Inspection on 10/07/07 for The Gables, Stroud

This inspection was carried out on 10th July 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Gables, Stroud 06/06/06

The Gables, Stroud 25/11/05

The Gables, Stroud 09/06/05

The Gables, Stroud 18/02/05

The Gables, Stroud 23/08/04

The Gables, Stroud 05/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 The Gables Lovedays Mead Folly Lane Stroud Glos GL5 1SB Lead Inspector Mr Paul Chapman Unannounced Inspection 10th July and 9 August 2007 09:00 th 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 DS0000016379.V336663.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 DS0000016379.V336663.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Gables Address Lovedays Mead Folly Lane Stroud Glos GL5 1SB 01453 762229 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) Stroud & District Mencap Homes Foundation Limited Louisa Merrick Care Home 5 Category(ies) of Learning disability (5) registration, with number of places The Gables DS0000016379.V336663.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: N/a Date of last inspection 6th June 2006 Brief Description of the Service: The Gables is a semi-detached house that provides care and accommodation for five adults with learning disabilities. The home is situated close to the local town of Stroud enabling easy access for community facilities. The home provides twenty-four hour care and is a spacious property with large gardens. The home is staffed and run by Stroud Mencap, which is affiliated to the national Royal Mencap Society but is essentially an independent organisation. The home has a Statement of Purpose and Service User Guide which is available in an additional symbol-based version. The weekly fees to live at the home range from £388.96 to £640.67. The Gables DS0000016379.V336663.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This site visit was completed over 2 visits, an 8-hour period on a day in July 2007 and a meeting with the organisation’s finance manager in August. The site visit in July started at 0900hrs and the registered manager was present throughout the day. The manager completed the CSCI annual quality assurance assessment prior to the site visit for this inspection. Completed surveys were received from two parents, one social care professional and three doctors. A tour of the premises was completed with the manager. The care of three people was looked at in depth that included looking at their financial, medication and personal records. Three staff were interviewed about the care they provide. Other records examined included staff files, health and safety information and quality assurance records. What the service does well: People living in the home are provided with accommodation that meets their current needs. The care plans examined covered a wide range of topics. People lead active lifestyles supported appropriately by members of the staff team. The staff take photos of people completing activities so they can build good photographic records that enable people to reflect on things they have done and places they have been. A survey completed by a parent stated “there is a happy and relaxed attitude”. Observations on the day of the site visit confirmed this. Menus are chosen by the people living in the home and they are empowered to do this through the use of pictures. The staff at the home have supported a person through a recent bereavement and the work completed by the home has helped the person through a difficult time. The Gables DS0000016379.V336663.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home’s statement of purpose should be reviewed to ensure that it meets the criteria of these regulations. Care plans must be reviewed to ensure they provide sufficient detail to allow the staff team to support people in a consistent manner. Current care plans do not provide sufficient detail as to exactly what staff need to do and some of the identified goals were unclear. Further risk assessments must be completed to ensure that unnecessary risks are identified and as far as possible minimised. The manager must ensure that sufficient staff are employed to meet the needs of the people living in the home. Regulation 26 visits must be completed as prescribed by the regulations. The manager must develop a quality assurance system. Please contact the provider for advice of actions taken in response to this The Gables DS0000016379.V336663.R01.S.doc Version 5.2 Page 7 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 DS0000016379.V336663.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Gables DS0000016379.V336663.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Some of the home’s statement of purpose has been updated as required by the previous inspection report, but it still does not meet the criteria of the regulations. The home’s admission policy minimises the risk of people being admitted to the home whose needs cannot be met. EVIDENCE: The previous inspection report made a requirement against standard 1. The manager had to update the home’s Statement of Purpose to include: • The updated names of the registered individual and manager. • The age (18 – 65) of the people living in the home. • Whether nursing was provided. • The size of the rooms or the indication that they exceed the national minimum standards. • The arrangements made with people living in the home for consulting with them about the running of the home. • Fire safety arrangements. The Gables DS0000016379.V336663.R01.S.doc Version 5.2 Page 10 Examination of the current statement of purpose showed a number of these areas are now covered, but some areas still need to be addressed. The manager must ensure the following items are included: • Whether nursing is provided. • Fire safety arrangements. The 2nd requirement of the previous inspection report was that the manager must obtain the completed assessment for the last person to move into the home. Examination of the person’s file showed that this was now present. There have been no new admissions to the home since the previous inspection. The home have an admissions/policy/procedure to follow. The Gables DS0000016379.V336663.R01.S.doc Version 5.2 Page 11 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, 9, 10 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans are in place that cover a wide range of topics but they require more detail to accurately reflect what staff must do meet peoples needs consistently. Staff support people to make decisions in their lives. People are put at unnecessary risk due to a number of areas of their lives not being appropriately risk assessed. EVIDENCE: A requirement of the previous inspection report was for the manager to produce an action plan to address the issues of the previous inspection report. Those issues centred around people’s objectives/goals not being addressed by care plans. Three people’s care was looked at in detail. All of the care plans for the three people were examined. All of the people living in the home have a key worker. The Gables DS0000016379.V336663.R01.S.doc Version 5.2 Page 12 The care plans seen covered a wide range of subjects/needs, these included: • • • • • • • • • Encouraging communication. Personal care. Dental care. Medication. Comprehension. Eating and drinking. Mobility. Domestic skills. Behaviour management. A number of shortfalls were identified that the manager and her team must address. 1. Goals – Some of the goals were unclear while others identified the issue that was to be addressed and did not say what the goal was. All goals should be clearly identified and measurable. 2. Detail – The care plans examined covered a wide range of topics and needs. A shortfall is the detail provided in them. The majority of the plans seen need to be reviewed and further detail added. Current plans do not explain the steps that staff actually need to take when supporting a person to achieve a goal. 3. Spelling/typing errors – the manager should monitor care plans as a number contained errors. 4. All care plans must be dated when they are written. All but 2 people have had review meetings in the past year. People living in the home have complex needs. The inspector spent time observing the interactions of staff with people living in the home. These were seen to be positive and respectful. People were seen being supported by staff to make decisions. The previous inspection report made two requirements relating to risk assessments. The first one was to ensure that they were reviewed regularly. The risk assessments examined had been reviewed regularly. The second requirement was to ensure that sufficient safety measures exist to prevent one person leaving the home unaccompanied. This has been addressed. A number of risk assessments were in place. Some additional risk assessments should be completed so as not to put people at unnecessary risk. Additional areas to be assessed include slips, trips, falls, transport, when people are using The Gables DS0000016379.V336663.R01.S.doc Version 5.2 Page 13 the local community, completing tasks in the kitchen and missing persons. It is also recommended that where completing a care plan may involve a risk to the person that the associated risk assessment is linked to the care plan. This could be achieved by either, noting the number of the risk assessment on the care plan, or attaching a copy of the risk assessment on the care plan. Documents are stored securely. The Gables DS0000016379.V336663.R01.S.doc Version 5.2 Page 14 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, 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff support people to lead active lifestyles that meet their needs. Staff support people to maintain their hobbies and interests. People are encouraged to choose what they would like to eat and they are empowered to do this through the use of pictures. EVIDENCE: The home has its own transport. People living in the home lead active lifestyles. Speaking to staff and examining records showed that people attend a local day service regularly throughout the week, go horse riding, go bowling, play skittles, do pottery, arts and crafts, music, line dancing and attend a social club. The Gables DS0000016379.V336663.R01.S.doc Version 5.2 Page 15 In addition to the regular activities completed by people, day trips are organised from time to time and recent trips have included going to Boughton on the Water and Weston Super Mare. The conservatory had lots of pictures of people completing various activities. In addition to this the staff have created an album of a person horse riding. One of the people living in the home “power walks” each day with a member of staff and other exercise equipment was available to use including an exercise bike and some weights. In house the manager has arranged for an appropriately qualified masseur to visit regularly. People had recently returned from a holiday in Greece supported by the staff. Since their return the staff team had worked hard with people in developing some photo albums making use of pictures taken while there. The inspector spent time with a person looking through one of the albums. People living in the home have varying degrees of contact with their families and staff provide support where it is required. One member of staff gave a good example of supporting one person to develop a friendship further, with a person they attend day services with. The CSCI received two completed surveys from parents. Both were generally positive about the service provided in the home. One comment was “There is a happy and relaxed atmosphere”. Another comment made was that they thought “communication could be better”. A menu for the week was on the wall of the dining room. Staff support people to choose the menu each week. To make this process easier for people the staff have developed a system of using pictures of meals and snacks. Each Tuesday staff sit with people and go through the pictures allowing them to choose from the pictures. Once the shopping list has been completed people are encouraged to help with the grocery shopping. The Gables DS0000016379.V336663.R01.S.doc Version 5.2 Page 16 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, 20 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans to address people’s personal care needs do not contain enough detail to allow for accurate review of their needs. Other professionals appropriately address peoples’ health and emotional needs. Risks to people are minimised through good management of the home’s medication administration. EVIDENCE: All of the files seen contained care plans to meet the personal care requirements for each person. Again, as with other care plans examined these care plans need more detail to enable staff to meet peoples needs consistently and truly reflect the needs of the people being supported. With plans not containing sufficient detail it is impossible to review a person’s needs in this area. This becomes a requirement of this inspection report. The files examined provided good evidence of other professionals being involved in meeting the health and emotional needs of the people living in the home. The inspector spoke to the manager about healthcare assessments. The The Gables DS0000016379.V336663.R01.S.doc Version 5.2 Page 17 inspector explained that the local partnership trust have created a comprehensive document which assesses people health needs. It is a recommendation of this inspection report that the manager contacts them and completes an assessment for each person in the home. The CSCI sent surveys to other professionals involved with people in the home. Three completed surveys were received from GP’s for people in the home, no concerns were highlighted. A completed survey from a care manager made comments including “workers show respect to people”, and “a more consistent approach towards staff and people living in the home would ensure quality assurance is achieved.” This report has already made comment about steps to be taken to improve the consistency and highlights it further later in this report. Medication administration was examined and seen to be well managed. The two requirements of the previous inspection report had been addressed. The manager and team have supported one person with a bereavement recently, and to support the person they have created a memory book. The book contains lots of photos and staff sometimes sit with them and go through the pictures letting them talk about their feelings. This is a good practice. The Gables DS0000016379.V336663.R01.S.doc Version 5.2 Page 18 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, 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Due to peoples complex needs it would be difficult for them to initiate the complaints procedure but staff showed a good awareness of how people may show they are unhappy. Income and expenditure records are detailed and minimise the risk of financial abuse. EVIDENCE: The home has a complaints procedure and the manager stated that this is under review by her line manager at present. No complaints have been made to the manager or the CSCI since the previous inspection was completed. Some people have complex communication difficulties which would make it impossible for them to make staff aware if they were unhappy about something. The inspector spoke to staff about other indicators they would watch for that may show someone is unhappy. All of the staff spoken with were able to give good examples of what may indicate a person is unhappy, and what steps they would take to ensure their safety and that their needs were met. Four staff have completed training in the protection of vulnerable adults, and the remainder of the team are due to complete theirs in September ’07. The Gables DS0000016379.V336663.R01.S.doc Version 5.2 Page 19 A requirement of the previous inspection report was that each person living in the home should have separate accounts to that used by the organisation to manage the home. The manager stated that each person has their own account. The inspector examined a sample of income and expenditure records and monies kept by the manager. All were seen to be correct at the time of this site visit. The meeting with the organisation’s finance manager provided evidence of each person having their own bank account, and statements showed income and expenditure. Records showed that people have a personal allowance each week but activities such as going to the cinema are paid for by the organisation. Stroud and District Mencap subsidise people’s expenditure and records were available for inspection. The Gables DS0000016379.V336663.R01.S.doc Version 5.2 Page 20 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, 25, 26, 27, 28, 29, 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a homely, comfortable environment that meets their current needs. EVIDENCE: As part of the site visit a tour of the premises was completed with the home’s manager. To the front of the property is a parking area and at the rear of the home is a secure garden. The manager explained that staff have been responsible for redesigning the garden with the support of some of the people living in the home. This work is on going. The building was clean and hygienic throughout, at the time of the visit one of the staff was working with a resident completing cleaning chores. People living The Gables DS0000016379.V336663.R01.S.doc Version 5.2 Page 21 at the home are asked to help with the cleaning and staff support them to clean their bedrooms each week. The building provides people with a separate lounge, dining room and a conservatory. People living in the home were seen to make good use of the conservatory during this site visit. The home provides sufficient space to meet the needs of the people that are currently living there. All of the communal rooms are decorated to good standard and furnished with a range of furniture and personalised with people’s belongings. The kitchen was replaced last year; staff have produced symbol/picture cards and fixed them to cupboard doors to help enable people to be independent. The carpet in the main hallway in the home is quite badly stained. The manager stated that they had tried cleaning it. The manager stated that they have asked for a new carpet to be fitted. It becomes a requirement of this inspection report that the provider provides a timescale for when this will be done. All of the bedrooms were seen. Each room was decorated to a good standard. One person’s room had just been decorated. Each room was decorated in different colours and personalised with their belongings. Where appropriate staff had fixed symbol/picture cards on drawers and cupboards to help people be independent. All of the bathrooms and toilets were seen. The main bathroom has an assisted bath and this had been serviced. Records showed that staff monitor and record the hot water outlet temperatures each time they are used. In one toilet the toilet paper holder was missing and should replaced. The other toilet had no lock on the door and the manager explained that this was due to the needs of one person who would lock themselves in and cause themselves distress putting them at risk. The manager must address this to ensure that people’s dignity is respected. The manager should research different locks that would enable the person to lock and unlock the door, also the door could have a sign on it that tells people when it is occupied so when it is being used people do not enter accidentally. The decoration in both of the toilets is now looking a little tired and the manager should plan to re-decorate them in the near future. The Gables DS0000016379.V336663.R01.S.doc Version 5.2 Page 22 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, 35 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff training minimises the potential risk that people’s needs will not be met appropriately. People are not put at unnecessary risk by the organisation’s recruitment procedures. The home is currently understaffed and this may effect the ability to meet peoples’ needs at all times. EVIDENCE: Training records were comprehensive with certificates present for all of the courses completed by the staff team. Speaking with staff they confirmed that training was available. A couple of the newer staff spoke about completing their induction that included an organised “in house” induction as well as attending externally organised training. Other staff spoke about starting NVQs (National Vocational Qualifications) in care, while others stated that they had completed theirs. A requirement of the previous inspection report was for the home to ensure the staff team have access to a clear policy/procedure for the organisations on The Gables DS0000016379.V336663.R01.S.doc Version 5.2 Page 23 call system. At this inspection the on call rota was on the home’s notice board and the policy seen made it clear about the management teams expectations of staff when using the system. The staffing rota was seen and showed that the home is staffed 24 hours a day, 7 days a week. There are usually 2 staff on each shift and 1 member of staff sleeps-in each night. The manager explained that the home currently has a staffing shortage and is 58 hours a week understaffed. This has been addressed temporarily by a member of staff from one of the organisation’s other services working 39 hours a week in the home. The manager stated that she understood that her line manager had advertised for staff. The manager must ensure that this is addressed and it becomes a requirement of this inspection report. The three staff files that were examined showed they contained all of the information required by these regulations. The Gables DS0000016379.V336663.R01.S.doc Version 5.2 Page 24 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, 42 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Although there are two shortfalls relating to quality and monitoring, outcomes for people living in the home are good. People living at the home are not put at unnecessary risk due to the health and safety procedures in place. EVIDENCE: The manager has been in post at the home for a number of years and is registered with the CSCI. The records in the home are well organised and from examining these records, speaking to staff and observations during the day peoples needs are being met. Regulation 26 of the Care Home Regulations (2001) states that where a registered provider is not in day-to-day charge of the home that they shall visit The Gables DS0000016379.V336663.R01.S.doc Version 5.2 Page 25 the home at least once a month. Reports completed to meet this regulation showed that the frequency of the visits varied and some of the reports were missing. The registered provider must ensure that this is addressed and it becomes a requirement of this inspection report. The inspector spoke to the manager about quality assurance. Due to the complex needs of the people living in the home it is difficult for the manager to involve all of the people meaningfully in this. A discussion took place about monitoring quality by different methods. This included the manager assessing areas including activities, food, care plans to see what was actually being achieved by the home. An example of this may be reviewing the activities completed over a 3 month period identifying what activities take place most? Who chooses them? Are they meeting peoples needs? The same could be done with reviewing care plans, are peoples goals being achieved? If not, why not? It becomes a requirement of this inspection report that the manager develops a system of quality assurance and makes the findings available for the next site visit. Health and safety around the home is well managed: • • • • • • • Portable Appliance Testing was completed in July. Hot water outlet temperatures are tested monthly. A food probe is used to test temperatures of prepared meals. Fridge and freezer temperatures are tested daily. Chemicals used for cleaning are stored securely and data sheets are available. Qualified engineers service specialised equipment. Fire safety equipment is tested regularly by staff. The Gables DS0000016379.V336663.R01.S.doc Version 5.2 Page 26 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 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 2 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 3 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 2 3 3 X 3 X 2 X X 3 X The Gables DS0000016379.V336663.R01.S.doc Version 5.2 Page 27 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 YA1 Regulation 4&5 Requirement The home’s Statement of Purpose and Service User Guide must include all the information required by the regulations. Care plans must be reviewed to ensure that people’s goals are clearly identified, and that they provide enough detail about the steps staff must actually follow to support people consistently. Timescale for action 31/08/07 2. YA6 15 & 12(1)(a)&(b) 26/10/07 3. YA9 13(4) b 4. YA18 12(3) 5. YA24 23(2) d Risk assessments should 26/10/07 be reviewed to ensure that there are no unnecessary risks to people. Personal care needs 26/10/07 must be identified in sufficient detail that allows people’s wishes to be met consistently. The carpet in the home’s 31/03/08 hallway should be replaced as it is stained. DS0000016379.V336663.R01.S.doc Version 5.2 Page 28 The Gables 6. YA27 12(4) a The toilet door must have a lock fitted to it to ensure that people’s privacy and dignity is respected. 21/09/07 7. YA33 18(1) a 8. YA39 26 9. YA39 24 Sufficient staff must be 05/10/07 employed in the home to meet the needs of the people living there. Regulation 26 visits 31/08/07 must be completed as prescribed by the regulations. An effective quality 26/10/07 assurance system must be developed and implemented that allows a review of the service and continuous improvement. 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 YA19 YA27 Good Practice Recommendations A health assessment should be completed for each of the people living in the home. Toilets and bathrooms should be included in any future plans for re-decoration of the home. The Gables DS0000016379.V336663.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 - 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!