furnished and in a good state of décor. There are infection control policies and procedures, dated February 1999. These have not been updated since the Department of Health issued revised guidance to care homes in June 2006 and the Fremantle Trust must address this. The Gables DS0000023055.V337301.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 34 and 35 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. There are sufficient staff with the right skills and attitudes to meet the needs of residents. EVIDENCE: The staff were observed to be caring towards residents. There were sufficient staff on duty on the day of the visit. The manager states that the home has vacant posts and that some agency staff are used. These are always regular agency staff who are known to the residents. The manager stated that it has been difficult to recruit to posts although a recent advertisement had had a number of applicants. There are training programmes in place and records showed that staff have the basic mandatory training in safe working practices. New staff join an induction programme. Five of the twelve care staff hold the National Vocational Qualification in Care at Level 2 or above and a further four are undertaking the course. The home does not yet meet the standard that fifty per cent of care staff hold this qualification but is on the way to achieving it. The recruitment records of three new members of staff were examined and found to contain the required documentation. The necessary checks as to the persons identity had been undertaken, references had been sought and The Gables DS0000023055.V337301.R01.S.doc Version 5.2 Page 20 criminal Records Bureau disclosures had been sought before the staff member commenced work. Interview records had been kept. The Gables DS0000023055.V337301.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 and 42 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. The home is well managed and provides a safe environment for residents. The organisation should update its policies and procedures in key areas to ensure that they reflect best practice in the field for the benefit of residents. EVIDENCE: The manager is experienced and is working towards the National Vocational Qualification in management and Care at level 4. She is registered with the Commission for Social Care Inspection. She has updated her skills regularly and is now a registered National Vocational Qualifications assessor. The family member spoken to on the day of the unannounced visit said that he had confidence in the management arrangements. The Fremantle Trust has a quality assurance programme, which is in place in the home. A senior manager visits the home regularly and reports of these visits are kept in the home. A comprehensive audit of care is undertaken annually and residents The Gables DS0000023055.V337301.R01.S.doc Version 5.2 Page 22 and relatives views are sought at that time as well as informally throughout the year. The results of the audit are made available to residents and their families and are available in the home for other stakeholders. The Fremantle Trust has written policies and procedures covering those areas of its operation as is required in the standards. However the pre-inspection documentation provided by the organisation showed that twelve of these had not been updated since 1999, including policies relating to accidents, bullying, infection control, medication, dealing with violence and aggression, restraint and sexuality and relationships. These must be reviewed and updated as necessary to ensure that the guidance available to staff is up to date and reflects current practice in the field. The equal opportunities and diversity policies are even more out of date and are dated 1995. This must be addressed by the organisation. There are health and safety policies and procedures in place. Regular safety checks of services and equipment are undertaken. The pre-inspection documentation showed that regular servicing of equipment is undertaken. A fire risk assessment has been carried out. Contracts are in place for the maintenance of fire safety equipment. Fire drills are carried out six monthly. Fire points are tested weekly and the emergency lighting is tested monthly. Residents’ likely response to the fire alarm is recorded. There are written assessments on hazardous substances (COSHH). Upstairs rooms have window restrictors and there are thermostically-controlled valves on water outlets. The Gables DS0000023055.V337301.R01.S.doc Version 5.2 Page 23 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 3 32 X 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 2 X 3 X The Gables DS0000023055.V337301.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Vocational Qualifications in Care at level 2 Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA30 Regulation 13(3) Requirement The control of infection policies and procedures should be updated to reflect guidance issued by the Department of Health in June 2006 and available on www.dh.gov.uk. Timescale for action 30/10/07 RECOMMENDATIONS These recommendations relate to National Vocational Qualifications in Care at level 2 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 YA6 YA27 YA40 YA40 Good Practice Recommendations Person centred care plans should be introduced for all residents. The bath showerhead should be adjusted so that it can be used to wash residents hair. The equal opportunities and diversity policies and procedures (dated 1999) should be updated. The organisation should update its policies some of which are eight years old to ensure that they reflect best practice in the field and provide up to date guidance for staff. The permeable areas on the kitchen work surface should be repaired to prevent the risk of infection. 5 YA42 The Gables DS0000023055.V337301.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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