Inspection on 23/01/06 for The Gables

This inspection was carried out on 23rd January 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 17/07/06

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 Unannounced Inspection 23rd January 2006 09:50 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.V277801.R01.S.doc Version 5.1 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.V277801.R01.S.doc Version 5.1 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.V277801.R01.S.doc Version 5.1 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. 24 (OP) 5(DE) 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 to 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. 18th August 2005 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 are two assisted bathing facilities 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 people mobility difficulties by means of a ramped front entrance with handrails. Gables, The DS0000062346.V277801.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over one day in January 2006 and was the second of the two statutory visits to the home for 2005/2006. To get a full overview of all the standards assessed this report should be read in conjunction with the report written following the inspection on August 18th 2005. During this visit a partial tour of the premises was undertaken, two resident and two staff files were sampled as well as other care and health and safety records. The inspector spoke with the manager, deputy manager, two staff and four residents. What the service does well: What has improved since the last inspection? Numerous improvements had been made at the home since the last inspection which had halved the number of requirements made following the last inspection. The statement of purpose and service user guide for the home had been completed ensuring prospective residents had all the information they required to make an informed choice as to whether the home could meet their needs. The process for undertaking risk assessments on individual residents had improved ensuring risks were identified and minimised wherever possible. The systems in place for medicine management had been further improved and ensured the medication needs of the residents were being met safely. Gables, The DS0000062346.V277801.R01.S.doc Version 5.1 Page 6 Records of food served to the residents had been further developed and evidenced the residents were receiving a varied and nutritious diet. Staff had undertaken training in the prevention of abuse and how this was to be reported if suspected or witnessed. The systems in place for managing money on behalf of the residents had vastly improved with individual records being maintained, receipts being obtained for all expenditure and records being signed by two staff. The system was auditable and ensured the protection of the residents. The CSCI was being appropriately notified of any accidents or incidents in the home ensuring the correct procedures were followed and giving the inspector an ongoing overview of what was taking place in the home. Further improvements had been made to the premises adding to the comfort of the residents and further improving their safety. These included, some new bedroom carpets and furniture, a new fire alarm system being installed, a wash hand basin had been installed in the laundry, a commode pot washer/disinfector had also been installed and the majority of the minor repairs noted at the last inspection had been addressed. 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.V277801.R01.S.doc Version 5.1 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.V277801.R01.S.doc Version 5.1 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): 1 There was information available for prospective residents to ensure they could make an informed decision as to whether the home could meet their needs. EVIDENCE: The statement of purpose and service user guide for the home had been completed and copies had been forwarded to the inspector for consideration. All the relevant information was included in the documents and apart from some minor additions and suggestions in relation to layout they met with the requirements of the National Minimum Standards. An application to vary the registration of the home had been received to enable them to accommodate five people with dementia as this had been raised as an issue at the previous inspection. The application was successful and was processed a little after the inspection. This change will have to be incorporated in the statement of purpose and service user guide. Gables, The DS0000062346.V277801.R01.S.doc Version 5.1 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 and 9. The new care planning system in the home was good and needed to be put in place for all residents detailing how their individual needs would be met. Risk assessments had improved and ensured all identified risks and strategies for managing them were clearly identified. There must be evidence that any identified health care needs have been followed up and monitored. The medication system had improved and ensured residents were not placed at risk. EVIDENCE: At the last inspection the manager was in the process of changing the care planning system in the home. This had not been completed for all the residents. Two care plans were sampled at random, one had a new style care plan the other did not. The new care plan was very well detailed and gave staff all the required information they needed to ensure the individual’s needs could be met, for example, likes dislikes and preferences, the types of assistance required and where the individual was able to care for herself, for example, is able to brush her own hair and can wash her own hands and face. There was also good detail of how staff were to meet the emotional needs when the resident was anxious and nervous. It was recommended that when reviewed the care plan was checked for repetition as this made it very long. Gables, The DS0000062346.V277801.R01.S.doc Version 5.1 Page 10 There was evidence that the resident had been consulted about the care plan and that a review had taken place in consultation with the resident. The second care plan checked was only just being changed to the new system. This included some good detail in relation to the individual’s poor sight and the issues that arose from this but needed to be further developed in all other aspects to ensure all needs were identified. All residents had manual handling risk assessments and separate personal risk assessments that detailed the actions to be taken by staff in the event of a fall. Nutritional and tissue viability screenings had been undertaken for all residents and where a risk had been identified details of how to minimise this were being incorporated into the care plans. Residents were being weighed on a regular basis. Daily records evidenced that the personal care needs of the residents were being met. Staff were identifying health care needs and in most instances there was evidence of these being followed up and monitored. It was noted on some daily records that staff were not always recording the monitoring of health care issues, for example, one daily record stated the G.P. would be called but there was no evidence of this happening, another stated that some medication had been given with good effect but with no explanation and another stated a resident was sore and treatment was administered but then there was no evidence that this had been checked. The manager needed to ensure that staff were vigilant about recording the monitoring of health care needs to evidence these had been followed up and met. Staff were trying to identify any visits from health care professionals by highlighting them however this could mean looking through numerous daily records. As at the last inspection it was strongly recommended that that visits from health care professionals were documented separately from daily records. Further improvements had been made to the management of medicines in the home ensuring the system was safe. All the medicines audited were found to be correct, there were no gaps on the medication administration sheets, all medication was being acknowledged as received into the home and the manager had put written protocols in place for the administration of PRN (as and when necessary medication). The manager was carrying out regular audits on the medication to ensure they were being administered correctly. The policies and procedures for medication administration were not assessed during this visit. Gables, The DS0000062346.V277801.R01.S.doc Version 5.1 Page 11 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): 15 Records of food being served to the residents evidenced that a varied and nutritious diet was being offered to the residents with choices available EVIDENCE: These standards were assessed at the last inspection and found to be met with only a minor requirement being made in relation to the records of food being served to the residents. This had been met and the records were in sufficient detail to be able to establish that a varied and nutritious diet was being offered with choices available. Gables, The DS0000062346.V277801.R01.S.doc Version 5.1 Page 12 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): 18 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: The majority of the staff had undertaken training in the prevention of abuse since the last inspection. The policies and procedures in relation to adult protection could not be located on the day of the inspection therefore it could not be determined if they had been amended as required following the last inspection. 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. The policy and procedure for physical intervention/restraint had been further developed and included what could be seen as restraint and that any used must be agreed by all professionals concerned, written into a care plan and regularly reviewed. Gables, The DS0000062346.V277801.R01.S.doc Version 5.1 Page 13 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 and 26. The home provided residents with a comfortable and homely environment that was generally well maintained and safe. EVIDENCE: There had been no changes to the layout of the home since the last inspection. The home was accessible to the residents via ramps. Furnishings, fittings and décor were homely in style and of an acceptable standard with the exception of some of the armchairs that were worn and remained in need of replacing. Since the present proprietors had taken over the home they had invested a lot of time and money in ensuring the home was safe for the residents and staff. Since the last inspection this had been ongoing. Numerous requirements had been made by the fire officer in relation to the safety of the building and with the exception of some minor issues these had been addressed including, smoke detection in the loft space, the fitting of new fire alarm system, adjusting doors as required and the fire risk assessment had been completed. Gables, The DS0000062346.V277801.R01.S.doc Version 5.1 Page 14 Other improvements that had been made since the last inspection included, a commode pot washer/disinfector had been installed, several bedrooms had had new carpets, some bedrooms had had new furniture and this was ongoing, the requirement made in relation to regulating the water temperature in the bathroom had been addressed, a wash hand basin had been installed in the laundry and the majority of the minor repairs noted at the inspection had been addressed. The only office space at the home is on the first floor landing and does not allow for any degree of privacy at all. It is a condition of registration for the proprietors to address this. Due to the considerable work and cost involved in this the time scale for completion has been extended. 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 it was strongly recommended that the possibility of a ramp be explored. There were appropriate numbers of toilet and bathing facilities in the home with two assisted bathing facilities, two bedrooms with en-suite showers and numerous toilets. Some of the facilities had been repainted others still needed to be addressed, electrical extraction had been fitted to the internal toilets. One of the en-suite showers had no showerhead and could not be used by the resident and this needed to be addressed. 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 emergency call system had been extended to all facilities however it was noted that it was not accessible from the bath on the ground floor and this needed to be addressed. 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. The condition of registration in relation to providing any missing items had been extended 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. Gables, The DS0000062346.V277801.R01.S.doc Version 5.1 Page 15 Infection control had improved since the last inspection with the fitting of a commode pot washer, a wash hand basin in the laundry and an insect-o-cute being installed in the kitchen. There were some outstanding issues from the last inspection that needed to be 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 (a food probe had been purchased but was not being used at the time of the inspection) and the untiled wall in the kitchen needed to have a finish that was easy to clean. Gables, The DS0000062346.V277801.R01.S.doc Version 5.1 Page 16 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, 29 and 30. Appropriate staffing levels were being maintained that enabled the residents’ needs to be met. The recruitment procedures were robust and ensured the protection of the residents. EVIDENCE: There had been little staff turnover at the home since the last inspection. Some of the staff had worked at the home for a considerable amount of time which was very good for the continuity of care of the residents. There were good relationships evident between staff and residents and all residents spoken with were very positive about the staff team and the service they received. Minimum staffing levels as set out in the conditions of registration for the home were being maintained with the manager’s as supernumerary on most occasions. The manager had developed individual training records for the staff and training had been undertaken in a variety of topics including fire procedures, skin care, optical training, manual handling, abuse awareness, health and safety, infection control and catheter care. The induction procedure for staff was not assessed during this inspection. The recruitment records for the two most recently employed staff were sampled. These evidenced that all the required documentation, with the exception of one POVA first check, had been obtained. Records included completed application forms, references and medical declarations. Gables, The DS0000062346.V277801.R01.S.doc Version 5.1 Page 17 The manager stated that the POVA first check that was not available had been obtained as she does not employ staff without this whilst awaiting the CRB check and that the checks were e-mailed to the proprietor once completed, however this must be available for inspection. Gables, The DS0000062346.V277801.R01.S.doc Version 5.1 Page 18 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, 35, 37 and 38. The management of the home had improved as the manager had become more familiar with her role and the home was being run in the best interests of the residents. The health and safety of the residents and staff was well managed. EVIDENCE: The registration process for the manager had been successfully completed since the last inspection. She had worked at the home for a considerable amount of time and it was evident she was growing in confidence in her manager’s role. She had worked very hard, along with the staff team and the proprietors, to meet many of the requirements made at the last inspection and showed an awareness of what other aspects needed to be improved. She had a very good knowledge of the residents in her care. She was undertaking the Registered Manager’s Award qualification. Gables, The DS0000062346.V277801.R01.S.doc Version 5.1 Page 19 The systems in place for the management of monies on behalf of the residents had vastly improved since the last inspection. The records had been individualised, were auditable, there were receipts available for expenditure and two signatures were being obtained for any transactions made on behalf of the residents. The issue of the residents paying for their own meals at luncheon and stroke clubs had not been addressed but the registered individual was pursuing this. As the residents pay for their meals in their fees then they should be reimbursed at the appropriate rate for any meals they pay for. It would be difficult to establish how far back to go with this, as it had been an ongoing arrangement since before the present proprietors took over the home. The responsible individual is one of the proprietors and although she regularly attended the home and had been visiting unannounced her reports on the conduct of the home were not available at the time of the inspection. All the copies of these were faxed to the inspector prior to this report being written. Health and safety were being well managed. Staff had received training in safe working practices but the manager was reminded that fire training must take place every six months not yearly as was thought. There was evidence on site that all the in house checks on the fire system had been undertaken and that the majority of the equipment was being serviced on a regular basis, with the exception of the bath hoist on the first floor of the home. There also needed to be evidence that the water system had been checked for the prevention of legionella. The premises risk assessments had been further developed and covered all the relevant areas. Accident and incident recording were appropriate and notifications to the CSCI had greatly improved since the last inspection. Gables, The DS0000062346.V277801.R01.S.doc Version 5.1 Page 20 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 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 2 3 2 2 X 2 3 2 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 3 X 2 2 Gables, The DS0000062346.V277801.R01.S.doc Version 5.1 Page 21 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 OP7 Regulation 15(1) Requirement All residents must have care plans that detail how all their needs in relation to health and welfare are to be met by care staff. There must also be evidence that wherever possible residents have been consulted in relation to the care plans. (Previous time scales of 01/03/05, 01/05/05 and 01/11/05 partially met.) There must be evidence that all identified health care needs are followed up and monitored. 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 G.P.s agreement is to be obtained for administration. - All policies must be signed and dated. (Previous time scale of 01/10/05 not assessed for compliance at this visit. DS0000062346.V277801.R01.S.doc Timescale for action 01/03/06 2. 3. OP8 OP9 12(1)(a) 13(2) 01/03/06 01/04/06 Gables, The Version 5.1 Page 22 4. OP18 13(6) 5. OP19 16(2)(c) 6. OP19 23(1)(a) (2)(a) 7. 8. OP22 OP21 23(2)(n) 23(2)(d) 9. 10. OP21 OP23 23(2)(c) 23(2)(f) 11. OP24 16(2)(c) 12. OP26 13(3) The homes adult protection procedure must be amended to ensure it is in line with the multi agency guidelines and be available to staff at all times. (Previous time scale of 01/10/05 not met.) Any worn armchairs must be replaced. (Previous time scales of 01/04/05 and 01/11/05 not met.) An office that affords some degree of privacy to staff when on the telephone, completing records or dealing with private matters must be provided. (Time given scale had not lapsed.) The emergency call system must be accessible from all bathing facilities. Any bathrooms and toilets in need of decoration must be addressed. (Previous time scales of 01/04/05 and 01/11/05 partially met.) The shower fitment in bedroom 15 must be repaired. (Previous time scale of 01/10/05 not met.) Bedroom 9 to be extended or cease to be used as a bedroom. (Time scale given had not lapsed.) 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.) The temperature of the food store in the same location as the laundry must be monitored to ensure food is not going to spoil. (Previous time scale of 01/09/05 not met.) The core temperatures of cooked foods must be monitored to 01/03/06 01/04/06 01/03/07 01/03/06 01/04/06 01/04/06 01/03/07 01/03/07 01/03/06 Gables, The DS0000062346.V277801.R01.S.doc Version 5.1 Page 23 ensure they are thoroughly cooked. (Previous time scale of 01/09/05 partially met.) The untiled wall in the kitchen must have a finish that is easily cleaned. (Previous time scale of 01/12/05 not met) 50 of care staff must be qualified to NVQ level 2 or the equivalent. (Previous time scale of 31/12/05 not assessed for compliance at this visit.) As a minimum there must be evidence on site that a POVA first check has been undertaken on all staff prior to their commencing their employment. The induction and foundation training for staff must be cross referenced to the specifications laid down by the Learning Skills Council to ensure it meets the requirements. (Previous time scale of 01/11/05 not assessed for compliance at this visit.) The manager of the home must be qualified to NVQ level 4 in management and care. (Previous time scale of 31/12/05 not met.) The home must have an effective quality assurance and quality monitoring system in place that is based on seeking the views of the residents. (Previous time scale given of 01/04/05 not met. Time scale of 01/11/05 not assessed for compliance.) The responsible individual must make arrangements for the residents to be reimbursed for any meals that they purchase that have already been paid for in their fees. (Previous time scale of 01/10/05 not met.) The home must have a suitable procedure for staff to follow in DS0000062346.V277801.R01.S.doc 13. OP28 18(1)(a) 01/04/06 14. OP29 19(1)(b) (i) 01/03/06 15. OP30 18(1)(a) 01/04/06 16. OP31 9(2)(b)(i) 01/06/06 17. OP33 24(1)(a) (b) 01/04/06 18. OP35 13(6) 01/03/06 19. OP37 17(2)4 (16) 01/04/06 Page 24 Gables, The Version 5.1 the event of an accident. The missing persons procedure must include notification to the CSCI. (Previous time scale of 01/10/05 not assessed for compliance at this visit.) Staff must have updated fire training every six months. There must be evidence on site that the water system has been checked for the prevention of legionella. There must be evidence on site that the bath hoist on the first floor has been serviced. 20. 21. OP38 OP38 23(4)(d) 13(3) 01/03/06 01/04/06 22. OP38 23(2)(c) 01/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 1. 3. Refer to Standard OP7 OP8 OP20 Good Practice Recommendations It is strongly recommended that when the care plans are reviewed that are checked for repetition as this is making them very long. It is recommended that visits from health care professionals are recorded separately from daily records to enable easy tracking. 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.V277801.R01.S.doc Version 5.1 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.V277801.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!