CARE HOMES FOR OLDER PEOPLE
The Gables Nursing Home 1595 Wolverhampton Road Oldbury West Midlands B69 2BJ Lead Inspector
Mrs Jean Edwards Unannounced Inspection 1st February 2006 09:30 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 The Gables Nursing Home DS0000004832.V281537.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. The Gables Nursing Home DS0000004832.V281537.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service The Gables Nursing Home Address 1595 Wolverhampton Road Oldbury West Midlands B69 2BJ 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) 0121 544 3988 0121 544 3989 Ashbourne Healthcare Limited (Southern Division) Ms Kim Jeffery Care Home 51 Category(ies) of Old age, not falling within any other category registration, with number (51) of places The Gables Nursing Home DS0000004832.V281537.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 19/07/06 Brief Description of the Service: The Gables Nursing Home is situated on the A4123 Wolverhampton Road, Oldbury. It is easily accessible by public transport and ample off-road parking is available. The Home is registered to provide care for a maximum of 51 elderly persons. It is a purpose-built property with three floors. Lounges and dining rooms are available on the ground and first floors. Residents bedrooms are also located on both floors. The kitchen, laundry and staff facilities are situated on the lower ground floor. All floors can be accessed via lifts or stairways. Access into and around the Home is suitable for wheelchair users. The reception area is comfortably furnished with a couch and occasional chairs and the piped music provides a relaxing atmosphere for visitors entering the Home. Residents and visitors may access the information kept in reception about the Home and the service it provides. Visitors are welcome at any time and for health and safety reasons are requested to sign the Visitors Book with their details, arrival and departure times. There is a staff team of 43 people including the Registered Manager, registered nurses, and care staff, domestic and catering staff. The Gables Nursing Home DS0000004832.V281537.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection visit was undertaken by the Inspector from the Commission for Social Care Inspection, over one day, using the following methods to obtain evidence and make judgements: information supplied by the home such as the action plan response from the home to the announced inspection in July 2005, monthly reports from the proprietor relating to the conduct of the home, and records held at the home. During the visit the inspector spoke to the majority of the 44 residents who are currently living at the home. The Registered Manager, Care Manager, trained nurses and catering manager took an active part in the inspection process. Discussions have taken place with residents, visitors and members of care staff, their comments are generally very positive. Comments commend the social events, catering and caring staff team. The inspector has toured the building, looking in particular at the kitchen, laundry, bathing facilities, communal areas of the home and a sample of residents’ bedrooms, with their permission. The home as part of the Ashbourne group has recently been acquired by the Southern Cross organisation. There are planned changes to use Southern Cross policies, procedures and documentation and the home is currently coping with the transition stage. For example existing documentation refers to Ashbourne but Southern Cross quality audits and checks have been introduced. What the service does well:
The registered manager, supported by the organisation, has responded to the previous inspection report with a comprehensive action plan, which gave dates for the required improvements to be put into place. The majority of improvements required at the last inspection visit are now in place. The manager and staff make sure that each resident and as appropriate their relatives are involved in the plan of how their care is to be provided. The home also has good relationships with the local GPs and other health care services, such as the community dietician and skin care specialists, providing support for the residents at The Gables. Staff encourage the residents to treat The Gables as their own home and to be as independent as much as possible. As a new initiative the manager has created a large bed-sitting room from an existing double room to allow more personal private space. This initiative may be extended if successful. Residents are able to make their own choices and can take an active part in meetings
The Gables Nursing Home DS0000004832.V281537.R01.S.doc Version 5.1 Page 6 and surveys if they wish. The residents meetings are now well established and well attended. Residents ask for the dates of future meetings and are keen to give their opinions about the running of the home. The manager is pleased to receive the constructive critique and there have been improvements as a result. For example there is now improved communication between night staff. The meals are thoughtfully and well prepared, and the menus, offer a range of options for each meal. The food is appetising and well presented. Members of staff ask residents what they prefer at each mealtime, with each persons preferences recorded each day. The food is of an exceptionally high standard and the majority of food is prepared using fresh ingredients. Special diets are prepared and served in a way, which tempts people to eat and the cook visits the residents to find out if there are any special foods that would tempt them to eat. The kitchen is exceptionally well organised and the cook takes time and trouble to obtain and prepare additional foods to meet residents preferences. Comments from residents are very complimentary, a resident says, really enjoyed the roast chicken dinner and sponge pudding - the foods always good here and theres plenty of it. Care staff offer sensitive help and assistance, according to each persons needs. The dining rooms provide attractive environments in which to eat, though people can choose to have meals served in their own rooms if they wish. There are plentiful drinks readily available throughout the day, throughout the home, with staff on hand to give assistance as needed. The Gables has a stable group of staff, many have worked at the home for some time and know the residents well. Nursing and care staff are caring, committed and flexible, often willing to work extra shifts. Residents and visitors spoke of staff being ‘friendly’, ‘welcoming’ and genuinely caring. One visitor who is not able to visit as often as she would wish says the staff do their best and feels she can trust them to look after her relative even when she is not there. There is lots of friendly, cheerful banter between residents and staff throughout the day, with residents teasing staff, especially when they are all together at mealtimes. During the visit staff demonstrated a dedicated approach to their work; they clearly know residents’ likes and dislikes and how to meet their needs. They are keen to share views and answered any questions in an open and honest manner. The home is tidy, homely and comfortable. People commented that they are very impressed with the standards of hygiene. The Registered Manager is attentive to maintaining good standards of health and safety and undertakes a regular analysis of all accidents occurring in the home, from which areas for improvement are identified. The manager and senior team operate an open style of management and make efforts to be around the home and be accessible. Comments are that the home is well run and staff professional and approachable.
The Gables Nursing Home DS0000004832.V281537.R01.S.doc Version 5.1 Page 7 This inspection was conducted with full co-operation of the Registered Manager, staff and residents. The atmosphere through out the inspection was relaxed and friendly. The Inspector would like to thank staff, and residents for their hospitality during this inspection visit. What has improved since the last inspection?
The Registered Manager has taken action to improve assessments so that each persons susceptibility to develop pressure sores is more accurately assessed and regularly reviewed to be consistent with any special pressure relieving equipment, especially if this is already in place. Records of the care provided to treat any pressure sores have improved and are now more detailed. The Registered Manager has made considerable improvements to make sure that all healthcare screening processes and records are regularly reviewed and accurately show the current situation for each person, especially where weight loss is noted. Any resident with significant weight loss over a period of time is referred to the GP and dietician in good time and there is ample evidence of advice and support now in place. Further action has been taken to improve the way medication is stored, administered and recorded and the home now has a rigorous medication system, which safeguards residents well being. Improvements have been made to the completion of medication records and these are now satisfactory. There are only a few minor improvements still to be made as a result of this visit. For example further investigation is needed to resolve the fluctuating temperatures recorded for the drugs fridges. The links made with the local church have been strengthened and additional small groups of people now attend for twice weekly events such as activity classes and bingo, on Mondays and Fridays. As part of the maintenance program, planners have visited the home, and progress has been made to adapt the two bathrooms not usable for residents. One now has a walk in / wheelchair accessible shower, which is well used and enjoyed by many residents. There is funding in place to adapt the bathroom on the first floor to a similar standard. The kitchenette on the first floor has now been renovated and made useable for visitors to make drinks and snacks for themselves and their relative if they wish. New carpets have been provided in some residents bedrooms and there are plans for the new organisation to continue the programme of redecoration, with a wider choice of colours and fabrics.
The Gables Nursing Home DS0000004832.V281537.R01.S.doc Version 5.1 Page 8 Record keeping at the home continues to improve, which benefits the delivery of care for the residents. The manager has issued the second year of resident and relative surveys to obtain views of how they think the home is performing. Completed surveys are in the process of being returned. Currently the majority are positive though there is a mix of views, which is encouraging and will help the home to continue to improve. The home is also in the process of producing its first newsletter, with a draft edition completed. 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 Gables Nursing Home DS0000004832.V281537.R01.S.doc Version 5.1 Page 9 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 The Gables Nursing Home DS0000004832.V281537.R01.S.doc Version 5.1 Page 10 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): These standards have been assessed at the inspection visit on 19 July 2005 and were satisfactory. EVIDENCE: The Gables Nursing Home DS0000004832.V281537.R01.S.doc Version 5.1 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,11 There is a clear and consistent care planning system in place to provide staff with the information they need to satisfactorily meet residents needs. The health needs of residents are generally well met with evidence of good multi disciplinary working taking place on a regular basis. The home has generally good arrangements for administration of medication, which safeguards the wellbeing of people living at the home. EVIDENCE: The Gables Nursing Home is currently continuing to use the standardised Ashbourne documentation and there is a very detailed and comprehensive care plan in place for each person, based on their assessed and identified needs. Examination of the records of a resident recently admitted to the home provides good evidence that care plans are developed in conjunction with the resident and their relatives. Although the resident is not able to provide a signature to indicate agreement, there are plans for the relative living some distance away to sign the documents at the weekend following this inspection visit. The Gables Nursing Home DS0000004832.V281537.R01.S.doc Version 5.1 Page 12 On the sample of residents’ care plans assessed there are records of the persons preferences for their daily routine, for example rising, retiring, and bathing. The daily notes of one person show that she had changed her mind and had refused her evening bath and wished to be bathed the following morning, which demonstrates that staff are sensitive to residents wishes. On the day of this visit the residents are well groomed, with coiffure hair, neat nails and clean laundered clothes. There are good risk assessments in place and generally appropriately recorded health care screening assessment tools are completed for each person. There is evidence that residents are weighed on admission and that their weight is monitored each month. From the sample of residents case files and care delivery assessed, (FW) with a grade 4 pressure sore did not have a tissue viability assessment score, which reflected the level of risk; this needs to be reviewed. There are turns charts and food and fluids charts in place, however entries are incomplete and do not demonstrate the level of changes of position or accurately show that sufficient efforts are being made to offer and encourage suitable nutrition and fluids. There is a comprehensive medication policy and procedure, which is well understood by the trained nurses consulted. Observations during the visit of the registered nurses administering medication shows that this is undertaken in a sensitive manner, taking time to encourage each person to take their medicines. Completion of medication records (MAR sheets) has improved and the MAR sheets are completed in a satisfactory manner. Random audits of prescribed medication are satisfactory with accurate actual balances. A small number of previous requirements remain outstanding, such as, the need for clarification of as directed dosages with the prescriber and/or the pharmacist, though the care manager is making progress and has arranged a meeting with the GP practice manager. In addition during this visit there have been two occasions when the drugs trolley was left unattended with medication not locked away. Care must be taken to ensure that this is not repeated. The home has policies and procedures relating to dying and death, however Southern Cross Healthcare policies and procedures are due to be introduced and staff will need familiarisation with any revised guidance. There is evidence from discussions about the care of the residents who are currently unwell that members of staff understand how to sensitively care for and support each person and their family. The Gables Nursing Home DS0000004832.V281537.R01.S.doc Version 5.1 Page 13 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): 14 Good contact is maintained with family and friends for the majority of residents and there is evidence that residents are supported to exercise control and make decisions about their lives. EVIDENCE: There is evidence that the home encourages residents, wherever possible to retain their independence to retain some control over their own financial affairs. Decisions regarding the management of residents financial arrangements are documented. Additionally the home proactively provides information about independent advocacy services, this can be found in the foyer. There is evidence from the tour of the premises and assessment of residents case files that people are encouraged to bring their personal possessions into the home if they wish, subject to health and safety considerations. These decisions are generally documented as part of the admission process, there are completed inventories held on the sample of individuals files assessed. The main meal of the day: roast chicken, fresh vegetables and trimmings / or sausage and mash and veg, followed by sponge and custard has been
The Gables Nursing Home DS0000004832.V281537.R01.S.doc Version 5.1 Page 14 thoroughly enjoyed by all residents consulted. Jugs of cold drinks are available in communal areas and bedrooms, and members of staff have been observed proactively encouraging residents to have a good intake of fluids. Hot drinks are regularly offered throughout the day and are available during the night as required. In addition visitors are able to make drinks in small kitchenettes on each floor for themselves and the residents they are visiting. These facilities continue to be well used and much appreciated. The Gables Nursing Home DS0000004832.V281537.R01.S.doc Version 5.1 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 The home has a satisfactory complaints system with good evidence that residents and relatives feel that their views are listened to and acted upon. There is evidence that residents are supported to exercise their rights as citizens. EVIDENCE: The Gables has a complaints procedure, which is displayed in the reception area and contained in the service user guide. However the Ashbourne documentation is due to change to Southern Cross Healthcare policies and procedures. The home has received three complaints since the inspection in July 2006. Two anon complaints were sent directly to the CSCI, one was not substantiated, one was partly upheld and made to the home was substantiated, resolved and all responses have been made within the 28 day timescale. Discussions have provided evidence that the manager and the homes administrator proactively facilitates each persons right to vote if they wish. There is evidence that residents are enrolled on the electoral register and have a proxy or postal vote to allow them to vote in elections. It is recommended that each persons decision about their wish to vote be documented on individual case files. The Gables Nursing Home DS0000004832.V281537.R01.S.doc Version 5.1 Page 16 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): 24, 25 The majority of these standards have been assessed at the inspection visit on 19 July 2005 and were satisfactory. The standard of the décor within this home is good with evidence of improvement through proactive planning and continuous maintenance. This is an attractive and comfortable environment for residents. EVIDENCE: During a tour of the premises there is evidence that the home continues to be refurbished, redecorated and repaired on an ongoing basis and is generally completed to high standards. A number of minor repairs have been undertaken as soon as they were noted during this visit. Examples are staining to a bathroom floor, which has been rectified and a broken lock in a ground floor bathroom has been repaired. The organisation has funded the provision of one walk in shower and quotations have been obtained for similar work to be undertaken in a second
The Gables Nursing Home DS0000004832.V281537.R01.S.doc Version 5.1 Page 17 bathroom. This will result in meeting the previously long outstanding requirement to ensure the two bathroom not used are made accessible to residents. Comments are that residents really enjoy their bathing experience in the newly installed shower. Examination of records of tissue viability advice and observations of one of the residents with a pressure sore nursed in bed demonstrate that the Quattro pressure relieving mattress does not fit the bed-base. Despite adjustments made by nursing staff the mattress continues to overhang the bed-base, reducing the effectiveness of the specialist equipment. Nursing staff have conducted an audit of residents using similar equipment on incompatible beds during this visit. The registered manager must ensure that the organisation provides suitable adjustable beds, which are compatible with pressure relieving mattresses in sufficient numbers to meet residents needs (currently 3) as a matter of priority. During the tour of the premises observation of the homes main kitchen demonstrates that it continues to be maintained in good order, and it is clean and tidy and well organised, with improved lighting. Appropriate food hygiene/safety measures are in place, with well-kept records, which are monitored by the registered manager, the organisation and Environmental Services. The home has achieved the Local Authority (Environmental Health) and NHS Trust gold food award. The homes laundry continues to be well organised and achieves good standards of infection control. Throughout the home good standards of cleanliness continue to be maintained and there have been no discernable malodours during this visit. The Gables Nursing Home DS0000004832.V281537.R01.S.doc Version 5.1 Page 18 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 These standards have been assessed at the inspection visit on 19 July 2005 and were satisfactory. This home continues to maintain stable substantive staffing levels and residents receive good and consistent care. EVIDENCE: Assessment of staffing rotas at this visit demonstrates that the home continues to maintain satisfactory staffing levels. The registered manager reviews staffing levels on a regular basis, taking account of the occupancy and dependency levels of residents accommodated, this is good practice. A copy of staffing rotas has been given to the Inspector during this visit. The Home now has a stable staff team of 43 people including 26 care staff, 2 domestic staff, 2 laundry staff, 1 housekeeper, 1 activities co-ordinator, 1 gardener / maintenance staff, 1 administration staff, 8 first level nurses, the Registered Manager and 4 catering staff previously employed by a separate company, who will now be direct employees of Southern Cross Healthcare. There are currently no staff vacancies. Random samples of staff files examined are satisfactory. Interview questions and answers are retained on staff personnel files as a matter of good practice. The manager has met the requirement to ensure that the hairdresser and any other self-employed therapists provide the home with evidence of satisfactory POVA/CRB clearance.
The Gables Nursing Home DS0000004832.V281537.R01.S.doc Version 5.1 Page 19 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,35,36,37,38 The registered manager, trained nurses and senior staff are effective in providing leadership and good clear communication systems throughout the home and staff demonstrate a good awareness of their roles and responsibilities. The systems for resident consultation at The Gables Nursing Home are good with a variety of evidence that indicates that residents’ views are both sought and acted upon. EVIDENCE: Residents, staff and visitors consulted feel that the management team of the home are approachable, supportive and people feel that they are able to air their views in an open manner. There are clear lines of accountability within the home, with Kim Jeffrey, the Registered Manager in day-to-day control of the home and there will be a designated Responsible Individual from the new Registered Provider, who must
The Gables Nursing Home DS0000004832.V281537.R01.S.doc Version 5.1 Page 20 provide supervision, support and monitoring through monthly unannounced Regulation 26 visits and reports. The registered manager is in the process of devising a new annual development plan for the home. Though there are a number of self-auditing systems introduced by Southern Cross Healthcare with monthly self-monitoring requiring documentary evidence to be produced by the registered manager, it is not clear whether an accredited quality assurance will be implemented. The monthly audits include assessment of 4 resident case files and 4 staff files in addition to other records on a monthly basis. The manager is required to score the homes performance in each area. The home continues to make efforts to involve residents, relatives, representatives and other community stakeholders in the running of the home. There are regular residents meetings, which have an increased attendance. Survey questionnaires have recently been distributed to residents and families and completed forms are in the process of being returned and views are being collated. The manager plans to feed back the results and take action in any area where there are concerns or where performance needs improvement. There is a previous requirement for the organisation (Ashbourne) to review and revise the policy and procedures relating to the management of service users finances to demonstrate compliance with Regulation 20(1) and the protection of vulnerable adults. This will be assessed against Southern Cross Healthcare policy and procedure at the next visit. The currently provides support for 31 of the 44 residents to manage their finances, providing temporary safekeeping for small sums of money. A random sample of balances and records assessed are satisfactory, with two signatures and numbered individual receipts, which is good practice. There is a structured formal supervision system for all staff. Supervision sessions are used to identify training needs, personal development. Record keeping at the home continues to improve, achieving good standards, with only minor improvements required at this visit. All personal information continues to be held, stored and disposed of in accordance with the Data Protection Act 1998. A sample of fire safety and maintenance documentation examined is satisfactory. The Manager ensures that all staff receive mandatory training commensurate with their roles; fire training, drills twice each year, moving and handling, first aid, food hygiene, health and safety and infection control training, commensurate with duties undertaken. It is recommended that a matrix be used to track attendance at fire drills and fire training to audit that every member of staff attends for 2 fire drills and 2 fire training sessions in each 12 month period.
The Gables Nursing Home DS0000004832.V281537.R01.S.doc Version 5.1 Page 21 The accident records examined are satisfactory. There have been 80 recorded accidents / incidents involving residents and 1 recorded accident involving staff since the last inspection visit in July 2005. The level of recordings provides evidence of good recording practice. In addition the Manager undertakes a regular documented accident analysis each month, which is used to identify trends and any additional control measures as needed. The Gables Nursing Home DS0000004832.V281537.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 X X X X X X 2 3 X STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 2 X 2 3 2 3 The Gables Nursing Home DS0000004832.V281537.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP2 Regulation 5(1) Requirement To review the contract / terms and conditions using the publication from the Office of Fair Trading: Guidance on Unfair Terms in Contracts in Care Homes (Timescale of 31/03/05 and 30/10/05 Not Fully Met) 1) To review the tissue viability assessment for the resident with the grade 4 pressure sore (FW) 2) To improve the monitoring arrangements to ensure that the prescribed 2 hourly turns are being carried out and that sufficient efforts are being made to offer and encourage suitable food and fluids for (FW) 3) To ensure that daily turn charts and food / fluid intake charts are fully completed for (FW) and any other resident requiring this level of care 1) To clarify as directed dosages with the prescriber and/or the pharmacist (Timescale of 31/10/04 and 31/08/05 Not Fully Met)
DS0000004832.V281537.R01.S.doc Timescale for action 01/04/06 2. OP8 12(1)(b) 13(1)(b) 03/02/06 3. OP9 13(2) 01/03/06 The Gables Nursing Home Version 5.1 Page 24 2) To record the actual dosage given where variable dosages are prescribed, for example 1or 2 tablets (Timescale of 31/10/04 and 31/08/05 Not Fully Met) 3) To investigate and resolve the fluctuating temperatures recorded for the drugs fridges on the ground and first floor, ensuring temperatures are maintained between 2 C - 8 C at all times (Timescale of 31/03/05 and 31/08/05 Not Fully Met) 4. OP9 13(2) 1) To ensure that the drugs trolley is not left unattended at any time with medication left exposed 03/02/06 5. OP19 23(2) 6. OP21 23(2)(j) 7. OP24 16(2)(c) 2) To define the code O on MAR sheets used as a reason for nonadministration of medication To renovate or replace the floor 01/04/06 covering in the first floor treatment room (possible change of use) (Timescale of 31/03/05 and 31/10/05 Not Fully Met) Action must be taken to ensure 01/04/06 the two bathrooms currently not in use are made accessible to service users - one completed (Timescale of 31/10/04 and 31/10/05 Not Fully Met) 1) To provide suitable adjustable 15/02/06 beds, which are compatible with pressure relieving mattresses in sufficient numbers to meet residents needs (currently 3) as a matter of priority 2) To ensure any pressure relieving equipment such as mattresses or cushions are fully The Gables Nursing Home DS0000004832.V281537.R01.S.doc Version 5.1 Page 25 8. OP29 17(2) 2,4 19(1) compatible with other equipment in use such as beds, wheelchairs 1) To take account of guidance from the DoH POVA/CRB certificates are to be available to for inspection at the home (Timescale of 31/10/04 and 30/09/05 Not Fully Met) To be assessed at next visit 01/04/06 9. OP35 17(2) 20(1) 2) To review and update the grievance procedure in view of the introduction of the protection of vulnerable adult abuse (POVA) register. (Timescale of 31/10/04 and 30/09/05 Not Fully Met) To be assessed at next visit 01/04/06 The organisation must review and revise the policy and procedures relating to the management of service users finances to demonstrate compliance with Regulation 20(1) and the protection of vulnerable adults (Timescale of 31/10/04 and 31/10/05 Not Fully Met) To be assessed at next visit 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. Refer to Standard OP17 OP38 Good Practice Recommendations That each persons decision about their wish to vote is documented on individual case files That a matrix be used to track attendance at fire drills and fire training to audit that every member of staff attends for 2 fire drills and 2 fire training sessions in each 12 month period .
DS0000004832.V281537.R01.S.doc Version 5.1 Page 26 The Gables Nursing Home Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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