Inspection on 31/10/06 for The Gables

This inspection was carried out on 31st October 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Gables 15/04/09

The Gables 16/04/08

The Gables 19/04/07

The Gables 13/03/06

The Gables 05/12/05

The Gables 08/02/05

The Gables 24/08/04

The Gables 18/02/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 The Gables 262 Ipswich Road Colchester Essex CO4 0ER Lead Inspector Marion Angold Key Unannounced Inspection 31st October 2006 09:45 The Gables DS0000028587.V317878.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 DS0000028587.V317878.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 DS0000028587.V317878.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Gables Address 262 Ipswich Road Colchester Essex CO4 0ER 01206 841515 01206 841515 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) Care Aspirations Limited Raymond Gilbey Care Home 7 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (1) of places The Gables DS0000028587.V317878.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 7 persons) One person, over the age of 65 years, who requires care by reason of a learning disability, whose name was made known to the Commission in January 2004 The total number of service users accommodated in the home must not exceed 7 persons 13th March 2006 Date of last inspection Brief Description of the Service: The Gables is a detached, two-storey house on the busy Ipswich Road in Colchester. There is parking for three vehicles at the front of the property and a large, enclosed garden to the rear. A keypad entry system is in operation. The home is registered for seven service users with a learning disability, each of whom has a fully en-suite bedroom, with either bath or shower. Recent alterations to the home include a conservatory extension, adjoining the lounge, for use as a dining room. The weekly charge for a room at The Gables is between £879.81 and £1435.32. An extra charge is made for hairdressing, toiletries and chiropody. The Gables DS0000028587.V317878.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector went to the home without telling anyone she was going to visit on the morning of Tuesday, 31 October 2006. During this visit the inspector • • • • • talked with residents talked with the manager and some staff watched how residents and staff got along together looked around some of the home looked at some records. In writing this report, the inspector also used records she already had about the home, including information sent in by the people in charge. Over all, 24 Standards were inspected. • 18 Standards were ‘met’. These are the things the home does well for residents. • 6 Standards were ‘nearly met’. These are the things that need a little improvement. What the service does well: Residents have full en suite bedrooms and their personal things around them. The lounge and dining areas adjoin the kitchen, creating a homely atmosphere. Residents enjoyed their meals. They could choose things like when to get up and whether to be alone. They had an advocate who could make sure that the home knew what they wanted and was doing what was best for them. Staff gave time to helping residents enjoy their lives, supporting them with activities, outings and holidays. Relatives felt welcome and able to see residents in private These were some of their positive comments. ‘I am very happy with the care my relative is receiving. The staff are brilliant and I have nothing but praise for the home.’ ‘I am extremely grateful for the way in which the home is run. Mr Gilbey, the manager, and his staff are cheerful, caring, helpful and professional. One could not ask for more.’ ‘Ray Gilbey deserves a star!’ The Gables DS0000028587.V317878.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. The Gables DS0000028587.V317878.R01.S.doc Version 5.2 Page 7 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 DS0000028587.V317878.R01.S.doc Version 5.2 Page 8 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. Quality in this outcome area is good. This judgement has been made using evidence from previous inspections, as there had been no new admissions to the home. • Residents’ individual needs and aspirations had been assessed. EVIDENCE: There had been no changes to the resident group. Existing residents had been admitted on the basis of individual assessments of need. The Gables DS0000028587.V317878.R01.S.doc Version 5.2 Page 9 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. • • Residents’ health, personal and social care needs were set out in an individual plan of care but needed to be reviewed more often. Residents were supported to take risks and to make choices and decisions about their lives. EVIDENCE: Two residents files were sampled. These identified needs, wants, risks, strengths, weaknesses, likes and dislikes and provided clear instructions to staff. It was evident from discussion and observation that care plans covered areas of relevance to the individual concerned; in one case they addressed four key areas, in the other seven. Three out of four respondents to the Commission’s survey felt they were consulted and kept informed about important matters concerning their relative. Staff confirmed the continuing effectiveness the key worker system. The care plans inspected had been reviewed on an approximately annual basis, rather than at the minimum recommended interval of six-monthly. The Gables DS0000028587.V317878.R01.S.doc Version 5.2 Page 10 Arrangements for supporting residents with their personal money were found to be satisfactory. Personal allowances were received into an account held by Care Aspirations, transferred to the home and distributed to each person in cash, held securely on their behalf. Records, receipts and balances, held by the home, were sampled for two residents, one of whom had some understanding of money and the other, who did not. Records clearly showed the process involved and corresponding receipts and cash balances were available and accurate. Residents continued to receive from Care Aspirations an allocation for clothing and activities. Since the last inspection arrangements had been made for a change of advocate. The Responsible Individual explained that the agency chosen by Care Aspirations to provide advocacy to residents of The Gables, was experienced in the area of learning disability. The manager reported that the new advocate had met residents and would be making regular visits to promote their rights and interests, both individually and as a group. Whilst this arrangement protects residents where they have limited capacity for making important decisions for themselves, it is recommended that any specific infringement of their right to act or decide for themselves (for example, with respect to taking medication or looking after their own money), is documented in their care plan. The Gables DS0000028587.V317878.R01.S.doc Version 5.2 Page 11 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, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. • • • • The lifestyle residents experienced at The Gables suited them. Residents maintained some contact with family and the local community. Residents’ rights were respected and responsibilities recognised in their daily lives. Residents were offered a balanced diet and enjoyed their meals and mealtimes. EVIDENCE: Particular residents continued to attend college or day centre-based activities during the week. Staff reported that the number who could drive the minibus had risen to four, which meant there was usually someone on shift to facilitate an outing and that this had increased the opportunities for residents. On the day of inspection, three staff accompanied 5 residents to a local Jam Factory with museum and teashop and then to buy what they needed for their The Gables DS0000028587.V317878.R01.S.doc Version 5.2 Page 12 Halloween celebration that evening. The manager stayed behind with the residents who chose not to go on this outing. Residents had enjoyed one of two five-day holidays, which either they had helped to choose or had been chosen to suit their particular needs and temperament. Three had gone to a holiday camp and three to a quieter location in Norfolk. In both instances, three staff had accompanied them. One resident spoke enthusiastically about their holiday. All four relatives responding to the Commissions’ survey felt that staff were welcoming and affirmed that they could visit the home at any time. The manager and staff had taken a proactive approach to involving relatives. Staff would escort residents to see their relatives, if necessary. The manager reported that relatives were also invited to meetings although they tended rather to discuss the matters of importance to them during their informal visits. A good level of interaction between staff and residents was observed throughout the inspection. Discussion and observation showed that residents were able to follow their preferred routines with respect to getting up, going to bed and meals. Those who wished to remain in their rooms or go in the garden did so. Staff were heard consulting residents about their choice of outing. Residents also had the option of staying at home. Although the home had a three-week menu cycle, staff acknowledged that they used the menus only as a guide because they consulted residents about what they would like and were familiar with their diverse preferences. Fridge and freezers were well stocked with a variety of fresh and packaged food, which staff prepared for residents. Residents were offered a variety of drinks and, in some cases, were able to make their own drinks under supervision. Fruit was available between meals and one person was observed eating an apple. The meal observed was relaxed and festive (for Halloween). The Gables DS0000028587.V317878.R01.S.doc Version 5.2 Page 13 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. • • • Residents were receiving personal support appropriate to their needs. Residents’ physical and emotional health needs were met. The home’s procedures for dealing with medicines protected residents. EVIDENCE: Residents continued to be receive personal support in the way they were used to and in the privacy of their rooms, which were fully en suite. Care plans evidenced that appropriate support was given. Key workers supported residents to choose clothes suitable for them and they appeared well presented. One family had continuing concern about their relative’s personal hygiene and the manager had been working with the placing social work team, to resolve the issues in the best interests of the resident. Care plans showed that staff monitored aspects of residents’ health, such as their weight, that residents were given appropriate support to manage their health care and that identified health care needs were appropriately referred The Gables DS0000028587.V317878.R01.S.doc Version 5.2 Page 14 for advice and treatment. It was evident from discussion that one resident’s physical health had improved significantly since coming to The Gables and receiving regular medical attention. Residents also continued to be supported, as necessary, by a psychologist on the establishment of Care Aspirations. Although the home was proactive in seeking medical advice, one of the two care plans sampled did not contain evidence of routine annual health checks. The five staff with responsibility for medication administration had attended training provided by their supplying pharmacy. The signatures on the medication administration records corresponded with the names of seniors permitted to administer medication. Medication administration records showed no gaps in recording and included homely remedies. Protocols were in place for administering PRN ‘as needed’ medication. Arrangements for storing medication were satisfactory and secure and included a small fridge. Minimal stocks showed good management of ordering and returns. Staff acknowledged that it was their responsibility to access the medications and other policies from the office. The matter of achieving a satisfactory level of personal hygiene for one resident without infringing their rights or putting them and staff in a vulnerable position, had not been fully resolved at the time of inspection, though it was clear, from discussion with the manager, that the situation was being monitored. The Gables DS0000028587.V317878.R01.S.doc Version 5.2 Page 15 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. • • Residents’ wishes and views were listened to and acted on. Residents could have been better protected from risk of abuse. EVIDENCE: The home had no record of complaints since the last inspection although one respondent to the Commission’s survey mentioned an ongoing issue, which was known to the manager and the Commission and had been addressed previously under the home’s complaints procedure. Although residents had experienced a change of advocate, they continued to have an independent person visiting them for the purpose of listening to their views and representing their best interests. On 24/5/06, the Director of Care Aspirations, rang to inform CSCI of an incident, occurring in October 2005, when a member of staff had behaved in an unseemly manner, whilst escorting residents on the home’s minibus. The staff member concerned was suspended and subsequently dismissed. The circumstances surrounding the delay in this incident coming to light were discussed with the registered manager during the inspection and the need identified for all persons working for The Gables to be fully informed and aware of their duty (under the Public Interest Disclosure Act 1998 and in line with the The Gables DS0000028587.V317878.R01.S.doc Version 5.2 Page 16 company’s whistle blowing procedures) promptly to report matters of concern, which they have seen or heard about. The Gables DS0000028587.V317878.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. • • Residents were living in a comfortable and safe environment. The home was clean and hygienic. EVIDENCE: No significant changes had been made to the premises since the last inspection, apart from new lounge furniture. All parts inspected were found to be well maintained, clean, fresh, safe and suitable for their purpose. The maintenance person, employed by Care Aspirations continued to make routine weekly visits to carry out work identified in the maintenance log. A day was also set aside each week to cover contingencies at any of the services, owned by Care Aspirations. Discussion with the manager showed that the home had complied with previous requirements of the Fire Service. The manager reported that, at their recent inspection, the Fire Officer had advised The Gables DS0000028587.V317878.R01.S.doc Version 5.2 Page 18 that pictorial signs must be displayed but that they should await the report for detailed instructions. The manager stated that the maintenance person would then undertake the required work. Compliance with Environmental Health requirements is evidenced under NMS 38. Following the installation of a DVD monitor for staff training in the residents’ dining room, the registered persons should ensure that residents are consulted about the use of their communal space for this purpose. The Gables DS0000028587.V317878.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): 32, 33, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. • • Residents were supported by sufficient numbers of competent and qualified staff. Residents were not fully protected by the home’s recruitment and training practices. EVIDENCE: Residents showed that they found the manager and staff on duty approachable. It was evident from discussion and observation that the manager and staff understood and respected the diverse needs of residents. It was reported that more than 50 of staff had completed the National Vocational Qualification in care, Level 2, (NVQ 2) and that senior staff had achieved NVQ 3. Only relatively new staff had still to undertake NVQ training. Two out of four respondents to the Commission’s survey said that in their opinion there were not always sufficient numbers of staff on duty. However, recent rosters showed and staff confirmed some improvement in daytime The Gables DS0000028587.V317878.R01.S.doc Version 5.2 Page 20 staffing levels. For the week beginning 30/10/06, and subsequent weeks, 3 staff were on duty throughout the week, supplemented by the manager from Monday to Friday. Two awake staff covered every night shift, as before. During the week beginning 23/10/06, rosters sometimes showed two staff plus the manager. The manager said that this was due to staff having annual leave and unexpected sickness. The manager acknowledged that, with the planned transfer of one support worker to another unit, they would have to recruit a new member of staff, in order to maintain the higher staffing ratio consistently. Staff confirmed that the availability of a third support worker had increased the scope for outings and a person-centred approach to activities. Staff acknowledged that it was their responsibility to access policies from the office but that key issues and changes were flagged up at staff meetings. Three staff files were sampled in respect of the home’s recruitment process. Recruitment continued to be organised by Care Aspirations and copies of the documentation forwarded to the home. Applications forms had been satisfactorily completed. One new member of staff had started work on 4/9/06 without a second reference or a disclosure from the Criminal Records Bureau, although they had a satisfactory POVA First check. A second reference had been requested from them in their supervision meeting on 20/10/06. Two out of 3 files did not include photographic identity. These omissions placed residents at risk. The initial training/information day for new staff, arranged by Care Aspirations, covered the organisation, legal framework, care practice, health and safety, report writing and workforce development. Records showed that new staff also completed induction training over 6 weeks, signed off by the manager or member of staff supporting/assessing them. However, records showed no evidence of the effectiveness of this training or how competencies were assessed. Staff indicated that individual mandatory training needs were notified routinely by head office. However, one staff file sampled showed that the person concerned had only attended 2 courses in the previous 12 months, one on equal opportunities, and the other on managing challenging behaviour. Their record of mandatory training showed some lapses. The other member of staff, whose file was sampled, had attended a fire safety course and completed their National Vocational Qualification Level 2 within the past year. Their record of mandatory training was satisfactory. Since the last inspection, three senior staff had attended a college-based course on supervisory development, which included an examination. The home had also acquired a DVD monitor for training purposes. This was fixed high on the wall in one corner of the dining room. The inspector was informed that, so far, it had only been used for fire safety and moving and handling training. Accounts of this method of training suggested that it was less helpful than having expert personal trainers, who involved staff at a practical level. The Gables DS0000028587.V317878.R01.S.doc Version 5.2 Page 21 Training in other health and safety topics continued to be arranged corporately. Records sampled showed that staff supervision was satisfactory and taking place at more or less two monthly intervals, in line with Standard 36. The Gables DS0000028587.V317878.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. • • • Residents benefited from a well run home. There was scope for greater consultation with residents about the way their home was run and for making their views known. More could be done to promote the health, safety and welfare of residents, I by addressing inconsistencies in health and safety training and updating risk assessments. EVIDENCE: In discussion, Mr Gilbey showed commitment to promoting the wellbeing of residents and the home was achieving mostly good outcomes for residents under his management. Mr Gilbey was seen to have a good rapport with people living and working at the home and two of the relatives, responding to the Commission’s survey, made a point of complimenting him for the way the home was run. The Gables DS0000028587.V317878.R01.S.doc Version 5.2 Page 23 Records show that Care Aspirations conduct a rigorous monthly audit of all aspects of the service provided by The Gables although their monthly monitoring reports, compiled for the purposes of Regulation 26 of the Care Homes Regulations 2001, have remained brief and given little indication of how the home is meeting the needs of residents. Whilst it is clear that, on a day-to-day basis, residents have a say in how their home is run, their views have not appeared in the annual independent customer satisfaction survey. Although it was evident that the outside company had been asked by Care Aspirations to involve service users where possible, most service users had not been able to participate, as all the interviews had been conducted by telephone. The Quality Assurance Advisor to Care Aspirations said that a more user-friendly approach would be introduced in time for the next survey. Whilst there was no written evidence to show how these surveys were used to inform the future development of the home, CSCI have been advised that the annual surveys are reviewed at Clinical Governance meetings and immediate action taken to address any issues arising. Environmental risk assessments had been completed in 2002, when the home was registered, covering hazardous substances, electrical installations and appliances, fire and food safety. These had not been updated or added to, to take account of changing circumstances. A newer risk assessment for one member of staff was not specific to The Gables. The manager said that the requirement to implement the new Food Safety Management System, arising from a Food Hygiene and Health and Safety inspection in June 2006, was being progressed by Care Aspirations and that the system would be up and running in November 2006. That particular inspection had generated no other requirements or recommendations. As highlighted under Standard 30, some staff had not covered all the necessary health and safety training. The Gables DS0000028587.V317878.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 2 36 3 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 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 X The Gables DS0000028587.V317878.R01.S.doc Version 5.2 Page 25 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 YA23 Regulation 13(6) Requirement The registered persons must take measures to ensure that all persons working at the care home are aware of their duty to protect residents from harm and abuse. The registered persons must ensure that the home’s recruitment procedures protect residents and that satisfactory information and documentation, as required by these regulations, are obtained before staff begin working at the home. The registered persons must ensure that staff have training appropriate to the work they are to perform. The registered persons must ensure that reviews of ‘customer satisfaction’, for the purpose of quality monitoring, are based, where possible, on consultation with residents. They must also demonstrate how their surveys and monitoring are linked to future planning and action. This requirement has exceeded the timescale for action agreed following the last DS0000028587.V317878.R01.S.doc Timescale for action 30/11/06 2. YA34 17 Sch 4 19 Sch 2 30/11/06 3. YA35 YA42 13, 18 31/01/07 4. YA39 24(2) 31/12/06 The Gables Version 5.2 Page 26 inspection. 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 YA6 YA7 YA18 YA28 YA34 Good Practice Recommendations The registered persons should ensure that residents’ care plans are reviewed at least every six months and clearly document any infringement of their rights. The registered persons should ensure that residents have minimum annual health checks. The registered persons should ensure that residents are consulted about the use of their communal space for staff training. The registered persons should keep a record of all telephone transactions pertaining to the running of the home. This recommendation has been brought forward because it was not covered at this inspection. The registered persons should ensure that records of staff training provide some evidence of the skills and competencies achieved. Care Aspirations should review the content of their monthly reports, compiled in accordance with the Care Homes Regulations 2001, Regulation 26. The registered persons should ensure that risk assessments are periodically reviewed and updated to protect residents and staff. 5. 6. 7. YA35 YA39 YA42 The Gables DS0000028587.V317878.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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. Extracts may not be used or reproduced without the express permission of CSCI The Gables DS0000028587.V317878.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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