Inspection on 06/06/06 for The Gables, Stroud

This inspection was carried out on 6th June 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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Gables, Stroud 10/07/07

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 Nick Jones Key Unannounced Inspection 6 , 13 and 20th June 2006 11:30 th th The Gables DS0000016379.V291793.R01.S.doc Version 5.1 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 DS0000016379.V291793.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 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.V291793.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Gables Address Lovedays Mead Folly Lane Stroud Glos GL5 1SB 01453 758318 01453 797399 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.V291793.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th November 2005 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 monthly fees charged by the home are £1351.35. The Gables DS0000016379.V291793.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced Key Inspection and was completed during one day and two mornings over the next two weeks over a total period of 9 and a half hours. Staff, including the manager, on duty were seen and spoken to individually. The manager was on leave over the first two visits, hence the third visit to feedback findings from the first two visits. All of the service users were met and whilst their ability to offer comment, in the main, was limited it was evident that they were happy in the home and had a positive relationship with the staff. All staff were helpful and well informed during the inspection. A visit was also made to the Stroud and District Mencap Society office situated next to the home to meet the Registered Individual, Group Manager and Administration Manager. A number of records were seen at the home and they were generally well maintained and contained the required information. A tour of the home and garden was completed. What the service does well: The home was seen as a comfortable and stimulating environment where staff are committed to meet the needs and wishes of the service users. The home is good at providing a flexible service by identifying the needs and wishes of the individual service users. Staff were seen as approachable, attentive and competent. Staff were observed to involve service users in the day to day running of the home and supported to make choices. A wide range of day-time and leisure activities are offered to service users. It provides a comfortable and spacious environment appropriate to the needs of service users. The Gables DS0000016379.V291793.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The Statement of Purpose and Service User Guide have been reviewed and produced in written/symbol format but need further work to ensure they contain the required information set out in the Standards and Regulations. The work undertaken to review and amend care plans is work in progress. They must be set out in way to provide clear and concise information about how service users should be supported. There must be evidence that regular reviews of care plans and risk assessments are taking place. The home provides a comfortable and homely environment but needs to address some requirements with regard to the safety of service users. A risk assessment must be completed to ensure the safety of service users should they choose to leave the building without staff support. Appropriate recruitment procedures must be implemented to ensure the safety of service users. POVAfirst checks must be completed on staff before they commence in post if the full enhanced CRB clearance is still pending. A comprehensive on-call policy and procedure must be available to all staff with a clear procedure for covering staff shortages included. The Gables DS0000016379.V291793.R01.S.doc Version 5.1 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Gables DS0000016379.V291793.R01.S.doc Version 5.1 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.V291793.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service User Guide give people living at the home and people wishing to live there information about the services provided. Amendments need to be made in order that they can make an informed decision about moving in. People wishing to move into the home have the opportunity to visit before deciding whether to live there. A copy of the Care Management needs assessment must be available for any new service user to ensure their needs are met. EVIDENCE: The Statement of Purpose and Service User Guide have been reviewed, as required from the previous inspection, and produced in a combined written and symbol format. They provide a considerable amount of detailed information. The Statement of Purpose needs to include the following in line with Schedule 1: • The updated names of the registered individual and manager • The age – 18-65 and sex of people living at the home • whether nursing is provided The Gables DS0000016379.V291793.R01.S.doc Version 5.1 Page 10 • • • the size of rooms or indication that they exceed the National Minimum Standards. The arrangements made with service users for consultation with them about the running of the home. Fire safety arrangements. The Service User Guide needs to include reference in the statement of terms and conditions about whether payment is expected for holidays or the use of transport. A new person has been admitted to the home in December 2005. All information relating to this person is available in the home providing staff with clear information about their needs and the way in which they like to be supported. Staff spoken with have a good understanding of the person’s needs. The service user and their family were able to visit the home on several occasions to assess the suitability of the home. Records of these visits were viewed. The placing authority conducted their own assessment but the home had not received a copy. The manager will write to Adult and Community Care Services to request a copy. An assessment by the home was viewed which provided a good range of information about the service user. The format used did not make reference to the leisure/cultural needs of the service user. A review of the placement was arranged after a period of four months after the date of admission. This involved the service user, their family, a Social Work assistant and staff from the home. The original assessment contained a standard question as to whether the service user wakes much at night, the answer being yes. The assessment did not contain details as to how a home with only sleep-in staff would be able to meet the needs of the service user at night. Staff are made aware of the need to support the service user at night by an alarm attached to the bedroom door. This arrangement was recorded in the review meetings held to confirm the placement. Staffing requirements are discussed further in this report in the Staffing section. The new service user’s file contained a copy of a signed social services contract. The Gables DS0000016379.V291793.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The needs of the service users are on the whole clearly identified and wherever possible met. The records of care plans and risk assessments of all service users must be reorganised, reviewed and updated to ensure consistency in staff support. Service users have been supported to make decisions and choices about their lives. EVIDENCE: A sample of records kept about service users were examined and these contained care plans and Individual Personal Plans (IPPs). The previous inspection report for the home required an action plan for addressing the administration and organisation of the care planning systems in the home. There was evidence that a considerable amount of work has taken place The Gables DS0000016379.V291793.R01.S.doc Version 5.1 Page 12 towards meeting this requirement. Files viewed contained well-written care plans that described a wide range of support needs and how staff should support them. Some of the care plans had evidence of regular review but one service user’s plans were overdue for review from April 2006. The record of review must also state who was involved and how the care plan was reviewed. The files examined contained a one page summary of some of the care plans in addition to a two or three page, more detailed summary of some of the care plans. These two records exist in addition to the detailed care plans. There were also records of ‘morning’ and ‘evening’ routines in addition to the care plans describing these personal support needs. It was not clear as to the purpose of these different records and could lead to confusion as to which care plans were current. The care plan of one service user did not contain details of their assessed preference to eat meals alone rather than with the group of other service users. Minutes of Individual Personal Plan (IPPs) meetings were viewed. These meetings are held on an annual basis and involve staff from the home, the service user and their family. They contained details of discussions that took place at the meeting including a review of the life of the person over the previous year. The minutes also contained details of goals and objectives for the coming year. These objectives had not been written up to form part of service user’s care plans. Observation of a mealtime routine and discussion with the manager showed that the preference of one service user to eat alone, or in a quieter environment, was not stated in their care plan. Though some progress has been made in addressing the requirement from the previous report, the requirement is re-stated to ensure the work on care plan and IPP formats is completed. Viewing care plans and risk assessments and spending time with service users demonstrated they are supported to make choices and decisions in their day to day lives. Any limitations to choice are documented. Service users were observed to choose where and what they did with their time. Staff were observed to offer service users not already at day services the chance to visit the shops in Stroud. The staff team are to be commended in their support of the varied needs of the service users. Risk assessments are in place for a variety of activities and scenarios, and some of these have been recently reviewed and updated where required. Others were overdue for review. One service user made a recent choice to leave the home unaccompanied and walk to their day centre venue in Stroud. A risk assessment completed stated that this person would need staff support at all times when outside of the home. A new risk assessment was completed on the last day of the inspection and forwarded to the Commission. This only partially addresses a possibly unacceptable risk in the service user leaving the building without staff support. The Gables DS0000016379.V291793.R01.S.doc Version 5.1 Page 13 Some of the doors to the outside of the house do not have an alarm sounder, including the door from the conservatory to the garden (which needs to be left open on hot days during the summer). The garden is not a closed environment, with easy access to outside of the home. The Group Manager stated further changes to the environment in the house and garden would be considered as a matter of urgency. Information about the risk assessment and possible changes to the service user’s care plan and the physical environment must be discussed with the service users’ family and placing authority. The Gables DS0000016379.V291793.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 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. Service users day time activities, social and leisure needs are identified and met. Service user’s choice and freedom of movement are respected so promoting the rights of service users. The home provides meals which the service users enjoy and promotes their health and wellbeing. EVIDENCE: Each service user has a weekly programme and this indicated the activities, times and venues. Considerable care has been taken by staff to ensure the wishes and needs of the individuals are, wherever possible, met. The programmes include attendance at a day centre and college courses, yoga The Gables DS0000016379.V291793.R01.S.doc Version 5.1 Page 15 classes, samba dance/drumming sessions, horse riding and swimming. Service users also attend a social club in the evening during the week. Two service users were being involved in baking cakes with staff and one service user was supported with verbal prompts to lay the table for lunch. Service users are supported to use a variety of community facilities. Records of this were viewed in the diary of the home and daily notes. Service users are offered holidays that meet their individual needs and wishes. This included a canal boat holiday, a visit to Butlins in Somerset and a trip to Spain. Social and family relationships are encouraged and supported and everyone has contact with family/friends. Daily notes viewed recorded the regularity of the visits from and to different relatives. The rights of the service users are respected and the staff were seen to provide a flexible response to the varied needs of each service user. Everyone in the home is involved in menu planning as much as is possible and staff place great emphasis on ensuring likes/dislikes are known and responded to. On the first day of the inspection the tea consisted of fish, potatoes, and vegetables. Staff had a clear understanding of the needs of service users at mealtimes. The menus provide a varied, nutritious and balanced diet. Mealtimes are seen as an important social occasion. Staff and service users sit together in the dining room for the main meals. One service user is assessed to prefer to eat their meals apart from the other service users. This support need must be recorded in the person’s care plans. The Gables DS0000016379.V291793.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a good standard of personal and healthcare support but action is required in relation to medication. The home and staff must ensure that all medication is correctly administered and any errors reported. EVIDENCE: Care plans provided good detail about how people like to be supported with personal care and the home has the specialist equipment required to meet people’s needs. Records are kept of health related appointments and recommendations from health professionals such as occupational therapists and speech and language therapists are implemented. Staff record any observations about changes in people’s health and refer to the GP if concerns arise. Staff administer medicines and there was a record of the receipt, administration and disposal of prescribed medicines. Medicines were being stored appropriately. A file is kept detailing any errors in administration of The Gables DS0000016379.V291793.R01.S.doc Version 5.1 Page 17 medication. This contained three entries, one of which had not been reported to the Commission. A further medication error notification was forwarded to the inspector on the final day of the inspection, resulting in disciplinary action being taken. The issues of both notifying the Commission with regard to medication errors and clarifying staff responsibilities for administration of medication were both requirements in the previous inspection report. A discussion with the manager identified the need to produce daily shift plans/duties that could be signed off by staff as duties such as dispensing and signing for medication were completed. The discussion also identified the need to improve shift handover procedures to ensure both the out-going and incoming staff responsible for administering medication verifies the administration and recording of medication has been completed correctly. Staff have received accredited training in the safe handling of medicines. The Gables DS0000016379.V291793.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The practices in the home ensures that service users have an active voice and are protected from any abuse. EVIDENCE: The home has a complaints procedure and there is a copy for service users in a “symbols” form. The manager informed the inspector that not all service users would be able to understand the current formats, however, in such cases there is a relative/friend who would act on their behalf. The manager stated relatives/friends are encouraged to express any thoughts or concerns when visiting the home. The home has not received any formal complaints. Staff receive training in Adult Protection; some staff were not aware of the ‘Whistleblowing’ policy and procedure. These are currently being reviewed and re-written. The staff team should be made aware of the completed policies and understand their role if needing to implement the policy. The records of service users financial affairs were viewed and were detailed and accurate. The personal savings of service users are held in the general company account. This has been the case for many years and the Commission has been satisfied that their funds are held appropriately. There was evidence that service users spend more on personal spending and holidays than their DSS benefits provide which is enabled by the funds available to the The Gables DS0000016379.V291793.R01.S.doc Version 5.1 Page 19 organisation from fundraising. This means individual service user’s recorded accounts are sometimes in deficit by the end of the financial year which is reimbursed by the charity. The inspector met with the Registered Individual as part of this inspection and discussed the possibility of setting up either a separate, but joint, Mencap service users’ account or individual trustee accounts. This is a requirement of this report. The Gables DS0000016379.V291793.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable, clean, hygienic and, largely, safe environment which meets the needs of service users. EVIDENCE: All areas of the home were viewed including all bedrooms. Décor and furnishings are of a good quality with bedrooms personalised to the tastes and preferences of service users. Fixtures and fittings were well maintained and appropriate to the needs of service users. There are plans to re-fit the kitchen in the coming months. The radiators in both toilets and bathroom are uncovered; the mobility of one service user has an implication as to whether they would be able to move away from a hot radiator should they experience a fall. The manager stated they would arrange for these to be covered and risk assess other uncovered radiators. A lock to a bathroom had recently been removed due to a service user being unable to re-open the lock to the bathroom. Staff were unable to open the The Gables DS0000016379.V291793.R01.S.doc Version 5.1 Page 21 door from the outside and gained entry through the bathroom window. The toilet doors had similar locks where the plastic slot to open the door from the outside is worn and is difficult to operate. The manager stated the week after the inspection that they had been removed and replaced. The home has various items of specialist equipment that have been regularly serviced and meet the needs of the service users. The means to know whether a service user has left the building or garden must be reviewed as to whether the current arrangements are satisfactory. This must form part of the risk assessment of one service user if they should leave the home unaccompanied by staff. The home was found to be clean and hygienic. Staff have access to disposable gloves, aprons and laundry bags. The Gables DS0000016379.V291793.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported by committed staff who demonstrate care and interest in providing the right care. The recruitment policy must be reviewed to ensure sufficient staff are available during periods when the home does not have a full complement of permanent staff. A suitable recruitment process must be used to support and safeguard service users. The training, development and supervision of staff ensures service user’s needs are met by a well-trained and supervised staff team. EVIDENCE: Discussions with the staff and observations during the visit provided evidence that staff are clear about their roles and responsibilities, are knowledgeable about people’s support needs and have the skills necessary to deliver this support in line with agreed care plans. The Gables DS0000016379.V291793.R01.S.doc Version 5.1 Page 23 There was good evidence that the home is well supported by other professionals such as clinicians from the Community Learning Disability Team. Staff from the home or staff from the other Stroud and District Mencap services cover staff absences. The home does not have access to locum/bank staff or agency staff. Recruitment is underway to replace two full-time care staff. This has affected the frequency that staff are able to support service users to access community facilities at weekends. The Group Manager stated the organisation is formulating a policy to aim to recruit bank/locum staff group and, as an occasional, last-resort basis, the use of agency staff. The organisation has an on-call rota which is staffed by the managers and deputies of the four Mencap services. It was not clear as to how and whether on-call staff could make contact with the Group Manager or Registered Individual in an out of hours, emergency situation. Staff meetings take place approximately every two months and minutes are kept. Regular staff supervision was being provided by the manager. Staff stated they feel the management of the home is supportive and accessible. Discussions with staff indicated that they receive sufficient support and supervision to carry out their jobs. The records of staff recruitment were viewed and found to contain evidence that most of the appropriate processes and checks had taken place. However two staff commenced their post a week before receiving their POVAFirst or CRB clearance. Discussions took place with the manager confirming that the home must consult with the Commission before commencing any staff before they have received a satisfactory enhanced CRB clearance. The manager stated that staff, during their first week, were undertaking a three day induction course away from the home or working in the home in a supervised capacity by other staff. The manager must clarify with the Commission the reasons for starting staff in post before a full CRB has been obtained, that all other required checks and evidence are in place and that a risk assessment has been completed stating the staff will be not working in an unsupervised capacity and who will be supervising them. It was confirmed that no staff should commence in post until a POVAFirst check has been received. Staff receive a variety of mandatory training and a structured induction. This was being co-ordinated by another manager from the group. The Gables DS0000016379.V291793.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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. The home benefits from a committed manager who promotes good care practices and person centred service. Service user’s and their relative’s views and preferences inform the aims of the home and staff practice. The home does not have a formal quality assurance system to evidence some of their consultative work with service users and their relatives. Health and safety monitoring is taken seriously in the home to ensure service users live in a safe environment, but the security and safety of the building must be risk assessed to ensure the safety of vulnerable service users. EVIDENCE: The Gables DS0000016379.V291793.R01.S.doc Version 5.1 Page 25 The Registered Manager was observed to be committed to providing a service –user led service with staff being well supported to achieve this. Staff stated they were always able to seek advice and support from the management team. The Registered Manager is due to complete their Registered manager’s Award over the next few months. Discussions with staff, observation of staff practice and viewing of records showed the home ensure service users’ individual wishes are considered and wherever possible met. Service user’s relatives visit on a frequent basis and are involved in IPP meetings. The Group Manager stated she would be introducing an appropriate quality assurance/monitoring system to be used at the home. Health and safety aspects of service provision are being maintained and monitored. Records viewed included fire safety checks and fire drills, water temperatures and servicing of equipment. The record of fire drills should include more details such as the staff on duty, the service users who may have refused to leave the building and the duration of the process. The safety and security of the building must be reviewed with particular regard to risk assessing service users leaving the building without staff support and the lack of low surface temperature radiators. The Gables DS0000016379.V291793.R01.S.doc Version 5.1 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 2 3 3 4 3 5 3 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 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X The Gables DS0000016379.V291793.R01.S.doc Version 5.1 Page 27 YES 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 must further update its’ Statement of Purpose and Service User Guide to include all the details as set out in Schedule 1 and Standard 1.2 respectively The Registered Manager must obtain a copy of the needs assessment of new service users from Adult and Community Care Services The Registered Manager must produce an action plan to address the issues in the text relating to the care planning within the home The Registered Manager must ensure risk assessments for service users are regularly reviewed The risk assessment for DS0000016379.V291793.R01.S.doc Timescale for action 30/09/06 2. YA2 14(1)(b) 30/09/06 3. YA6 15 & 12(1)(a)&(b) 30/09/06 4. YA9 14(2)(a) 15(2)(b) 31/08/06 5. YA9 13(4) 31/07/06 Page 28 The Gables Version 5.1 6. YA20 13(2) one service user must be reviewed as to whether sufficient safety measures exist to prevent unaccompanied absence from the home. Clarification must be given to staff over their responsibility for correctly administering medication ( the requirement not fully met from the previous inspection 31/01/06) The home must ensure that all errors in medication are reported to the Commission ( the requirement not fully met from the previous inspection 31/01/06 ) 31/07/06 7. YA20 13(2) 31/07/06 8. YA23 20(1) 9. YA24 10. YA33 11. YA34 Service users’ monies must be held in a separate account(s) to that used by the organisation to manage the home. 12(1)(a) Low surface temperature 13(4)(a) covers must be fitted to the radiators in the bathroom and toilets highlighted in the report; all other uncovered radiators must be risk assessed 12(1)(a) All staff must have 18(1)(a) access to a clear policy and procedure on the organisation’s on-call procedures to include details with regard to how staff shortages would be covered 12(1)(a)&19(1)(4)(5) The Registered Manager must ensure that DS0000016379.V291793.R01.S.doc 31/01/07 31/08/06 31/08/06 31/07/06 The Gables Version 5.1 Page 29 recruitment procedures are followed that comply with the regulations as described in this report. 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 Refer to Standard YA39 Good Practice Recommendations The regulation 26 visit recording format should be reviewed to provide a more detailed review of the service The Gables DS0000016379.V291793.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Gables DS0000016379.V291793.R01.S.doc Version 5.1 Page 31 - 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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